4/15/2013

1

Keynote Address:

Multi-Sectoral Approach (MSA) to Prevent Non-Communicable Diseases

Lokman Hakim S, MD, PhD Deputy Director General of Health (Public Health)

Ministry of Health, Malaysia

NSM NCD Conference 2013 26 March 2013 Kuala Lumpur

lokman.hakim@moh.gov.my

Ministry of Health

Malaysia

The Causation Pathway For

Non-Communicable Diseases

Underlying Determinants •Globalization •Urbanization •Population Ageing

Common Risk Factors •Unhealthy diet •Physical Inactivity •Tobacco & Alcohol use •Age (non modifiable) •Heredity (non modifiable)

Intermediate Risk Factors •Overweight/obesity •Raised blood sugar •Raised blood pressure •Abnormal blood lipids

Source: Adapted from Preventing Chronic Disease: A Vital Investment. Geneva, WHO 2005.

2

4/15/2013

2

There are Four Major Groups of Non-Communicable Diseases; Four major lifestyles related risk factors

Modifiable causative risk factors

Tobacco use Unhealthy

diets

Physical

inactivity

Harmful

use of

alcohol

Non

com

mu

nic

ab

le d

isea

ses

Heart disease

and stroke

Diabetes

Cancer

Chronic lung

disease 3

8.3

14.9

20.8

6.5

9.5 10.7

1.8

5.4

10.1

4.3 4.7 5.3

0

5

10

15

20

25

NHMS II (1996) NHMS III(2006)

NHMS 2011

Pre

vale

nce

(%

)

Prevalence of Diabetes, ≥30 years (1996, 2006 & 2011)

Total diabetes

Known

Undiagnosed

IFG

Source: National Health & Morbidity Surveys (NHMS)

32.2 32.7

12.8

19.8

0

5

10

15

20

25

30

35

NHMS III (2006) NHMS 2011

Pre

vale

nce

(%

)

Prevalence of Hypertension, ≥18 years (2006 & 2011)

Total HPT

Known

Undiagnosed

20.6

35.1

8.4

26.6

0

5

10

15

20

25

30

35

40

NHMS III (2006) NHMS 2011

Pre

vale

nce

(%

)

Prevalence of Hyper-cholesterolaemia, ≥18 years (2006 & 2011)

Total HChol

Known

Undiagnosed

4

TRENDS IN NCD RISK FACTORS

4/15/2013

3

16.6

29.1 29.4

4.4

14.0 15.1

0

5

10

15

20

25

30

35

NHMS II(1996)

NHMS III(2006)

NHMS 2011

Pre

vale

nce

(%

)

Prevalence of Overweight & Obesity, ≥18 years (1996, 2006 & 2011)

Overweight

Obesity

Prevalence of Abdominal Obesity, ≥18 years (2006 & 2011)

19.6

28.6

33.6

44.7 48.0

51.0

55.7

62.8 63.2 61.4

63.2

56.2

50.4

10

20

30

40

50

60

70

18-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

PR

EVA

LEN

CE

(%)

AGE GROUPS (years)

30.1

37.1

47.1

54.1

20

30

40

50

60

NHMS 2006 NHMS 2011

PR

EVA

LEN

CE

(%)

MALES FEMALES

Prevalence of Abdominal Obesity by age groups (NHMS 2011)

5

Burden of Diabetes in Malaysia: (Adults age 18 years & above)

6

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

5,000,000

0

5

10

15

20

25

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Esti

mate

d p

op

ula

tio

n

Pre

vale

nce (

%)

Year

Est. population, 2006 Est. population, 2011 Prevalence projection, 2006 Prevalence projection, 2011

Current projection

4/15/2013

4

Admissions to MOH Hospitals due to Circulatory Diseases & Cancer

7

y = 130995e0.0208x R² = 0.7959

y = 53166e0.0523x R² = 0.8716

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

200,000

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Circulatory diseases Malignant neoplasms Projected, Circulatory diseases Projected, Cancer

Primary Renal Diseases

8

y = 314.5x + 1735.7 R² = 0.9634

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

New dialysis patients

New dialysis patients Projected new dialysis patients

Since 2003, diabetes accounted for > 50% of the primary renal disease of new dialysis patients

4/15/2013

5

9

2000

2003

2004

2008

Global Strategy for the Prevention and Control of Noncommunicable Diseases

Global Strategy on Diet,

Physical Activity and Health

Action Plan on the Global Strategy for the

Prevention and Control of NCDs

2010

2009

2011

Global Strategy to

Reduce the Harmful

Use of Alcohol

WHO Global Status

Report on NCDs

Political Declaration on NCDs

WHO's global road map to prevent and control NCDs

2012+ Realizing the commitments made in the Political Declaration

UN Secretary-General: NCDs in developing countries are hidden, misunderstood and under-recorded

A rapidly rising epidemic in developed and developing countries…

… with serious socio-economic impacts, particularly in developing countries.

Workable solutions exist to prevent most premature deaths from NCDs and mitigate the negative impact on development.

The way forward: These solutions need to be mainstreamed into socio-economic development programmes and poverty alleviation strategies.

10

4/15/2013

6

11

UN High-level Meeting on NCDs (New York, 19-20 September 2011)

Hig

h-l

evel

Mee

tin

g 113 Member States

34 Presidents & Prime Ministers

3 Vice-Presidents and Deputy Prime Ministers

51 Ministers of Foreign Affairs & Health

11 Heads of UN Agencies

100s of NGOs Po

litic

al D

ecla

rati

on

Establish multisectoral national plans by 2013

Integrate NCDs into health-planning processes and the national development agenda

Promote multisectoral action through health-in-all policies and whole-of-government approaches

Build national capacity

Wh

at W

HO

is d

oin

g Develop a Global Monitoring Framework and targets

Develop a global implementation plan 2013-2020

Provide technical support to developing countries

Identify options for partnerships

Coordinate work with other UN Agencies

Measure results

World Health Assembly in May 2012: Decided to adopt a global target of a 25% reduction in premature mortality from NCD by 2025

12

4/15/2013

7

Highlights: UN Political Declaration

Heads of States and Governments and representatives committed to:

• Establish/strengthen, by 2013, national multisectoral policies and plans for NCDs, taking into account the Global Strategy for NCDs and its Action Plan;

• Integrate NCDs policies and programmes into health-planning processes and the national development agenda of each Member State;

• Develop national targets and indicators based on guidance provide by WHO and give greater priority on surveillance;

• Accelerate implementation of the WHO FCTC, the Global Strategy on Diet, Physical Activity and Health, and the Global Strategy to Reduce the Harmful Use of Alcohol;

• Strengthen health systems that support primary care, prioritise early detection and treatment, and improve access to affordable essential medicines for NCDs.

13

What is Multi-Sectoral Approach?

• Working together across sectors to improve health and influence its determinant

• A number of other terms are used, often inter-changeably, for engaging sectors outside of health. These include:

• Inter-sectoral action for health.

• Multi-stakeholder action.

• Whole-of-government.

• Health-in-all policies.

• Healthy public policies.

14

4/15/2013

8

Why MSA?

• Governments can make substantial achievements in reducing the burden of NCDs through MSA.

• Forging new collaborations and partnerships are critical in making progress in addressing the NCD epidemic.

• Partnership occurs at different levels:

• Individuals, families and communities.

• Government, communities and NGOs.

• Government, development partners (within countries), civil society and, as appropriate, the private sector.

15

‘Whole-of-Government’ and ‘Whole- of-Society’ approach

• ‘Whole-of-Government’ denotes public service agencies working across portfolio boundaries to achieve a shared goal and an integrated government response to particular issues

• Responsibility for health and its social determinants rests with the whole society, and health is produced in new ways between society and government.

16

4/15/2013

9

Social Determinants of Health

17

Challenges in operationalising Multi-sectoral Approach (MSA)

• No or ineffective multisectoral mechanism at national level;

• No high-level commitment and support for coordinated operation;

• No or low level representation from different sectors in MSA mechanisms;

• No mandate, agreed roles and responsibility of sectors;

• No joint plan with agreed target, indicator approach, and inputs; and

• No auditing and valid reporting mechanism.

18

4/15/2013

10

NCD Targets & MSA

• 25% relative reduction in NCD mortality (between 30-70 years) has been adopted as a global target during the 65th World Health Assembly in May 2012.

• A set of global targets and indicators has been decided in a Formal Meeting with Member States in November 2012, and will be presented for adoption in the 66th World Health Assembly (WHA in May 2013).

• The Global Monitoring Framework on NCDs consists of 25 indicators, with 9 voluntary global targets.

• Having targets and indicators will provide clear direction for MSA and facilitate identifying the role and responsibility and accountability for the different sectors.

19

What is new? "Best buys" interventions to address NCDs

Population-based interventions addressing NCD risk factors

Tobacco use

- Excise tax increases - Smoke-free indoor workplaces and public places - Health information and warnings about tobacco - Bans on advertising and promotion

Harmful use of alcohol

- Excise tax increases on alcoholic beverages - Comprehensive restrictions and bans on alcohol marketing - Restrictions on the availability of retailed alcohol

Unhealthy diet and physical inactivity

- Salt reduction through mass media campaigns and reduced salt content in processed foods

- Replacement of trans-fats with polyunsaturated fats - Public awareness programme about diet and physical activity

Individual-based interventions addressing NCDs in primary care

Cancer - Prevention of liver cancer through hepatitis B immunization - Prevention of cervical cancer through screening (visual

inspection with acetic acid [VIA]) and treatment of pre-cancerous lesions

CVD and diabetes

- Multi-drug therapy (including glycaemic control for diabetes mellitus) for individuals who have had a heart attack or stroke, and to persons at high risk (> 30%) of a cardiovascular event within 10 years

- Providing aspirin to people having an acute heart attack

20

4/15/2013

11

Tobacco use

Harmful use of alcohol

• Excise tax increases

• Smoke-free indoor workplaces and public places

• Health warnings

• Bans on advertising and promotion

• Excise tax increases on alcoholic beverages

• Comprehensive restrictions and bans on alcohol

marketing

• Restrictions on the availability of retailed alcohol

• Salt reduction through mass media campaigns and

reduced salt content in processed foods

• Replacement of trans-fats with polyunsaturated

fats

• Public awareness programme about diet and

physical activity

HEALTHY CITIES AND ISLANDS SETTINGS SUCH AS SCHOOLS, WORKPLACES

ADVOCACY, HEALTH IMPACT ASSESSMENT HEALTH IN ALL POLICIES

MSA, ‘Best Buys’ and Sectors

MSA

Unhealthy diet and physical inactivity

Ministries including • Health • Agriculture • Finance •Transport • Trade and Industry • Education • Labour • Urban planning • Justice

Other stakeholders including • Industry • Civil society • NGOs • Academia

MINISTRIES Health, Agriculture, Finance, Transport, Trade and Industry Education, Labour, Urban planning, Justice OTHER STAKEHOLDERS Civil society, NGOs, Academia, Private sector, Donor, development partners

21

Examples of best practices and effective approaches for MSA - Tobacco Control

• Tobacco taxation and Health Promotion Foundations in Australia, Lao PDR, Korea, Malaysia, Mongolia, Tonga, Viet Nam

• Plain packaging- a path breaking approach in Australia

22

4/15/2013

12

Examples of best practices and effective approaches for MSA - Promoting Healthy Diet

• Healthier foods in Singapore-Hawker Fare

• Salt reduction in China and Mongolia

• Eat smart restaurants (700+), Hong Kong (China)

• Eat smart @ school (400), Hong Kong (China)

23

Examples of best practices and effective approaches for MSA -Promoting Physical Activity

• Exercise equipment in public parks in Lao PDR, China, Korea

• Walk paths, and cycling tracks in Cambodia, Korea, China, Malaysia

• Community physical exercise groups clubs in Seongbuk, Korea and Shanghai, China

• Walking days in Dalin, Seongbuk, Xiamen

24

4/15/2013

13

Examples of best practices and effective approaches for MSA - Tobacco Control & Reducing Harm from Alcohol

• The Mongolia’s President initiative in alcohol control, non- alcohol in government’s function and new alcohol legislation.

• Development of legislation: drinking and driving, use of helmet, blood testing: China, Cambodia, Philippines, Vietnam.

• Regulating informal alcohol control in Vietnam. 25

Examples of best practices and effective approaches for MSA -Healthy Cities • Smoke-Free Cities:

• Harbin, QingDao, China.

• Makati and Marikina, Philippines.

• Luang Prabang, in Lao PDR.

• Siem Reap, Cambodia .

• Environmentally sustainable healthy urban transport (ESHUT) in 5 Asian cities: • Promote walking, cycling.

• Public transport system.

• Reduce use of private vehicles.

• Smoking ban.

• Promoting health and hygiene.

• Barrier-free transport environments.

26

4/15/2013

14

Examples of best practices and effective approaches for MSA -Healthy Settings: Health Promoting Schools and Work Places • Health Promoting schools for multiple

health interventions - Singapore, Hong Kong, Macao (China).

• Healthy workplaces - Shanghai, Hong Kong, China.

27

MSA-Entry Points

National multi-ministerial forum National

• Effective only with commitment at the highest level, need a good driver, Health in All Policies

City/District/Village level Subnational

• More feasible, leverage local government, collective voice of community, government closer to the community, local ordinances

Tobacco/Alcohol/Physical Activity Risk factor

• Facilitators-activism, pressure groups, champions, international agreements (FCTC), global reporting, more palpable interventions, common good /common enemy

Inter

ministerial

Local

Government

Cross sector

working groups 28

4/15/2013

15

MSA – Accountability and Reporting

• Experiences from MDG 4 and 5 in accountability framework.

• Agreed national targets and indicators.

• Sector-specific roles, responsibility, target, inputs and outputs.

• Joint statement and joint plan.

• Across sectors audit, evaluation.

• Public reporting.

29

Rio+20: “NCDs constitute one of the major challenges for sustainable development”

“We understand the goals of sustainable development can only be achieved in the absence of a high prevalence of debilitating communicable and NCDs, and where populations can reach a state of physical, mental and social well-being.” [paragraph 138]

“We acknowledge that the global burden and threat of NCDs constitutes one of the major challenges for sustainable development in the 21st century.” [paragraph 141]

30

4/15/2013

16

UN System Task Team on the post-2015 UN Development Agenda: NCDs is a priority for social development and investments in people

“The MDGs did not adequately address … increase in NCDs. ” [paragraph 19]

“Priorities for social development and investments in people would include: … NCDs. Access to sufficient nutritious food and promotion of healthy life styles with universal access to preventive health services will be essential to reduce the high incidence of NCDs diseases in both developed and developing countries.” [paragraph 67]

31

National Strategic Plan for Non-Communicable Diseases (NSP-NCD) 2010-2014

• Presented and approved by the Cabinet on 17

December 2010

• Provides the framework for strengthening NCD

prevention & control program in Malaysia

• Adopts the “whole-of-government” and “whole-of-

society approach”

Seven Strategies: 1. Prevention and Promotion

2. Clinical Management

3. Increasing Patient

Compliance

4. Action with NGOs,

Professional Bodies & Other

Stakeholders

5. Monitoring, Research and

Surveillance

6. Capacity Building

7. Policy and Regulatory

interventions

32

4/15/2013

17

Strategy 7: Policy & Regulatory Interventions

• Main thrust of NSP-NCD

• Health promotion and education will increase awareness and knowledge

• However changes in behaviour is strongly influenced by our living environment

Awareness Knowledge Behavioural

Change

Supportive living environment

Health promotion & educations

Policies & regulations 33

Cabinet Committee for A Health Promoting Environment • To support the implementation of NSP-NCD, the Cabinet on 17 December 2010

approved the establishment of a Cabinet-level committee, chaired by the Right Honourable Deputy Prime Minister, and comprises of 10 members

1. Minister of Health 2. Minister of Education

3. Minister of Information, Communications, Arts & Culture 4. Minister of Rural & Regional Development

5. Minister of Agriculture and Agro-based Industry 6. Minister of Youth & Sports

7. Minister of Human Resource 8. Minister of Domestic Trade, Co-operatives and Consumerism

9. Minister of Housing and Local Governments 10. Minister of Women, Family and Social Affairs

Main TOR: To determine policies that creates a living environment which supports positive behavioural changes of the population towards healthy eating and active living

34

4/15/2013

18

Challenges for Malaysia

• The main challenge in policy and regulatory interventions remain that they are mostly under the responsibilities of ministries and departments other than Ministry of Health

• Ministry of Health needs to take leadership role.

• Need to find a win-win solution – “mutuality of interest”.

• Economic and “political” consideration remains paramount and needs to be acknowledged.

• For Malaysia, the establishment of the Cabinet Committee was an important initial step to achieve the “whole-of-government approach”.

• The health sector needs to play a strong advocacy role.

35

Summary

• Preventing and controlling NCD is an urgent priority for all countries.

• Most of the drivers of NCDs and their risk factors lie outside the control of the health sector.

• MSA is required to create enabling environments, so that healthy choices are the easy choices.

• MSA is also required to break the cycle of poverty and NCDs.

• The prevention and control of NCDs and their risk factors have a positive impact not only on health, but also on productivity and economic and social development.

36

4/15/2013

19

Thank you

37