Transcript Non-Communicable Diseases – progress and potential to do

Non-Communicable Diseases –
recent progress and potential to
do more together.
Deputy Minister of Health
Dr G. Ramokgopa
What do we include as NCDs?
• For the purpose of this talk (and in terms of
the NCD Strategic plan) Non-communicable
Diseases include Cardiovascular diseases,
Diabetes, Chronic respiratory conditions,
Cancer, Mental disorder, Oral diseases, Eye
disease, Kidney disease and Muscular-skeletal
conditions.
2012 Lancet report on Global Burden
of Disease
• In 1990, 47% of DALYs worldwide were from
communicable, maternal, neonatal, and nutritional
disorders, 43% from non-communicable diseases, and
10% from injuries.
By 2010, this had shifted to 35%, 54%, and 11%,
respectively.
• Thus there is a 11% relative increase in burden from
NCDs within 20 years. Projections are that there will be
an even steeper rise over the next 20 years with the
greatest increase being in Africa.
• Ischaemic heart disease was the leading cause of DALYs worldwide
in 2010 (up from fourth rank in 1990, increasing by 29%), followed
by lower respiratory infections (top rank in 1990; 44% decline in
DALYs), stroke (fifth in 1990; 19% increase), diarrhoeal diseases
(second in 1990; 51% decrease), and HIV/AIDS (33rd in 1990; 351%
increase).
• Major depressive disorder increased from 15th to 11th rank (37%
increase) and road injury from 12th to 10th rank (34%
increase).there was also a very substantial rise in the burden from
muscular-skeletal disorders.
•By 2030 it is estimated that NCDs will contribute 75% of global
deaths. 13% of deaths from NCDs in developed countries occur in
people under 60 – in Africa it is 29%
Research for prevention and control of
Non-communicable Diseases
• Globally:– NCDS currently cause over 60% of all deaths
– 80% of these deaths occur in developing countries
– Around a quarter of these deaths occur in people
under 60 years of age.
• The Burden of disease in South Africa is still
somewhat different from the above global
picture given the HIV and AIDs and TB
epidemics, but as HIV becomes more
controlled and people will live longer as well
as high co-morbidities with NCDs, there is
little doubt that burden from NCDs will
increase substantially.
National Burden of Disease Study 2000
Unintentional
injuries
7%
Intentional
injuries
7%
Total DALYs=16 297 203
Neuropsychiatric
8%
HIV & AIDS
31%
Cardiovascular
and diabetes
7%
Respiratory
disease
5%
Respiratory
infections
3%
Neoplasms
3%
Other noncommunicable
10%
Perinatal.matern
al and nutritional
10%
Infectious and
parasitic
(excluding
HIV/AIDS)
9%
Source: Revised South African National Burden of Disease Estimates for 2000
Norman et al, 2006
Mortality in South Africa (Stats SA)
Injuries
9%
Cardiovascular
18%
Cancer
7%
Respiratory
4%
Infectious,
maternal,
perinatal and
nutritional
51%
Diabetes
2%
Other NCD
9%
• In 2010, the three leading risk factors for
global disease burden were:– high blood pressure,
– tobacco smoking including second-hand smoke
– alcohol use.
(Compared with 1990 where the leading risks
were childhood underweight, household air
pollution from solid fuels and tobacco smoking
including second-hand smoke).
National Development Plan 2030
recognizes the growing threat of NCDs
to Development
• The NPA health section begins with the words:“South Africa’s health challenges are more than
medical. Behaviour and lifestyle also contribute
to ill-health. To become a healthy nation, South
Africans need to make informed decisions about
what they eat, whether or not they consume
alcohol, and their sexual behaviour, among other
factors”.
NDP also says…
• Promoting health and wellness is critical to
preventing and managing lifestyle diseases,
particularly the major non-communicable
diseases among the poor, such as heart
disease, high blood cholesterol and diabetes.
These diseases are likely to be a major threat
over the next 20 to 30 years.
So what have we been doing about
this growing threat to health and
development?
• In Sept 2011 we held a summit with major
stakeholders. A declaration was agreed to which
included 10 targets.
• Reduce by at least 25% the relative premature mortality (under 60
years of age) from Non-communicable Diseases by 2020;
• Reduce by 20% tobacco use by 2020;
• Reduce by 20% the relative per capita consumption of alcohol by
2020;
• Reduce mean population intake of salt to <5 grams per day by 2020;
•Reduce by 10% the percentage of people who are obese and/or overweight by 2020;
•Increase the prevalence of physical activity (defined as 150 minutes of moderateintensity physical activity per week, or equivalent) by 10%
•Reduce the prevalence of people with raised blood pressure by 20% by 2020 (through
lifestyle and medication.
•Every women with sexually transmitted diseases to be screened for cervical cancer
every 5 years, otherwise every women to have 3 screens in a lifetime (and as per
policy for women who are HIV/AIDS positive).
•Increase the percentage of people controlled for hypertension, diabetes and asthma
by 30% by 2020 in sentinel sites; and
•Increase the number of people screened and treated for mental disorder by 30% by
2030.
UN Summit and Political Declaration
• Following the SA summit Minister Motsoaledi
led the SA delegation to the UN High level
meeting on the Prevention and Control of
NCDs.
• The meeting adopted a Political Declaration
which inter alia called on the WHO to develop
global targets.
• The next important step was to develop a
strategic plan of how the summit targets
would be reached.
• This was completed and passed by the
National Health Council.
• On 7th April, which is World Health Day with
theme of hypertension we will launch this
strategy!
3 Main sub-strategies of the Strategic
plan for the prevention and Control of
NCDs
• Sub-strategy 1: Prevent NCDs and promote
health and wellness at population, community
and individual levels.
• Sub-strategy 2: Improve control of NCDs
through health systems strengthening and
reform.
• Sub-strategy 3: Monitor NCDs and their main
risk factors and conduct innovative research
What has been done over the past
year and what is planned with regard
to each of these themes?
1. Prevention and Promotion
 It has been recognized that prevention of NCDs
requires a “whole of government” and “whole of
society approach. Plans have started to establish
a “National Health Commission” to be chaired
from the Presidency and involving all relevant
government departments and others. The
Deputy Chair will be an expert from outside of
government.
Prevention and Promotion cont.
• Regulations were gazetted last week to reduce the salt
content in specified foods. This is a major breakthrough in
order to get the population down to a maximum of 5g
intake of salt. These regulations will be accompanied by a
big information and education campaign that we are
planning together with NGOs (led by the Heart and Stroke
Foundation) and possibly industry (if we agree on the
messages).
• Salt is responsible for around a third of all hypertension
which is a growing problem (as illustrated in the next slide).
• Regulations for trans fatty acids were passed in 2010 with
an implementation date of 2011.
Alcohol
• The DoH is a key member of the Inter Ministerial
Committee on prevention of substance abuse.
• Each department is committed to taking actions
within their designated responsibilities and the
DoH has taken the lead, amongst other
initiatives, to present a Bill to Cabinet on Control
of the Marketing of alcohol.
• The DoH is also responsible for implementation
of the Mini Drug Master Plan.
While abstention
from drinking is
high in SA, among
drinkers we fall into
category of
countries having
highest
consumption of
AA/drinker per year
Background: Drinking in
SA
WHO, 2011
WHO, 2010
Background: Drinking in
SSA
We fall into 2nd
highest category
of countries in
terms of having
harmful pattern of
drinking (looking
at whether people
drink apart from
meals, engage in
heavy episodic
drinking, etc.)
WHO, 2010
Consequences of drinking in SA (Burden of Disease
Research)
31.5%
Unsafe sex
9.1%
Interpersonal violence
7.0%
Alcohol
*
95% CI 6.6-7.4
4.0%
Tobacco
High BMI
2.9%
Childhood and Maternal underweight
2.7%
Unsafe water sanitation and hygiene
2.6%
High blood pressure
2.4%
Diabetes
1.6%
Iron deficiency
1.4%
High cholesterol
1.3%
Low fruit and vegetable intake
1.1%
Physical inactivity
1.1%
Vitamin A
0.7%
Lead
0.4%
Urban air pollution
0.3%
Alcohol accounted for 7% of all DALYs in
South Africa in 2000 (Schneider et al.,
2007, SAMJ)
*Rehm et al., 2009: 6.3% (in 2004)
Indoor smoke 0.1%
Attributable DALYs (% of 16.2 million)
Tobacco legislation works!
• Results show that over 12 years the 5 million
children aged 13 to 18 demonstrated
consistent reductions in smoking behaviour at
a time when adolescent smoking globally was
increasing.
• Grade 8-10 learners
1999
2002
2011
23% (smokers) 18.5%
16.9%
Tobacco control cont.
• Additional actions are still being taken to
further reduce tobacco use. For example
regulations will be passed soon on smoking
outside public places. We are also examining
possibilities of brandless containers containing
visual images of tobacco harm.
NCD screening
• It is clear that more screening for NCDs is
required. (See next slide that shows that more
than half of people with hypertension don’t know
this fact!).
• The HIV Counselling and Testing (HCT) campaign
which has already tested over 13 million people
for HIV and offers an excellent opportunity for
screening for NCDs. We have instructed that
health testing must become comprehensive so
that NCDs are tested for at the same time as HIV
and TB.
Quality of care – hypertension
(BP<140/90mmHg or med)
Source: SADHS 1998, DOH
HPV (Human Papilloma Virus) vaccine
• We have made an in principle decision to
provide HPV vaccines to pre-pubescent girls.
• Details of this will be announced in due
course.
Sub-strategy 2: Improve control of NCDs
through health systems strengthening and
reform.
• Perhaps our most important initiative in this
regard is the development and starting roll out of
an Integrated Chronic disease Management
Model in three districts (ie. Dr Kenneth Kaunda
(North west); Bushbuckridge sub-district
(Mpumalanga) and West Rand (Gauteng).
• This model considers all chronic diseases,
whether from communicable or noncommunicable diseases, as requiring a single and
integrated approach.
• Evidence available suggests that the Chronic
Care Model including community outreach in
its various forms can lead to better processes
and outcomes of care, including better clinical
outcomes, improved patient satisfaction, and
lower costs.
• We plan to roll this out to all districts within
the next 3-5 years while learning from the
pilot sites.
Other systems and treatment progress
areas.
• We have commissioned a simple symptom based
diagnostic tool for implementation within
primary care – known as Primary Care 101. This is
currently being implemented in the 3 IMCD sites
and tested in other areas as well by the
developers. We believe that this will substantially
improve patient care.
• Guidelines for diabetes care were finalised.
• A draft cervical cancer policy has been
completed.
Other systems and treatment progress
areas.
• NCDs have been included in the primary care
package and the supervisors manual of the
Department.
• In phase 2 of the training of Community
health Workers NCDs will be included.
• NCDs are integral to the school health
programme.
Price Reduction Achievements
• NDOH manages all pharmaceutical tenders on
behalf of provincial departments since 2011
• Introduction of a Reference Price List when
tenders are advertised to encourage suppliers to
meet internationally competitive prices
• Have managed a 53% reduction in the total cost of
ARVs
• R 90 million savings on oncology tender
Sub-strategy 3: Monitor NCDs and
their main risk factors and conduct
innovative research
• It has been recognized that monitoring is not going to
be possible until we have accurate baseline data to
measure progress against. To this end we have
consulted with major role-players such as the MRC and
are working on costing a plan for comprehensive NCD
surveillance.
• In the interim we are hoping to get important
information of risk factors and prevalence of major
NCDs from SANHANES (South African Health and
Nutrition Examination Survey) – which is due to report
its research findings very soon.
• Reporting of cancers was made compulsory in
2011 through regulation.
• We believe that much more innovative
research is possible in South Africa that will
help reduce NCDS and assist us to reach our
targets.
Ministerial Advisory committee on
cancer
• The following individuals have been appointed to the Ministerial
Advisory committee on cancer:• Prof Cristina Stefan
• Prof Vikash Sewram
• Prof Paul Ruff
• Prof Raymond P. Abratt
• Dr Anil Bramdev
• Dr Jennifer Moodley
• Nonthuthuzelo Somdyala
• Sue Janse van Rensburg
• Kwanele Asante-Shongwe
• Emma Nomonde Belot
• The first meeting of the committee is scheduled for 16th April.
Mental health progress (a few
highlights)
• A mental health summit was held in April 2012
which adopted the Ekhurhuleni declaration. This
followed summits in 7 of the 9 provinces.
• A new mental health policy was adopted by the
National Health Council.
• A plan for implementing the summit resolutions
and the policy has been developed and will be
tabled at the next National Health Council.
• An amendments to the Mental Health Care
Act of 2002 has been accepted by the National
Assembly and will be taken to the National
Council of provinces soon.
• Draft amendments to the regulations to the
Mental Health care Act have been drafted by
an expert team and will be sent for public
comment in due course.
Limitations
• The new prioritization of NCDs resulting from
acknowledgement of the growing burden has not
as yet been accompanied by changes in staffing
and other resources at the National Department.
• Some NCD areas are still not receiving the
attention required. For example:–
–
–
–
–
Women’s cancers (cervical and breast cancer),
NCDs in children,
Muscular skeletal disorders,
Oral health
Eye health
• Not enough is being done yet around reducing
obesity and increasing physical activity
• There is growing understanding that various
legacies have left the mental health status of
the country at less than optimal levels. This
impedes social and economic development.
More plans and actions are needed in this
regard.
Partnerships
• We are well aware that from a capacity
perspective and from the perspective that
NCDs can only be tackled through a “whole of
Society” approach, that greater collaboration
and commitments are required from all
sectors.
• While recognizing the sterling assistance and
collaborations already achieved we still
require more assistance in for example:– Surveillance and research innovation
– Public education
– Training
– Private public partnerships in service provision
– Reducing costs of medicines and equipment.
• We look forward to even better collaboration
and partnerships than before!
• I thank-you.