Non-Communicable Diseases – recent progress and potential to do more together.

1. Non-Communicable Diseases – recent progress and potential to do more together. Deputy Minister of Health Dr G. Ramokgopa

2. 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.

3. 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.

4. 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%

5. 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.

6. 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.

8. Mortality in South Africa (Stats SA)

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).

10. 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. Behaviourand 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”.

11. 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.

12. 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;

13. 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 moderate-intensity 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.

14. 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.

15. 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!

16. 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

17. What has been done over the past year and what is planned with regard to each of these themes? • 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.

18. 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.

20. 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.

21. Background: Drinking in SA • While abstention from drinking is high in SA, among drinkers we fall into category of countries having highest consumption of AA/drinker per year WHO, 2011 WHO, 2010

22. 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

23. Consequences of drinking in SA (Burden of Disease Research) 95% CI 6.6-7.4 * 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)

24. 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%

25. 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.

26. 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.

27. Quality of care – hypertension (BP<140/90mmHg or med) Source: SADHS 1998, DOH

28. 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.

29. 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 non-communicable diseases, as requiring a single and integrated approach.

30. 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.

32. 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.

33. 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.

34. 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

35. 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.

36. 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.

37. Ministerial Advisory committee on cancer • The following individuals have been appointed to the Ministerial Advisory committee on cancer:- • Prof Cristina Stefan • Prof VikashSewram • Prof Paul Ruff • Prof Raymond P. Abratt • Dr Anil Bramdev • Dr Jennifer Moodley • NonthuthuzeloSomdyala • Sue Janse van Rensburg • Kwanele Asante-Shongwe • Emma NomondeBelot • The first meeting of the committee is scheduled for 16th April.

38. 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.

39. 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.

40. 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

41. 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.

42. 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.

43. 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.

44. We look forward to even better collaboration and partnerships than before! • I thank-you.