Strengthening NCD Management for Targeted Health Interventions

1. Preventing premature mortality from CVD: a risk based approach (Targets: 25% relative reduction in the prevalence of raised blood pressure and at least 50% of eligible people receive drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes) Dr Cherian Varghese MD., PhD. Coordinator, Management of NCDs (MND/NVI)

2. Objectives and structure • Objectives • How to strengthen NCD management within NCD prevention and control • Discuss the options, identifying problems and solutions • Communicating NCD management • Presentation (30 minutes) • Group work (30 minutes) • 3 groups • Problem solution tree, developing a plan, communication • Group presentation • Presenting to the minister of health • Discussion

3. 9 global NCD targets to be attained by 2025 (against a 2010 baseline) A 25%relative reduction in risk of premature mortality from cardiovascular disease, cancer, diabetes or chronic respiratory diseases At least a10%relative reduction in the harmful use of alcohol A10%relative reduction in prevalence of insufficient physical activity A 25%relative reduction in prevalence of raised blood pressure or contain the prevalence of raised blood pressure A30%relative reduction in mean population intake of salt/sodium At least50%of eligible people receive drug therapy and counselling to prevent heart attacks and strokes A30%relative reduction in prevalence of current tobacco use An80%availability of the affordable basic technologies and essential medicines, incl. generics, required to treat NCDs Halt the rise in diabetes and obesity

4. NCD progression and implications for prevention and control Health and economic burden Healthy Population to be covered Risk factors Health promotion High risk Risk reduction NCD Complications Treatment Rehabilitation Psycho-social support Progression of NCD

5. NCD CCS 2013Results: management guidelines for NCDs and risk factors (Availability and implementations)

6. Percentage of countries with select components integrated into their primary health-care system, 2013

7. Availability of procedures for the treatment of NCDs, 2013

8. NCD Management within NCD national plans

9. WHO - CVD management guidance and PEN 2001 2002 2005 2007 2010 2012 2013

11. Preparing for PEN • MoH agreement • National PEN/NCD in PHC steering group • MoH, clinical specialists, primary care managers, hospital service managers, chief pharmacists, officer in charge of laboratories, health information officer • Review available materials, current situation in the country, gaps and strengths • Agree to strengthen NCD management in a phased manner

12. Phased approach • Phase 1: Conduct situation analysis • Create a conducive policy environment: include prevention of heart attacks and strokes through the total-risk approach in the essential services package and set national targets • Phase 2: Address key gaps and strengthen the health system as far as possible – Demonstration site • Phase 3: Achieve optimum NCD care within the constraints of the situation • Estimate the cost of scale-up and track resources • Identify/correct missed opportunities • Integrate vertical disease-specific primary care programmes (e.g. on hypertension, diabetes) • Phase 4: Systematic scale-up and monitoring • Strengthen supply and quality of services, with emphasis on primary care • Improve demand for primary care • Find innovative solutions to overcome barriers to improving supply and demand • Monitor performance and progress towards attaining the target

13. Phase 1 – Situation analysis • It is useful to review the current NCD management at different levels • Facility assessment • What is the current service delivery • Patient pathways • What happens to the person who has high blood pressure/DM or who suffers from a Stroke?

14. ? ? Purchased only for 3 days (expensive), consumed for 2 days, and left the rest in a bottle Goes to health center for check up; medicines prescribed for 3 weeks and review Lack of knowledge After 2 years-symptoms ? ? ? Rushed to hospital No symptoms/ no time/ no money Had stroke, ends up paralyzed

15. Is your health centre PEN ready?Identify at what level it is possible to introduce PEN

16. Core Set of WHO-PEN Interventions WHICH INTERVENTIONS DO YOU WANT TO INCLUDE? IF THEY ARE AVAILABLE, ARE THEY MEETING THE TARGETS, CAN THEY BE STRENGTHENED?

17. JNCI 7 (Joint national committee on prevention, detection, evaluation and treatment of high blood pressure US DHHS) • The ultimate public health goal of antihypertensive therapy is the reduction of cardiovascular and renal morbidity and mortality. • The most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivated. Motivation improves when patients have positive experiences with, and trust in, the clinician. • Empathy builds trust and is a potent motivator.

18. absolute risk of CVD associated with increasing blood pressure & other CVD risk factors 5 year CVD risk (%) Reference: 50 yr old females Jackson et al. Lancet 2005. 365:434-41

19. Many risk factors coexist in the same individual Smoker Ischaemic heart disease High BP High Uric acid Fatty liver Dyslipidaemia High Blood Sugar

21. Performance of WHO/ISH charts in predicting CVD risk of individuals • First set of cardiovascular risk prediction charts for low and middle income countries, developed about 10 years ago. • All risk prediction engines including WHO/ISH charts have certain limitations. • To develop these charts WHO used the estimates of mortality and cardiovascular risk factor data available at that time. • Low and middle income countries do not have cohort data on mortality and risk factors. • Currently, these charts are being recalibrated using more recent mortality and risk factor data. • The objective is to improve discriminatory power and accuracy of prediction of cardiovascular risk, to the extent possible.

22. Coverage • CVD risk assessments • for people with ‘NCD’s attending health facilities • for all people attending the health facility (for any complaint) • for all people and their visitors • for a defined population with a target • 80 % of adults in the population of 10,000

23. Better yield… (get most of the red balls)10 $ for one scoop 30-40 years 40-50 years 50-60 years

24. Better management of those at high absolute risk and prevent complications Less heart attacks, strokes, renal failure and amputations Medication, counseling, foot care, periodic check up for urine protein, compliance…

26. HEARTSCORE

27. Score

28. Referral

29. Alternative risk prediction methods when blood tests are not feasible • Global data are not adequate for WHO to develop or recommend alternative risk prediction methods that do not rely on blood tests. • WHO considers blood glucose and cholesterol assays as essential basic technologies. • The objective of global NCD target 9 is to gradually improve access to these blood tests in primary care to at least 80% by 2025. • WHO PEN specifies that cardiovascular risk may be higher than indicated in the charts in the presence of several conditions including overweight and obesity.

30. FINRISK https://www.thl.fi/en/web/chronic-diseases/cardiovascular-diseases/finrisk-calculator

31. Q RISK http://www.qrisk.org/index.php

32. NIH risk score http://cvdrisk.nhlbi.nih.gov/evalData.asp

33. HEARTSCORE EUROPEhttp://www.heartscore.org/Pages/online.aspx

34. Cardiovascular Risk charts – recalibration • The methodology of recalibration is based on the assumption that the observed 10-year CVD mortality rates in a population can be linked with the average CVD risk factor profile observed in that population. • The 10-year CVD mortality risk for a person can be expressed as a function of • the average age- and sex-specific 10-year CVD mortality risk in the population • the average age- and sex-specific risk factor levels in the population • the weights linking risk factors with CVD mortality risk • In all six WHO regions, countries will be classified into different risk categories based on their 2012 age-standardized CVD mortality rates. For each of these ‘regional risk categories’, a separate recalibrated SCORE risk chart will be established.

35. WHO recommendations on screening (under development) • Targeted screening for cardiovascular risk with blood glucose testing and blood pressure measurement as part of cardiovascular risk screening (total risk approach), is more cost-effective than mass screening of the whole population and is more likely to identify individuals at high cardiovascular risk at lower costs. • Mass screening for diabetes alone does not result in significant reductions in all-cause mortality, diabetes-related mortality or cardiovascular-related mortality when compared with no screening.

36. Proportion of adults with > 30% risk for fatal or non fatal cardiovascular event in the next 10 years

37. Essential Medicines for WHO-PEN NCD Interventions ARE THESE MEDICINES IN NATIONAL ESSENTIAL DRUG LISTS? WHAT IS THE SUPLY AND DISTRIBUTION?

38. Essential Technologies and Tools for WHO-PEN NCD Interventions AT WHICH LEVEL ARE THESE TECHNOLOGIES AVAILABLE? CAN THEY BE SUSTAINED WITH REAGENTS/STRIPS?

39. Identify the Stakeholders

40. Stakeholder Analysis Minister of Finance MOH Prov’l Director Medical Asstn A Source: Schmeer, Kammi. Guidelines for Conducting a Stakeholder Analysis. Nov 1999. Bethesda MD: Partnerships for Health Reform, Abt Associates, Inc.

41. Phase 2: Address key gaps and strengthen the health system as far as possible- Demonstration site • Develop a PEN (NCD management steering group) • Hospital management, senior doctors, professional associations, Nurses, allied professionals, NCD programme officers etc to be part of the group. • Identify bottlenecks and address them, time bound actions are needed. • Develop a service model to be delivered in a STEPwise approach

42. Demonstration Site PHC Referral Hospital DISTRICT HOSPITAL CHW

43. Service delivery model

44. Referral Thresholds (as per national context) • Acute events (e.g. MI, CVA), Specialty Units eg • Acute MI or Acute Stroke Unit • Linkage with other services DH Known CVD; Angina, claudication; Worsening heart failure; Raised BP ; Any proteinuria Newly diagnosed DM DM which is uncontrolled or w/ complications PHC w/ MD PHC w/o MD CHW

45. Capacity building • Programme managers • What is needed for the service model • Task shifting • Supervision • Service providers • Observe the current work • Case studies • Training in health centres • Review and re training • Consider turn over of staff

46. Schematic diagram of Capacity Building

47. Health system support • Many countries are redefining tasks, developing new service delivery and looking at financing. • TB, HIV, Malaria, EPI, MCH etc have clearly defined services, easy for countries to understand… • NCD services? Need more engagement with health system colleagues

48. Continuing Care in the Community (Volunteers linked to health system) Emotional support Basic nursing Diabetic foot care Follow up Linking up with the professional team Social support to the affected family by way of Helping with transport to hospital Linking with other support groups Helping to get benefits from various sources Rehabilitation

49. Guideline development, implementation, review

50. WHO Guidance to countries on treatment thresholds and improving access to medicines • All WHO guidelines are to be adapted to country context • WHO guideline on screening for cardiovascular risk will be released this year. • NCD risk factor surveys (STEPS) • Countries can use these data to determine the age cut-off for screening of cardiovascular risk • to monitor progress on the attainment of global NCD targets including target 8, on assessment and management of cardiovascular risk to prevent heart attacks and strokes