Discussion on Health Systems Strengthening with emphasis on NCD prevention

1. Discussion on Health Systems Strengthening with emphasis on NCD prevention Dr A. Alwan

2. The NCD Acton Plan Six objectives: 1. Raising the priority accorded to noncommunicable diseases in development work at global and national levels, and integrating prevention and control of non-communicable diseases into policies across all government departments 2. Establishing and strengthening national policies and programmes 3. Reducing and preventing risk factors 4. Prioritizing research on prevention and health care 5. Strengthening partnerships 6. Monitoring NCD trends and assessing progress made at country level

3. What is a health system? • A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health • It includes private sector, health insurance organizations; other providers • It includes efforts to influence determinants of health as well as more direct health-improving activities and behaviour change programmes; • It includes inter-sectoral action by health staff, for example, encouraging the ministry of education to promote female education, a well known determinant of better health.

4. Health systems Governance Six Building blocks Policies and plans Financing Human resource Infrastructure Medicines and products Technologies Health information systems Output Service capacity and quality Services availability and coverage Service utilization Social determinants of health Health outcomes Intersectoral factors Health seeking behaviour

5. Health System Goals • Improving health and health equity, in ways that are responsive, financially fair, and make the most efficient, use of available resources. • The route from inputs to health outcomes is through achieving greater access to and coverage for effective health interventions, without compromising quality and safety.

6. Guiding principles The Underpinning values of Alma Ata • universal access, • equity, • participation and • intersectoral action • Central to WHO’s work and to health policies in many countries

7. Indicators of health systems Performance Fairness in financing Equity in health outcomes Responsiveness Financing risk protection

8. The public-private mix of health financing in low-income and low middle-income countries economies

9. National Health Expenditure Source: World Health Report (2008) Page 84

10. Health System Strengthening • Improving the six health system building blocks and managing their interactions in ways that achieve more equitable and sustained improvements across health services and health outcomes.

11. The six building blocks • Leadership/governance, ensuring strategic policy frameworks, effective oversight and the provision of appropriate regulations and incentives • Good health services delivering cost-effective, safe, quality health interventions to those who need them, when and where needed. • A well-performing health workforce, i.e. sufficient numbers and mix of staff, fairly distributed; well trained and competent • A system ensuring equitable access to essential medical products and technologies of assured quality, safety, efficacy and cost-effectiveness • A good health financing, ensuring that people can use needed services, and are protected from financial catastrophe or impoverishment • A well-functioning health information system to produce, analyze, disseminate and use reliable information on health determinants, health status, and health systems performance.

12. Constraints that need to be addressed NCDs do not feature as a health priority despite high burden of disease. They are often inadequately covered or mainstreamed in strategic health planning Gaps between plans and implementation including legislative action/plans and monitoring/evaluation Social determinants are not adequately addressed Weak links between NCD prevention and development initiatives including MDGs and poverty reduction strategies Inadequate emphasis and lack of effective mechanisms for intersectoral action Lack of broad reform measures Addressing constraints is dependent on reform measures which can address them at the health systems level Success depends on strengthening the capacity for developing and implementing comprehensive national health strategies and plans Partnerships with other health providers including the private sector

13. Constraints in health care financing Major gaps in coverage with essential package of NCD intervention at the PHC level Predominant proportion of financing through out of pocket payments make treatment for NCDs out of reach for a majority of poor population Reform measures to expand the base of public means of financing to cover the essential healthcare costs are critical to ensuring access to care. (Combination of conventional and innovative means for Health System financing) Tobacco taxation to finance health promotion and health care

14. Constraints in Health Services • Major gaps in coverage and quality of NCD interventions • Lack of prioritzation in terms of essential cost effective interventions

15. Priorities for strengthening NCD services • Need to improve effectiveness of prevention and better disease management • Create financial incentives through provider payment to control growth of health expenditures • Improve cost-effectiveness analysis for treatment measures

16. Coronary angiographies & revascularization procedures in developed countries Angiography Revascularization Number of procedures per million population Schilling et al 2003

17. Where does Out of Pocket Spending Go in China?

18. Long hospital stays suggest need for modernizing treatment, changing hospital payment, and moving care to lower levels Source: WHO 2005. Average length of stay in acute hospitals (ALOS)

19. Constraints in integrating health care into PHC • Essential interventions identified • Management Guidelines developed • Training of the health workforce initiated but often not sustained • Ineffective monitoring and evaluation

20. Constraints in health information systems • Good progress in risk factors surveys over the last decade but NCD surveillance systems are still generally weak in member States • No consensus on key components of an NCD surveillance system and lack of standardized indicators to monitor NCD trends at national and global levels – duplication/inconsistencies • When it exists, NCD surveillance work is not institutionalized and rarely integrated into the national health information systems of LMICs • Limited capacity in epidemiology and surveillance in Member States • Limited capacity of WHO and partners

21. Major Gaps in Treatment 2003-2005 Overall Percentage in 10 countries Drugs Percentage WHO PREMISE 2003

22. Affordability (WHO 2006) Number of days' wages for 1 month medicines after a heart attack Days

23. Low public sector availability leads patients to the private sector, where medicines are unaffordable

24. Reliance on originator brand products makes treatment more unaffordable

25. Differences in the availability of selected medicines for acute and chronic conditionsResults from 50 medicine price and availability surveys undertaken using the WHO/HAI methodology in 40 countries (2003 – 2008) Source Roubos I 2010

26. High prices, low availability and poor affordability can have many causes • Low public sector availability: • lack of resources or under-budgeting • inaccurate forecasting • inefficient procurement / distribution • low demand/slow-moving products • High private sector prices: • high manufacturer’s selling price • high import costs • taxes and tariffs • high mark-ups

27. Many policy options exist • Improve procurement efficiency • Ensure adequate, equitable, and sustainable financing, e.g. • Health insurance systems that cover essential medicines • Make chronic disease medicines available in the private sector at public sector prices • Prioritize medicine budget, i.e. target widespread access to a reduced number of essential generic medicines for NCDs, • Promote generic use: • preferential registration procedures, e.g. fast-tracking, lower fees • ensure the quality of generic products • permit generic substitution and provide incentives for the dispensing of generics • educate doctors/consumers on availability and acceptability of generics

28. Policy options (cont'd) • Provide tax exemptions for medicines • Where there is little competition, consider regulating prices

29. NCD surveillance systems: key components Dr Ala Alwan Assistant Director-General World Health Organization

30. Recommendations from the ERG and WHO staff Framework for a national NCD surveillance system • Exposures (Risk factors) • Behavioral and dietary/nutritional risk factors • Physiological and metabolic risk factors • Outcomes • Mortality • Morbidity • Health System Response • Interventions • Health system capacity Determinants of Health • Education, Gender, Material well being … What is Core?

31. Surveillance indicators An indicator should be • central to NCD with an established science base • modifiable as a result of intervention • measurable with valid tools • feasible and affordable to collect • practical and achievable within a country's technical capacity • acceptable (culturally) • policy relevant

32. Activity to date on Surveillance • Development of Objective 6 Implementation Plan (January 2009) • Expert Reference Group for NCD Surveillance and Monitoring established (February 2009) • Development of tools for monitoring NCD trends, progress and country capacity (ongoing from February 2009 with data collection underway in 2010) • Meeting of Expert Reference Group on key components of a national NCD surveillance system (April 2009) • NCD Surveillance meeting with HQ Clusters, Regional Advisers, representatives of the Epidemiology reference Group (August 2009) • Overview document in preparation dealing with technical issues for national NCD surveillance systems development • Third Global Survey on Assessing National Capacity for NCD Prevention & Control

33. Conclusions and Lessons learned • There are three key components of a national surveillance system that need to be monitored: risk factors and determinants, morbidity, and cause specific mortality. • An additional element is to assess health system capacity and response • A major gap in obtaining reliable cause specific mortality data from at least half of WHO’s member states- This calls fro scaling up work in assisting countries to strengthen mortality statistics. In the meantime, countries can consider verbal autopsy methods • For an NCD surveillance system to be effective in advocacy, policy development and M&E, it has to be integrated into the NHIS.It requires long-term funding • NCD surveillance systems need to be legally constituted by a central level of government which can provide the necessary legal framework of legislation and regulation for the system to be able to function • There is a pressing need for a network of collaborating centres and experts adopting a standardized approach to NCD surveillance to assist countries in building their information systems • There is an urgent need for international collaboration in the area of NCD surveillance

34. First Global Status Report on NCDs (Dec 2010) Why are the poorest people in low- and middle-income countries affected the most? What will NCDnet be doing? Objective 6 – WHO's progress to date Surveillance tool (2009): Country capacity assessment Data collection in 193 Member States (2009/2010) Data analysis (2010) Assessing trends in mortality, morbidity and risk factors (data will be derived from existing WHO data sources)

35. Lessons • Essential interventions in primary care • Task shifting required • Capacity building • Need for integrated approaches (similarities in secondary prevention of stroke/MI) • Overuse of invasive interventions • Evidence on affordability/effectiveness needed • Realities in LMIC –Implementation gap