Prof. Masami MATSUDA , Dr.H . Sc. , Prof. of P ublic Health, Dep. of Health Nutrition,

1. PNC 2103 ,Kyoto Univ. Japan, Dec.11th, 2013 Area informatics in community health policy & system development to cope with changing health needs in South East Asia Prof. Masami MATSUDA, Dr.H. Sc., Prof. of Public Health, Dep. of Health Nutrition, Tokyo Kasei-gakuin University

2. The recent development process of community health policy & health system change in Thailand show the position as the leading case of the area informatics in health field in South East Asia. From the viewpoints of health status & policy reports on global health such as in WHO (World Health Organization: United Nations’ Technical Agency in Health established in 1948), the current innovative programmer of TCNAP/RECAP on community health, nursing & information system in Thailand will be overviewed in the framework of international trend to understand the meaning of those activities in world health. The overview of framework in international health include such as 1.Primary Health Care in 1978 (Alma-Ata Declaration) & Primary Health Care 2008 (The World Health Report 2008, PHC: Now more and ever, 1)universal coverage, 2)primary care,3)public policy, and 4)leadership & government), 2.Health Promotion in 1986 (Ottawa Charter), 3.NCDs (the Political Declaration on Noncommunicable Diseases adopted by the UN General Assembly in 2011), 4.SDH (Rio Political Declaration at the World Conference on Social Determinants of Health in October 2011 in Rio de Janeiro, Brazil & Conceptual framework on Social determinants of health inequities,2010:CSDH) ,5.Global health risks,2009(WHO) & GBD (Global Burden of Disease) 2010 (Institute for Health Metrics and Evaluation).

3. The position of Data analysis and informatics in current innovative health activities in South East Asia is on the frontline in community health planning & policy implementation from the health statistics in national level. The content of health data in community include not only quantitative data but also qualitative data and how to marge those data is the critical issue in the actual field to cope with changing health needs such as aging, lifestyle diseases, NCDs. The factors which affect health policy change are the emerging four changes in population structure & social environments, such as rapidly aging society, epidemiological transition, risk behaviors & economic crises. The current health activities of TCNAP in Thailand are ample examples of the five sectors (1.Community empowerment, 2.Health literacy and health behavior, 3.Strengthening health systems, 4.Partnerships and intersectoral action, 5.Building capacity for health promotion) of the 7th Global Conference on Health Promotion, Kenya, 2009.

4. Change of Community & health issue in 40 years • Disease structure (DM, hypertension, cancer) • Lifestyle(obesity) • Economic development • (4C: Car, Cooler, Calar TV, Computer) • Autonomy in local government • Information revolution-personal computer • Educational level • Globalization • Loan, increasing debt • Aging • Disabilities: ＩＣＦ（International Classification of Functioning, Disability and Health）May,2001（ＷＨＯ）,1980 ＷＨＯ（ＩＣＩＤＨ）, ICD(International Statistical Classification of Diseases) to Health & • Indicators from death rate to DALY

5. PHC in 1978-2000 • Health: infectious diseases (Diarrhea, TB, AIDS) • Development: occupational training, water supply, etc. • Information: IEC • Participation: to Care provision such as VHV(health volunteer ) • GIS: nothing • Equipment in community: few telephone, no computer, • Manpower: PHC worker but no RN/NP

6. Development of Nursing Practitioner and Community Nurse in Thailand Sources of Fund Primary Health Care (Until 2000) Universal coverage scheme (2001-2007) Health Security (2007-2013) ?? Merging of Health Funds Started the bachelor degree program The National Health Care Reform and the Universal Health Care Coverage System was implemented , demanded NP in PCU = 15,000 prs. Demanded on Neonatal NP Needed more CN belonging to community National Health Security office , Thailand signed MOU with TNMC to produce NP 10 yrs to response the needs at PC level Not enough doctor specialists to meet the needs of the peopleand lacked of skill nurses to screen and provide basic Tx to eyes pts Needed students to diagnosed and screening to work in rural but no competent teacher To comply with the regulations of government. Demanded on ER NP to be able to manage cases Program of Nursing of Community students started at FON/KKU Asean Economic Community Demographic impact of the HIV/AIDS epidemic Lacked of Community Nurse who could provide screening and treatment Needed more institutes to produce NP Thailand Economic crisis/IMF NP’s performances were unacceptability by the physicians. 2008-2014 2007 1979 1970 1977 1980-1981 1984 1988 1990 1997 2002 2004 2005 2015 2001 Established th 3rd- formal program 6 m for ER-NP for Faculty of Medicine, Ramathibodi Hosp, Mahidol Uni. MoPH released regulations for NPs to provide treatment legally. Established the 1 year course for th 1st- formal Program to train nurses at the Department of Public Health Nursing, Faculty of Public Health, Mahidol University Established th 2rd- formal program 6 m. eye-NP program, by a physician from the Dept. of Ophthal. in collaboration with Dept. of Nursing, Faculty of Medicine, Ramathibodi Hosp., Mahidol Uni. Established th 4rd- formal program 4 m for Neonatal-NP to work on growth, development, overall health of newborns Nursing institues in Thailand provided 4 m. NP course and 2 Yrs. for Advance nursing practice (APN) -a master degree Started the 6 M NP course under physician authorities at Ramathibodi School of Nursing, Mahidol University First group of selected students by community learned at FON/KKU Expanded to Local Admin. Org.+ private sector for funded selected students Th 3rd- formal program reduced to 4 m for ER-NP Stopped th 1st- formal programtraining activities The Thailand Nursing and Midwifery Council (TNMC) took the lead in responding to this need. Able to produce the undergrade CN apporx . 20prs./yrs. To return to their communities Be a NOC model. Other 26 NU institutes apply this idea. Able to produce NP 1000 prs/ yr and APN of community 250 prs/ yr Faculty members and nursing staff= 4 NPs Produced ER-NP Produced 12 groups (apprx.10-15 nurses/gr.) Apprx. 700 people produced totally Produced Neonatal-NP Produced and entitled the ‘Public Health Nurse Practitioner Program” 4 m for ER-NP course Sources: Khanitta Nuntaboot, 2007; Somchit Hanucharunkul,2007

7. タイの保健システム発展の外的・内的要因 Her Royal highness Princess Sirasm, Royal Consort of His Royal highness Crown Prince Mahavagiralongkorn The Ottawa charter for Health Promotion Bangkok charter for health promotion The Nairobi charter for health promotion Health Risk /Health demands • Economic crisis • Thai Royal election/political party’s interest • Demanded on decentralized Public Health Ministry Policy Constitution of Kingdom of Thailand Ministry of Social Development and Human Security Policy 2012 2007 2008 2001 2009 1986 2005 2010 1999 School Health Policy Healthy Thailand’ policy Oral Health Promotion Saiyairak project 地方分権化の開始（市町の自治権） Millennium Development Goal ユニーバル・ヘルス（国民皆保険）制度の開始 タイヘルス・プロモーション財団の設立 国民保健法 参考　KhanittaNuntaboot

8. オタワ憲章・ヘルス・プロモーション(HP) タイの保健システム発展の外的（図上）・内的（図下）要因（1986-2013） ナイロビ憲章HP バンコク憲章HP ミレニアム開発目標 経済危機 2012 2010 2007 2008 2001 2009 1986 2005 1999 憲法改正 王立健康増進プロジェクト 健康タイ政策 公衆衛生省政策の革新 社会保障省の新政策 地方分権化の開始:市町の自治権 ユニーバル・ヘルス（国民皆保険）制度の開始 国民保健法 タイヘルス・プロモーション財団の設立 参考　KhanittaNuntaboot

9. タイのNursing Practitioner と地域看護師の発展過程 Primary Health Care (Until 2000) Universal coverage scheme (2001-2007) Health Security (2007-2013) IMF経済危機 学部の看護教育開始 HIV/AIDS の広がり NP /PCU が 15,000名必要 NPの質が問題化 2008-2014 2007 1979 1970 1977 1980-1981 1984 1988 1990 1997 2002 2004 2005 2001 年間 1000 人のNP と 250 人の地域APN Advance nursing practice NPの養成700名で停止 ｺﾝｹﾝ大で地域NP　　養成 公衆衛生省NPの治療を許可 学部の地域看護強化 NPの養成開始 救急 ER-NPの養成 新生児NPの養成 保健師 NP 眼科NP 参照:KhanittaNuntaboot, 2007; Somchit Hanucharunkul,2007

10. TCNAP in 2009-2012 • Health: lifestyle diseases (DM ,hypertension, cancer),Aging, disability • Development: economic development (from bicycle to car in local area) etc. • Information: information system • Participation: in all revel of decision making (from data collection, analysis, policy) • GIS: challenging • Equipment in community: mobile telephone, computer, camera,PHCunit(curative care & preventive care) • Manpower: RN,NP

11. Comparison of TCNAP with PHC PHC in 1978-2000 TCNAP in 2009-2012 Health: lifestyle diseases (DM ,hypertension, cancer), Aging, disability Development: economic development (from bicycle to car in local area) etc. Information: information system Participation: in all revel of decision making (from data collection, analysis, policy) GIS: challenging Equipment in community: mobile telephone, computer, camera, PHC unit(curative care & preventive care) Manpower: RN,NP • Health: infectious disease • Development: occupational training, water supply, etc. • Information: IEC • Participation: to Care provision such as VHV(health volunteer ) • GIS: nothing • Equipment in community: few telephone, no computer • Manpower: PHC worker but no RN/NP

12. Change the health & welfare system with rapidly aging society What is the factor to change the role of PHNs & health system ? • Population structure(Aging) • Disease structure (cause of death, communicable diseases, NCDs) • Risk factors(life style ) • Economic conditions

13. Community data base in health promotion policy making with Multi-sectoral Collaboration & Multi-stakeholders Partnership

14. % High blood pressure 12.8 Tobacco use 8.7 High blood glucose 5.8 Physical inactivity 5.5 Overweight and obesity 4.8 High cholesterol 4.5 Unsafe sex 4.0 Alcohol use 3.8 Childhood underweight 3.8 Indoor smoke from solid fuels 3.3 59 million total global deaths in 2004 % Childhood underweight 5.9 Unsafe sex 4.6 Alcohol use 4.5 Unsafe water, sanitation, hygiene 4.2 High blood pressure 3.7 Tobacco use 3.7 Suboptimal breastfeeding 2.9 High blood glucose 2.7 Indoor smoke from solid fuels 2.7 Overweight and obesity 2.3 1.5 billion total global DALYs in 2004 Leading causes of attributable global mortality and burden of disease, 2004 (WHO) Attributable Mortality Attributable DALYs

16. GBD2010

17. Nature of Change • Quantitative change (such as 10 % to 15% increase, 50 % to 35 % decrease) • Qualitative change(epidemiological transition, health transition, population transition) • Speed( low, high, very high) • Aging (Slow Speed: Quantity, Quality: Europe) • (High Speed: Japan, Asia, other countries) • Age: 0,5,10,15,20,30,40,50,60,70 • : 0,5,20,40

18. Globalization of unstable- welfare state such as Japan which is rapidly Aging society with family collapse There are four types of welfare states in sociology. Japanese health & welfare system is a mixture of four welfare states. 1.Libertarian type(Market system) : US, Canada, Australia In Japan; Fee- for Servicein medical care mixed with social insurance 2.Beveridge-libertarian type (National minimum) : UK In Japan; Welfare system for child care, elderly care, disability care 3.Social insurance type : Germany, France, Italy In Japan; National Medical Care Insurance from 1965 National Care Insurance for aged from 2000 4.Scandinavian type(De-commercialization of labour with maternity leave, parental leave & educational leave) : Sweden, Denmark, Finland, Norway In Japan;??? (Esping-Andersen, The three worlds of welfare capitalism, Polity press, 1990) (Kenichi Tominaga, Welfare state in social change, p156-157, Chuokouron-shinsha, 2001 in Japanese)

19. Socio-economic condition and population aging 1947; Social Right (Beveridge-libertarian ) in the new constitution of article 25 1950’; Priority is recovery of economy (Libertarian ) 1961 ; National health insurance and pension system (toward Beveridge-libertarian type) 1973 ;Starting point of welfare state (strengthen Beveridge-libertarian type) (Matsuda in Tokyo University) 1982 ; budget cut(Libertarian) (Matsuda in Graduate school of Tokyo Univ. & in MahidolU.,Thailand) 1989-2000; Gold plan for the Aged and care insurance scheme for the Aged requiring nursing care (Scandinavian type or Social insurance type) (Matsuda in RITB & U.Shizuoka) 2001-2013;Libertarian with budget cut (Matsuda in U.Shizuoka, Care of my mother, in U. Kasei-gakuin) (K. Tominaga, Welfare state in social change, p182-196, Chuokouron-shinsha,2001 in Japanese)

20. Rapidly Aging Society-speed of Aging 2-4 times ( 7%→14%Japan 25 years、Europe, US 45～115 years 10%→20%Japan 21 years、Europe, US 43～ 86 years) 7% to 14% 10% to 20% canada USA Italy France Japan

21. Rapidly Aging Society-Japan as a Model of Countries in Asia, Latin America & Eastern Europe in future Japan Japan USA,EU Thailand,Korea,Singapore,China,Indonesia

22. How to cope with Rapidly Aging Society like Japan • Do not rely on the western model of aging society but try to create own activities based on each community settings. • Change the target of health & welfare services from the longevity of life to healthy life expectancy plus QOL(Quality of Life).(Development of New data system) • Putting together the experiences of PHC (TB control, MCH) into NCDs prevention with emphasis on health promotion with academic society: JAHWP.(Reform Health & Welfare System and Society)

23. Policies influencing health promotion scheme in Thailand Her Royal highness Princess Sirasm, Royal Consort of His Royal highness Crown Prince Mahavagiralongkorn The Ottawa charter for Health Promotion Bangkok charter for health promotion The Nairobi charter for health promotion Health Risk /Health demands • Increasing prevalence of chronic illness • Changing demographics of aging adults • Risk Behavior i.e.smoking Alc. Drinking, Changing diet habit and unsafe sex practices • Economic crisis • Thai Royal election/political party’s interest • Demanded on decentralized Public Health Ministry Policy Constitution of Kingdom of Thailand Ministry of Social Development and Human Security Policy Thai Royal Government Policy Statement 2012 2007 2008 2001 2009 1986 2005 2010 1999 Launching of the Universal Health Coverage Scheme Establishment of the ThaiHealth Promotion Foundation as a HP funding mechanism Embraces the principle and direction of health promotion School Health Policy Healthy Thailand’ policy National Health Act Oral Health Promotion Saiyairak project Decentralization started Millennium Development Goal Embraces the principle of human rights and key principles of the Ottawa Charter in 2005. It is a result of five years of extensive public dialogues on important health issues that enhanced public awareness and nation wide networking on health promotion Cost USD 2 billion for health promotion activities a year • Draws upon a 2 percent surcharge levied on alcohol and tobacco excise tax, approximately USD 50-60 million a year • ThaiHealthfunds programs health risks/issues such as alcohol, tobacco, accidents, exercise, as well as area or setting based programs, for example, school, work place, community, and programs that target specific population groups such as the youth, the elderly, Muslim community • Open grants program invites proposals from all kinds of organizations/groups interested in launching HP initiatives • Breast feeding policy • Baby friendly hospital • Mother-Child policy • Child care center/ Kindergarten • Teenage health promotion ( Pregnant, Youth council from school-to-University) • Healthy working place • Woman Health (Violence, CA screening) • Health promotion • The "3 Generations Weave Family Love” Center • Elderly people club • Accident and Emergency prevention • National institute of Emergency medicine/Disaster management • Decentralization to LAO (Authorities and fund) • Sub- district fund allocation • Control social determinants to health • Welfare to population • Largest aerobic display • Against drunk driving and controls on tobacco • Thailand is committed to reducing substance

24. GBD2010

25. GBD2010

26. GBD2010

27. GBD2010

28. Role of public health • Policy, quality assurance, evaluation(ABM) • traditional public health practitioners and institutions are reaching out (or could reach out) to the public through social media. "Public Health 2.0" is used to describe public health research that uses data gathered from social networking sites, search engine queries, cell phones, or other technologies.(Wiki)

29. Brief History; PHN Role(3) • Contemporary roles • Community Developer • Facilitator of self-health promoter/self-help • Resource Manager • Policy Formulator • Remarkable topics today :lifestyle disease, frail elderly • Community level activities • Health problems of the growing elderly population, so on • PHNs are using a variety of health promotion strategies • The role of PHN has become bigger and bigger in Japan. Feb. 5th 2009Katsumasa Ota

30. New role of head PHN in Shizuoka government for the policy in health promotion (Eguchi A.) • Several key health promotion concepts were identified in various health promotion initiatives. • The mindsets in PHNs’ activities became the driving force behind the initiatives. • In the development of health promotion initiatives, PHNs work proactively in order to understand the opinions and concerns of both municipalities and residents through a variety of channels. • By observing both the overall picture and disparities in health status in different areas, prefectural PHNs supported the “visualization” of processes involved in and results produced by initiatives undertaken by its municipalities, while also promoting the “visualization” of reliable health information. • PHNs created an administrative system for ensuring the effectiveness of initiatives. • Advancing community development through win-win partnership that exceeds the boundaries ofhealthsectorappears to be linked to positive participation in health promotion by both individuals and private corporations.

32. Box 1: Disability-adjusted life years (DALYs) DALYs are a common currency by which deaths at different ages and disability may be measured. One DALY can be thought of as one lost year of “healthy” life, and the burden of disease can be thought of as a measurement of the gap between current health status and an ideal situation where everyone lives into old age, free of disease and disability. DALYs for a disease or injury are calculated as the sum of the years of life lost due to premature mortality (YLL) in the population and the years lost due to disability (YLD) for incident cases of the disease or injury. YLL are calculated from the number of deaths at each age multiplied by a global standard life expectancy of the age at which death occurs. YLD for a particular cause in a particular time period are estimated as follows: YLD = number of incident cases in that period × average duration of the disease × disability weight The disability weight reflects the severity of the disease on a scale from 0 (perfect health) to 1 (death). The disability weights used for global burden of disease DALY estimates are listed elsewhere (6). In the standard DALYs in recent WHO reports, calculations of YLD used an additional 3% time discounting and non-uniform age weights that give less weight to years lived at young and older ages (7). Using discounting and age weights, a death in infancy corresponds to 33 DALYs, and deaths at ages 5–20 years to around 36 DALYs.

33. Development of Healthy Japan 21st–National & Regional/Local Level(A.Eguchi)

34. Achievements of Healthy Japan 21st(1st Stage :2000-2012) National Level: Decrease the Smoking Rate of Male from 50 % to 35 % (still high) National Level: Decrease the Suicide Population from over 30000 per year to under of it in 2012 (-1997 over 20000, increased during 1998-2011 over 30000) Local Level: Average Prefecture of Shizuoka in any health & welfare outcomes became No.1 in healthy life expectancy in 2012(Male 71.68 years, Female 75.32 years)

36. Empower local city & town using area data on Smoking & heart disease-A Case of Shizuoka- (A.Eguchi) Example “Visualization of Health Indicators” Smokers (male) (2004-2008) Significantly lower Lower Higher Significantly higher Heart disease SMR (2004-2008) Significantly lower Lower Higher Significantly higher ※significant level P<0.05 ※significant level P<0.05 Smokers (female) (2004-2008) Source: Shizuoka Municipal Health Index, 19,2011 Source:2010 Report on Health Checkup and Guidance by Shizuoka Municipal, 2012

37. JAHWP compare with TCNAP;Community Strengthening Actions HP 10 Acts/law (Nishimoto) HFA21Japan,9 HPP,130 Targets 7 HPP Healthy Public Policy (84 proposals) TCNAP (1) RECAP Health : (1) Health care (2) Social Health Determinant Case; 1.Shizuoka Prefecture (Eguchi,et al) 2.Hachioji city (Noyama) 1. Disaster management 2. Learning & Education 3. Welfare 4. Health Care Environment & natural resources management Food security & organic agriculture Governance in administration of local government 1. Technical Team 2. Management Team 3. Communication Team 4. Mayor/Administrator Team Shimane; GIS-Social capital (Shiwaku, Hamano) Systems/Civil groups (SOJO method; Iwanaga) Management of effective Initiatives & Actions Outcomes & Impacts of initiatives & actions Multi-sectoral Collaboration Multi-stakeholders Partnership Alcohol Consumption 2. Smoking 3. Accident 4. Healthy Food (Shokuiku;eating education) 5. Physical Activity(100ys old Ikiiki; Horikawa) 6. Health Care (Economics, Politics) 7. Health Investment (Inequality & social divide) 8. Disastermanagement (Kobe,Fukushima) (Climate & Nuclear disasters)Etc. Evaluation of HFA21Japan 8+ Impacts of Health

41. PHN:Role in the pastHealth Systems in Transition Kozo Tatara, Etsuji Okamoto,WHO,2009 Health education For improvements in community involvement, it is essential to provide opportunities for residents to obtain information about health planning promoted in their community. This has yet to be fully implemented in Japan, although residents may have had such opportunities in the various actions for health education organized by public health nurses in their community. Reduction Long life expectancy in Japan is largely the result of a reduction in infant mortality and deaths from TB and cerebrovascular diseases. The recent decline in deaths from cerebrovascular diseases reflects the strong network of community activities, with an important role of public health nurses (Tatara et al., 1984).

42. Brief History; PHN Role(1) (truncated) • The first PHN activities started in 1920. • Prevalence of Tuberculosis; prevalence rate 223.7 • Main role; prevention and visiting care for TB patients, school nursing, et. al • The systemized education of PHN began • 1928 ; Japan Red-Cross • 1930 ; Japan Saint-luke’s Nursing School, so on. • PHN Act was established in 1941. • To promote health condition of the candidate for soldiers by the governmental request. Feb. 5th 2009Katsumasa Ota

43. Brief History; PHN Role(2) • After WW-II • Japanese health condition in general; so terrible • The American General Head Quarter GHQ re-organized Japanese nursing system and unified the legislation of nurse, PHN and midwife into one ACT.. • The conventional role of the PHN: • cutting off vicious circle of poverty and disease • prevention of disease • supporting the effort of self-improvement by residents, et. al. • An episode of the PHN in those days • PHNs completed successfully to give the poliomyelitis vaccine to 13 million children within a month in 1955. • This resulted in big contribution for termination of poliomyelitis in Japan, afterwards. Feb. 5th 2009Katsumasa Ota

44. Education System for Nurses 4-year Univ/ColBScNProgram RN PHN MW PHN 1-year PHN Course 3-year RN School DiplomaProgram RN 1-year MW Course MW 2-year RN School (JH grads need min. 3-year clinical exp.) High School 2-year LPN School LPN Junior High Feb. 5th 2009Katsumasa Ota

46. GBD2010