Integrating the care of NCD
into PHC
ECOSOC/UNESCWA/WHO
Doha, May 10th 2009
Nabil M Kronfol MD, DrPH
The Stake for NCD Control
• The health problems caused by NCDs are today
leading to premature death of more than 35
million people every year because of heart
disease, stroke, cancer, chronic lung disease
and other chronic health problems.
• Out of 58 million deaths estimated to take place
annually, more than 30% are caused by various
forms of heart disease, about 16% by cancer
and another 16% by other chronic diseases.
Message One
•
Evidence from many countries, both
industrialized and developing, show that
countries that have a health system
anchored on Primary care have better
health outcomes, including morbidity and
mortality indicators for NonCommunicable Diseases.
Evidence from Canada
• HCS based on PHC reduce health disparities, particularly for areas
with the highest income inequality, including improved vision, more
complete immunization, better blood pressure control, and better
oral health. (Lynn Wilson)
• Better access to general practice care offers reduced all-cause
mortality and mortality caused by cardiovascular and pulmonary
diseases
• More continuity of care leads to better management of chronic
disease
• GPs offer better preventive care
• A higher primary care physician supply leads to decreased
incidence and mortality caused by colon cancer, and improved
detection of breast cancer and cervical cancer
• General practice offers fewer tests, high patient satisfaction, less
medication use, with lower care related costs
• Adequate resources for general practice care offers reduced
emergency departments and hospital presentations with fewer and
shorter hospitalizations
The Evidence
• Many other studies done within countries, both
industrialized and developing, show that areas
with better primary care have better health
outcomes, including total mortality rates, heart
disease mortality rates, and infant mortality, and
earlier detection of cancers such as colorectal
cancer, breast cancer, uterine/cervical cancer,
and melanoma. The opposite is the case for
higher specialist supply, which is associated with
worse outcomes (Starfield).
Lessons Learned From International Experience
• NCDs are preventable through interventions against their
risk factors
• Strategies to reduce established risk factors should be
combined with strategies to prevent the emergence of
risk factors
• To have an impact, interventions should be of
appropriate intensity and sustained over extended
periods of time
• Success requires community participation, supportive
policy decisions, legislation, and health care reforms
• More health gains are achieved by influencing public
policies in other sectors like trade, education, agriculture,
food production, urban development and taxation than
by changes in health policy alone.
Message No Two
• There is evidence that primary health care
systems that support decentralization,
community empowerment, an integrated referral
system and universal coverage have achieved
better outcomes for the promotion of health, the
prevention of chronic illnesses, the screening for
NCD and the care of patients afflicted with NCD.
There is a need for health systems to evolve and
adapt to address the risks of NCD.
Decentralization
• ‘Everybody’s Business’, (WHO 1998)
suggested that lack of progress with PHC
implementation, and poor outcomes, can
often be attributed to a reluctance to
decentralise authority to local levels, a
failure to move resources between
curative, promotive and preventative
activities and a weak capacity in social
epidemiology and health services
research.
A different paradigm for health
systems
• The burden of chronic diseases is high in low-income and
middle-income countries and is predicted to increase with the
ageing of populations, urbanisation, and globalisation of risk
factors.
• An integrated approach to the management of chronic
diseases, irrespective of cause, is needed in primary health
care.
• Management of chronic diseases is fundamentally different
from acute care, relying on assessment of risk factors,
detection of early disease and identification of high risk status;
• A combination of pharmacological and psychosocial
interventions and long-term follow-up.
• To meet the challenge of chronic diseases, primary health
care will have to be strengthened substantially.
Vertical programs versus PHC
• Gish:“Alma-Ata affirmed health as a human right and
sought to have interventions focus on the underlying
social, economic and political causes of disease and
illness as well as for comprehensive health care.
• Mahler: ” Vertical programs do not do this. We were
crushed by the IMF. The hammer that was used to crush
us was the vertical intervention – ‘selective primary care’.
• Cueto: “Vertical programs make it appear that we are
“helping”, while in fact we are undermining political
interventions that deal with the underlying causes of
disease.
• Even if vertical programs improve indicators widely, they
do not fundamentally change power relationships or the
underlying social structures that are the ultimate cause
of diseases”.
Effective interventions for NCD
• Usual medical care often fails to meet the needs of
chronically ill patients, even in managed, integrated
delivery systems. The medical literature suggests
strategies to improve outcomes in these patients.
• Effective interventions tend to fall into one of five areas:
the use of evidence-based, planned care
Reorganization of practice systems and provider roles
Improved patient self-management support
Increased access to expertise; and
Greater availability of clinical information.
• The challenge is to organize these components into an
integrated system of chronic illness care (Wagner et al).
Cardiovascular Diseases
• “This report paints a clear and strong argument that
we need now to increase the attention we give to
cardiovascular disease in low- and middle- income
countries because of the health and economic
impacts.
• This argument becomes even stronger in light of the
emerging demographic profile of the world, where
every nation is facing a change in its age structure
• The time to act to minimize the impact of chronic
disease is now, both to protect today’s work-forces
and to diminish the burden of costly disability in the
future. (The Earth Institute Report)
Message No Three
• Controlling Non-Communicable diseases
requires active participation from
individuals, communities and Government.
NCD intervention necessitates Legislation
from several Ministries to create an
environment that supports prevention and
sustainable actions.
Strong Government Commitment
• NCDs are already the leading health problems and are on the rise
• Market forces will further promote tobacco use, unhealthy diet.
• NCD prevention cannot be considered an issue of personal choices
and behavior. The Role of the Government is key and action by
various sectors is mandatory
• Cost-effective interventions exist and can be implemented at the
PHC level.
• Initial response should include establishment of a surveillance
system and initiate policy changes as early as possible
• Integrating interventions into PHC is effective but health systems
needs to be strengthened
• There is a need to develop a conducive environment which requires
action by all sectors and requires legislation and regulation
• This requires a strong role and responsibility for the government.
Message No Four
• Addressing NCD necessitates a
performing health workforce that is well
prepared and incentivized to respond to
the needs of patients for care (including
self care and home care) and for
information and communication.
Importance of Communications
• Patients want better communication. Instead of
receiving a physical examination or a prescription,
patients would rather spend precious time with their
doctors discussing their conditions and hearing about
ways to stay healthy.
• Three specific areas that patients want their doctors to
emphasize: Communication, Partnership and Health
Promotion
• Patients wanted an open discussion of their feelings
about treatments in order to reach cooperative decisions
• Patients wanted to learn about ways in which they can
improve their health or prevent future illness
• Fewer patients wanted an examination and only a
quarter of those surveyed wanted a prescription.
Coordination of care
• Coordination between care providers of different disciplines is
essential to improve the quality of care, in particular for
patients with chronic diseases (Haggerty et al) .
• The way in which general practitioners (GP’s) and medical
specialists interact has important implications for any
healthcare system in which the GP plays the role of
gatekeeper to specialist care (the Netherlands and the UK).
However, in countries without a gatekeeper system,
coordination of care is a concern as well (Shoen).
• A large European study showed that patients in different
countries value different aspects of healthcare (Groenwegen).
‘Being taken seriously’ is generally regarded as most
important and ‘waiting time the least important.
• “When evaluating the transition from primary to secondary
care and vice versa, we need to have a thorough knowledge
of the experiences and preferences of patients”.
The cost of caring
• The rise of chronic diseases has
uncovered further problems: the burden of
long-term care on health systems and
budgets, the costs that drive households
below the poverty line, and the need for
prevention in a situation in which most risk
factors lie outside the direct control of the
health sector. In other words: fairness,
efficiency, and multi-sectoral action.
Catastrophic Impact
• Cost studies are scarce, but in middle-income countries,
the cost of illness not only represents much of the direct
costs of medical care, but also has an impact on family
disposable income.
• Studies have reported that in low-resource settings,
given incomplete health coverage and partial insurance,
out-of-pocket expenses are high. Persons with chronic
conditions often have to forego care because of their
inability to pay.
• This warrant attention from poverty-reduction programs.
• Evidence shows that to have an impact on the burden of
chronic diseases, action must occur at three levels:
population-wide policies, community activities, and
health services.
The impact of NCD
• Chronic diseases in 23 countries were
responsible for 50% of the total disease
burden in 2005.
• If nothing is done to reduce the risk of
chronic diseases, an estimated US$ 84
billion of economic production will be lost
from heart disease, stroke, and diabetes
alone in these 23 countries between 2006
and 2015. (Abegunde et al study)
Summing up the evidence: The OECD
Review
• The strength of a country's primary care system was
negatively associated with (a) all-cause mortality, (b) allcause premature mortality, and (c) cause-specific
premature mortality from asthma and bronchitis,
emphysema and pneumonia, cardiovascular disease,
and heart disease.
• This relationship was significant even while controlling
for macro-level (GDP per capita, total physicians per one
thousand population, percent of elderly) and micro-level
(average number of ambulatory care visits, per capita
income, alcohol and tobacco consumption) determinants
of population health.
• Conclusions: “Strong primary care system and practice
characteristics such as geographic regulation,
longitudinality, coordination, and community orientation
were associated with improved population health”.
The Doha Declaration Nov 2008
The Member States express their highest level of commitment to:
• Strengthen the decentralization of the health system
• Establish and/or scale up family practice models
• Ensure integration of vertical programs into primary health care
• Promote healthy lifestyles
• Ensure community-oriented training programs for a health workforce with
appropriate skills mix
• Ensure good remuneration and clear career paths to encourage the health
workforce into primary health care;
• Expand the role of primary health care workers as community leaders
• Strengthen partnership for primary health care between government, civil
society, community leaders, academia and the private sector;
• Monitor and evaluate health system performance through the development
and use of national health information systems and national and regional
health observatories
• Promote policy and health systems research, community-based
participatory research and knowledge translation for evidence-based policymaking.
To sum up
• ''If we didn't already have primary care
medicine, we'd just have to invent it. It's
the way we want to be cared for.'' (Allan
Goroll)