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Preventing premature mortality from CVD: a risk based approach (Targets: 25% relative reduction in 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. , Ph. D. Coordinator, Management of NCDs (MND/NVI)

Objectives and structure • Objectives – How to strengthen NCD management within NCD prevention 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

9 global NCD targets to be attained by 2025 (against a 2010 baseline) A 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 a 10% relative reduction in the harmful use of alcohol A 30% relative reduction in mean population intake of salt/sodium A 30% relative reduction in prevalence of current tobacco use Halt the rise in diabetes and obesity A 10% relative reduction in prevalence of insufficient physical activity An 80% availability of the affordable basic technologies and essential medicines, incl. generics, required to treat NCDs A 25% relative reduction in prevalence of raised blood pressure or contain the prevalence of raised blood pressure At least 50% of eligible people receive drug therapy and counselling to prevent heart attacks and strokes

NCD progression and implications for prevention and control Po Healthy pu lat ion Risk NCD progression and implications for prevention and control Po Healthy pu lat ion Risk factors to High risk be NCD Health promotion Health and economic burden co ve re Complications Risk reduction d Rehabilitation Treatment Progression of NCD Psycho-social support

NCD CCS 2013 Results: management guidelines for NCDs and risk factors (Availability and implementations) NCD CCS 2013 Results: management guidelines for NCDs and risk factors (Availability and implementations) Surveillance and Population-based Prevention Department of Prevention of Noncommunicable Diseases

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

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

NCD Management within NCD national plans Management Prevention Tobacco Diet/PA/Alcohol Treatment Mechanism, linkage, surveillance NCD Management within NCD national plans Management Prevention Tobacco Diet/PA/Alcohol Treatment Mechanism, linkage, surveillance

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

Preparing for PEN • Mo. H agreement • National PEN/NCD in PHC steering group Preparing for PEN • Mo. H agreement • National PEN/NCD in PHC steering group – Mo. H, 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

Phased approach Ø Phase 1: Conduct situation analysis Ø Create a conducive policy environment: Phased approach Ø Phase 1: Conduct situation analysis Ø 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 Ø Phase 2: Address key gaps and strengthen the health system as far as possible – Demonstration site Ø Phase 3: Achieve optimum NCD care within the constraints of the situation Ø Estimate the cost of scale-up and track resources Ø Identify/correct missed opportunities Ø Integrate vertical disease-specific primary care programmes (e. g. on hypertension, diabetes) Ø Phase 4: Systematic scale-up and monitoring Ø Ø 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

Phase 1 – Situation analysis • It is useful to review the current NCD 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?

? Lack of knowledge ? Goes to health center for check up; medicines prescribed ? Lack of knowledge ? Goes to health center for check up; medicines prescribed for 3 weeks and review Purchased only for 3 days (expensive), consumed for 2 days, and left the rest in a bottle After 2 yearssymptoms ? ? ? l to ed sh a spit o h Ru No symptoms/ no time/ no money Had stroke, ends up paralyzed

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

Core Set of WHOPEN Interventions WHICH INTERVENTIONS DO YOU WANT TO INCLUDE? IF THEY Core Set of WHOPEN Interventions WHICH INTERVENTIONS DO YOU WANT TO INCLUDE? IF THEY ARE AVAILABLE, ARE THEY MEETING THE TARGETS, CAN THEY BE STRENGTHENED?

JNCI 7 (Joint national committee on prevention, detection, evaluation and treatment of high blood 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.

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

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

Performance of WHO/ISH charts in predicting CVD risk of individuals • First set of 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.

Coverage • CVD risk assessments – for people with ‘NCD’s attending health facilities – 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 NCD PHC + Population

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

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

HEARTSCORE HEARTSCORE

Score Score

Referral Referral

Alternative risk prediction methods when blood tests are not feasible • Global data are 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.

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

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

NIH risk score http: //cvdrisk. nhlbi. nih. gov/eval. Data. asp NIH risk score http: //cvdrisk. nhlbi. nih. gov/eval. Data. asp

HEARTSCORE EUROPE http: //www. heartscore. org/Pages/online. aspx HEARTSCORE EUROPE http: //www. heartscore. org/Pages/online. aspx

Cardiovascular Risk charts – recalibration • The methodology of recalibration is based on the 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.

WHO recommendations on screening (under development) Targeted screening for cardiovascular risk with blood glucose 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.

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

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

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

Identify the Stakeholders State-Level • Ministry of Health • Ministry of Finance • Ministry Identify the Stakeholders State-Level • Ministry of Health • Ministry of Finance • Ministry of Social welfare • Political leaders at state or division-levels Local/ Community. Level • Local political leaders • Community leaders • Public sector health providers • Private sector health providers Other Sectors • NCD Specialists (cardiologists, internists) • Media • Research groups or academic institutions • Civic groups or healthoriented NGOs

Stakeholder Analysis Key Stakeholders Support High ------Mod Neutral Opposition High------Mod Political Sector: National Public Stakeholder Analysis Key Stakeholders Support High ------Mod Neutral Opposition High------Mod Political Sector: National Public Sector Ministries of Health Central Level Local Level Minister of Finance MOH Prov’l Director Informal Sector Private Practitioners Academic/ Teaching Medical Asstn A NGOs Source: Schmeer, Kammi. Guidelines for Conducting a Stakeholder Analysis. Nov 1999. Bethesda MD: Partnerships for Health Reform, Abt Associates, Inc.

Phase 2: Address key gaps and strengthen the health system as far as possible- 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

Demonstration Site PHC Referral Hospital DISTRICT HOSPITAL CHW Demonstration Site PHC Referral Hospital DISTRICT HOSPITAL CHW

Service delivery model Referral hospital • Management of complications • Supportive supervision of lower Service delivery model Referral hospital • Management of complications • Supportive supervision of lower levels Health centre with MO/NP • CVD risk assessment • Management of uncomplicated cases Village health worker • Tobacco control • Health education, compliance to treatment • Foot care

Referral Thresholds (as per national context) DH PHC w/ MD PHC w/o MD CHW Referral Thresholds (as per national context) DH PHC w/ MD PHC w/o MD CHW Acute events (e. g. MI, CVA), Specialty Units eg Acute MI or Acute Stroke Unit Linkage with other services Known CVD; Angina, claudication; Worsening heart failure; Raised BP ; Any proteinuria Newly diagnosed DM DM which is uncontrolled or w/ complications Age > 40 yrs, Smoker, Central adiposity, Raised BP, Diabetes and a Family History of hypertension, stroke or heart attack, diabetes or kidney disease

Capacity building • Programme managers – What is needed for the service model – 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

Schematic diagram of Capacity Building Schematic diagram of Capacity Building

Health system support • Many countries are redefining tasks, developing new service delivery and 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

Continuing Care in the Community (Volunteers linked to health system) • • • Emotional 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

Guideline development, implementation, review Guideline development, implementation, review

WHO Guidance to countries on treatment thresholds and improving access to medicines • All 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

National guidelines • National guidelines are better developed at country level with leading clinicians National guidelines • National guidelines are better developed at country level with leading clinicians and experts in the country. • This will have more acceptance in the country. • WHO can facilitate national guideline development. • They will not be WHO guidelines, but national guidelines.

Process monitoring • Numbers of patients: screened, foot care inspections, advised/treated • Health centres: Process monitoring • Numbers of patients: screened, foot care inspections, advised/treated • Health centres: returning data, overall patient numbers, implementing PEN, private facilities, medicine useage, availability tobacco cessation

Impact monitoring • PEN adherence, private health care facilities involved, stock-outs, eqpt issues • Impact monitoring • PEN adherence, private health care facilities involved, stock-outs, eqpt issues • Patients returning for follow-up/scoring changes. • Coverage with screening and treatment • PEN community activities

Outcome monitoring • Existing data: – Number heart attacks and strokes, amputations – Mortality Outcome monitoring • Existing data: – Number heart attacks and strokes, amputations – Mortality CVD, cancer, COPD – Cancer registry data

Dashboard for health facilities Dashboard for health facilities

Personal score cards Personal score cards

Cause of death certification Cause of death certification

Phase 3: Achieve optimum NCD care within the constraints of the situation • In Phase 3: Achieve optimum NCD care within the constraints of the situation • In the current situation, which level of health care service can implement PEN? • First priority should be to ensure management of patients currently attending health facilities. • Instead of single risk factor treatment, can they get total CVD risk assessment? • What should be the management protocol and patient pathway?

Service delivery – depending on resources District Hospital Comprehensive NCD Management Specialist availability PHC Service delivery – depending on resources District Hospital Comprehensive NCD Management Specialist availability PHC (with MD) Risk assessment Risk Management PHC (no MD) Risk screening procedures Risk Assessment CHWs Health Education

NCD management system Community Healthworker PHC DH Tertiary care • Screening of population for NCD management system Community Healthworker PHC DH Tertiary care • Screening of population for risk factors • Running non-medical interventions (smoking cessation, exercise, diet) • Referral of individuals with risk factors to PHC • Regular review of all patients with NCDs/Risk Factors • BP, BM, Urinalysis measurement • Counselling or referral • Medication if Doctor available (DH Outreach) • Review of high-risk patients and all secondary-prevention cases • Review of complex cases • Provision of Doctor to run medical clinics in PHCs • Review of patients requiring specialist services. • Training of NCD delivery staff • Supervision

Phase 4: Systematic scale-up and monitoring ØStrengthen supply and quality of services, with emphasis Phase 4: Systematic scale-up and monitoring ØStrengthen supply and quality of services, with emphasis on primary care ØImprove demand for primary care ØFind innovative solutions to overcome barriers to improving supply and demand ØCase managers ØPatient support groups Øm. Health ØMonitor performance and progress towards attaining the target

Costing- different scenarios ØEstimate the cost of scale-up and track resources ØHow much does Costing- different scenarios ØEstimate the cost of scale-up and track resources ØHow much does it cost – construct different scenarios ØIdentify/correct missed opportunities ØIntegrate vertical disease-specific primary care programmes (e. g. on hypertension, diabetes)

Scenario – Restricting target age range to 50 -69 years Solomon Islands 120, 000 Scenario – Restricting target age range to 50 -69 years Solomon Islands 120, 000 $3, 500, 000 $6. 90 100, 000 $3, 000 $6. 70 80, 000 $2, 500, 000 $6. 50 60, 000 $2, 000 40, 000 $1, 500, 000 20, 000 $1, 000 0 $500, 000 40 -69 years 50 -69 years Average annual number of people in target group 48. 8% decrease $6. 30 $6. 10 $5. 90 $5. 70 $5. 50 40 -69 years $0 40 -69 years 50 -69 years Average annual cost person Total 5 year cost 44. 9% decrease 50 -69 years 11. 6% increase All costs converted to US dollars

Total CVD risk management for UHC • Prevention of heart attacks and strokes through Total CVD risk management for UHC • Prevention of heart attacks and strokes through a total cardiovascular risk approach is – more cost effective than treatment based on individual risk factor thresholds only, – and should be part of the basic benefits for pursuing universal health coverage.

Communicating NCD management • • Solution more than the problem Specific Viable Realistic Result Communicating NCD management • • Solution more than the problem Specific Viable Realistic Result oriented Phased approach Partnership

The cycle of health systems for NCD Rehabilitation Care in the community Risk identification The cycle of health systems for NCD Rehabilitation Care in the community Risk identification and reduction in the community HEALTH PROMOTION ENABLING ENVIRONMENT Referral care and Specialized management Risk and disease Management in the health centre

Ø Set national targets Ø Use evidence based guidance and tools adapted to local Ø Set national targets Ø Use evidence based guidance and tools adapted to local context Ø Focus on easy wins Ø Start in one district/province Ø Learning by doing Ø Develop a service delivery model Ø Protocol based management Ø Buy in from senior clinicians Ø Task shifting Ø Promote self care Ø Minimum measures to monitor Ø Strengthen programme management

Expanding coverage of NCD services Expanding coverage of NCD services

Thank you! Thank you!

Objectives and structure • Objectives – How to strengthen NCD management within NCD prevention 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

Group work • Three groups – Group 1 • SEARO – Group 2 • Group work • Three groups – Group 1 • SEARO – Group 2 • EMRO and AFRO – Group 3 • AMRO and EURO • Problem solution tree • Identify a problem which is affecting the sale up NCD management in health systems • Standing group work

PRIORITIZATION OF INTERVENTIONS AND ACTION PLAN ON RISK FACTORS ACTIVITY PROBLEM-SOLUTION TREE INSTRUCTIONS: 1. PRIORITIZATION OF INTERVENTIONS AND ACTION PLAN ON RISK FACTORS ACTIVITY PROBLEM-SOLUTION TREE INSTRUCTIONS: 1. Identify the specific problem. Write this in the box provided. 2. Identify the direct and indirect causes of the specific problem. This can be achieved by asking the question “why? ” several times until all possible causes/roots of the problem are exhausted. 3. Draw arrows to show the relationships of the causes among one another and their pathways toward the problem. Once all possible causes are considered, identify possible solutions to address these causes.

PROBLEM-SOLUTION TREE: EXAMPLE Incorporate health indicators related to trans fat consumption in surveillance instruments PROBLEM-SOLUTION TREE: EXAMPLE Incorporate health indicators related to trans fat consumption in surveillance instruments Health risks of trans fats / trans fat contents in food not monitored in the population Lack of local studies or evidence on trans fat risks to health Support local studies on trans fat and health effects Build capacity for policy advocacy on trans fat Implement awareness-raising activities to raise the attention to health risks of trans fat Poor awareness on importance & benefits of policy on trans fats among policy leaders Little interest for policy development on trans fat No policy on trans fats Conduct policy development training on trans fat Lack of policy advocacy and policy development skills of technical staff

PROBLEM-SOLUTION TREE CORE PROBLEM: PROBLEM-SOLUTION TREE CORE PROBLEM:

NCD ADVOCACY ACTIVITY – Presenting a plan to the health minister INSTRUCTIONS: 1. Each NCD ADVOCACY ACTIVITY – Presenting a plan to the health minister INSTRUCTIONS: 1. Each team has 5 minutes to complete their advocacy pitch to the minister of health of the country. 2. Situation, as NCD programme mananger you happen to meet the minister of health of your country in the airport lounge. Minister was reading a news paper article on increasing deaths from CVD in the country. She asked about NCD management and you have 5 minutes to present an approach/plan 3. Each group has to identify one spokesperson who will brief the minister. Participant from another group will act as the minister. team of NCD buyers/investors. 4. You can use any audio-visual means of communication to get your advocacy message across clearly and compellingly.

Alternative risk prediction methods when blood tests are not feasible • Global data are 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.

WHO Guidance to countries on treatment thresholds and improving access to medicines • All 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

Service delivery – depending on resources District Hospital Comprehensive NCD Management Specialist availability PHC Service delivery – depending on resources District Hospital Comprehensive NCD Management Specialist availability PHC (with MD) Risk assessment Risk Management PHC (no MD) Risk screening procedures Risk Assessment CHWs Health Education

NCD management system Community Healthworker PHC DH Tertiary care • Screening of population for NCD management system Community Healthworker PHC DH Tertiary care • Screening of population for risk factors • Running non-medical interventions (smoking cessation, exercise, diet) • Referral of individuals with risk factors to PHC • Regular review of all patients with NCDs/Risk Factors • BP, BM, Urinalysis measurement • Counselling or referral • Medication if Doctor available (DH Outreach) • Review of high-risk patients and all secondary-prevention cases • Review of complex cases • Provision of Doctor to run medical clinics in PHCs • Review of patients requiring specialist services. • Training of NCD delivery staff • Supervision