Development and Implementation of National NCD Programme Dr Lal Panapitiya Director / NCD P & C Unit Ministry of Healthcare & Nutrition, Sri Lanka

Sri Lanka Demographic Details Total population( in thousands) 19,886* Surface area( Sq.km) 62,705** Population density (persons per Sq.km) 317.1*** Population growth rate (%) 1.1*** Sex ratio( No. of men/ 100 females) 97.9*** Urban population (%) 14.6*** Adult literacy rate( %) Total Female Male 90.2*** 89.2*** 92.2*** Administrative divisions of Sri Lanka 9 Provinces 25 Districts 322 Divisional Secretary Areas * Registrar General’ Department 2006 ** Survey General’s Department 1988 *** Department of Census and Statistics 2006 **** Population census 2006 ***** Demographic Survey 1994

Health and Nutrition Indicators Life expectancy at birth (yrs) Female Male 76.4* 71.7* Maternal mortality rate( per 100,000 live births) 14.3** Neonatal mortality rate( per 1000 live births) 8.4** Infant mortality rate (per 1000 live births) 11.7** Under five mortality rate (per 1000 live births) 13.39** Total fertility rate( per Woman) 1.9** LBW per 100 live births in Government Hospitals 17.0*** % of Children Under weight Acute under nutrition( Wt for age) Chronic malnutrition 21.6**** 15.0**** 18.0**** *Department of Census and Statistics 2001-2006 **Registrar General’s Department ***Medical Statistical Unit 2006 ****Demographic and Health Survey 2006/07

Situational Analysis Sri Lanka

Demographic transition in Sri Lanka Population pyramids 1981 and 2001 WHO Country Cooperation Strategy 2006 – 2011: Democratic Socialist Republic of Sri Lanka(WHO, 2006)]

NCDs as a highest priority in Sri Lanka Source: WHO Country Cooperation Strategy 2006 – 2011: Democratic Socialist Republic of Sri Lanka (WHO, 2006)]

Mortality by major Disease category

Trends of hospital deaths due to NCD Vs CD in years 1985- 2007 Source: Annual Health Bulletin

Morbidity – Prevalence of major NCDs

Present situation of major risk factors Male Female Source- WHO

Structure and organization of health services (In relation to NCD) Central level structure D/NCD D/LS D/MH D/MS D/TCS D/PCS D/Nurse Education D/ Cancer Control /MS D/PH Nursing D/Training D/E&OH D/E&UHMS D/ Finance D/YED&D D/Planning& Research D/Inform D/IH D/ Policy Analysis D/Org Develop

Provincial level structure Community Volunteers / Volunteer organizations PHNS PHM PHI

Information system MOH PHM / PHI Provincial institutions PD (Planning Unit) PC / SC Hospitals RD (Planning Unit) TC / Special Hospitals Preventive programmes MoH institutions Director / Information (MoH) NCD unit (MoH) Directorates/ Sections Provincial authorities Annual Dissemination National / International organizations

Health Expenditure Category 2005 2006 2007 National Expenditure (Rs million) 803,546 713,145 885,952 GNP per capita at current prices (Rs) 120,875 Per Capita Health Expenditure (Rs) 2,215 2,734 2,151 Government Health Expenditure ( GHE - Rs million) Total Government Health Expenditure 43,564 54,364 43,022 GHE as a % of National Expenditure 5.4 7.6 4.9% GHE as a % of GNP 1.85 1.95 1.22 Recurrent Expenditure 35,137,468 45,781,186 54,736,763 (84.21% of THEx) Capital Expenditure 8,430,891 8,582,739 8,727,260 (15.79% of THEx) Expenditure for patient care services 24,250 31,587 40,779 (56.6% of TGHE) Expenditure for public health services 1694 3719 4720 ( 9.2 % of TGHE) Source: Statistic Unit / MSD, 2008 and Annual Health Bulletin 2007& Ministry of Finance

Existing Measures in NCD Prevention & Control

Existing measures in NCD prevention & Control Development of a national programme Improving & Strengthening Service provision Planned & Piloted New interventions

Achievements In legislation In the system Tobacco Control Act and proper implementation In the system Identification of NCD as a priority in Health Policy and Health Master Plan Development of policy and strategic plan and district level implementation plans Pilot projects are being completed Coordination of other stakeholders – in the MoH as well as outside Advocacy and cooperation from other sectors to make their policy and environment healthy  

In the structure Strengthening the Central Level structure Appointing D/ NCD with a facilitated unit and staff Approval to appoint DDG/ NCD in order to coordinate all relevant directorates National Steering Committee for proper intesectoral collaboration National Advisory Board and National Working Group for technical matters In the provincial level Appointing MO/NCDs in each district to coordinate all NCD prevention activities District Coordinating Committees for operational level intersectoral coordination

Capacity development of NCD team National NCD Program National Health Policy National NCD Policy and strategic plan District and operational plan Central and district level structure Capacity development of NCD team

Vision: Mission: Goal: A country that is not burdened with avoidable NCD deaths and disabilities.   Mission: The underlying mission of the national NCD policy of Sri Lanka is to reduce the burden due to chronic NCDs by promoting healthy lifestyles, reducing the prevalence of common risk factors, and providing integrated evidence based treatments for diagnosed patients. Goal: The overall goal of the National NCD Policy of Sri Lanka is to reduce the burden due to chronic NCDs by promoting healthy lifestyles, reducing the prevalence of common risk factors, and providing integrated evidence based treatments for diagnosed patients.   

Policy Objective To reduce premature mortality due to chronic NCDs by 2% annually through expansion of evidence based curative services and to reduce the prevalence of risk factors, through individual and community wide health promotion measures.

Key Strategies NCD Policy Support prevention of chronics NCDs by reducing level of risk factors of NCD in the population Implement a cost-effective Cardio Vascular Disease screening program Provide integrated , quality evidence based curative and preventive services appropriate for each level of care Encourage Community participation and empowerment for health promotion and disease control Enhance Human resource development to facilitate NCD prevention and care Strengthen National health information system including disease and risk factor surveillance Promote Research for prevention and control of NCD Facilitate coordination, monitoring & evaluation of prevention and control of NCDs and their determinants Ensure a sustainable financing mechanism that support both preventive and curative sector cost effective health interventions Integrate NCD prevention into policies across all government ministries, departments and private sector organizations. Key Strategies NCD Policy

Sri Lanka Medical Association (SLMA) Colleges (Physicians, GPs) NGOs National NCD Program Health Ministry Other Ministries Sri Lanka Medical Association (SLMA) Colleges (Physicians, GPs) NGOs Media

Coordination of National NCD Programme MOH PHNS PHM / PHI National Steering Committee Chaired by Secretary / Health National Health Council NCD unit MoH National Technical Working group PDHS Stakeholders / Pilot projects National Advisory Board Chaired by DGHS RDHS MDT/ HPO/ Volunteers Community District Advisory Committee Chaired by RDHS Sec by MO/ NCD

Inter Ministerial Collaborations Ministry of Education Health & Nutrition Ministry Ministry of Agriculture Ministry of Public administration & Home Affairs Ministry of Social Services Ministry of Media & Mass Communication

Health Ministry inter departmental collaboration NCD Unit Mental Health Unit Planning Unit Nutrition Division NATA Youth / Elderly & Disability Unit Trauma Secretariat Health Education Bureau Epidemiology Unit Family Health Bureau

Funding Agencies World Bank JICA WHO

Coordination of current pilot projects NCD Prevention Project (NPP) – JICA PEN (Package of Essential NCD Interventions) – WHO NATA – Bloomberg Fund SLMA – MoH – WDF Diabetes Prevention project (NIROGI Lanka) Quality Improvement in Clinical Care - WB ( HSDP) - MoH Curative Care Survey - WB

Essential Equipments Essential Recording Tools/MIS PEN Assess Capacity & Coverage Identify Needs Essential Equipments Medicines Essential Essential Recording Tools/MIS WHO/ISH Risk Charts Protocols for primary Care

Activities Management Protocols for NCD at primary care – piloted through WHO PEN / JICA Protocols for Primary Care Evidence Based Cost Effective Symptom Based Integrated Multifactorial Risk Approach Patient Oriented Training of Workforce on implementation of the protocols

Objectives Non-communicable diseases Prevention Project Development objective (overall goal) Effective & efficient strategies of controlling chronic NCDs developed in the project are implemented in districts other than the project target areas Actions are initiated regarding the appropriate deployment of human resources and infrastructure of medical institutions for the NCD prevention at the national level Immediate objective (project purpose) Effective and efficient implementation strategies for controlling chronic NCDs and the resultant cardiovascular diseases are developed through pursuing the evidence for chronic NCDs Purpose: To develop effective and efficient implementation strategies for controlling chronic NCDs and the resultant cardiovascular diseases through pursuing the evidence Note on strategies - low cost, using the existing structures and mechanisms Goal: To scale up the NCD prevention programmes to other districts in the country 33 33

Future Plans

Further strengthening the coordination of interventions with other ministries through the National Advisory Board (NAB) & National Technical Working Group (NTWG) for NCD Formulation of an Ideal Primary Health care model to capture the increased burden of NCDs Sensitizing and creating awareness on major NCD (using IEC approach ) and other interventions - At Central level / District level Quality improvement measures in clinical care -revision of National Treatment Guidelines for Primary, Secondary & Tertiary Care Management Protocols for NCD care at primary care – piloted through WHO PEN Training of MOs / nurses involved in follow up care for proper NCD (DM) care Advocacy for legislation / policy changes and enhanced financial allocations

Countrywide expansion of the NCD programme (with cost effective screening, health promotion, social marketing campaign) Advocacy meeting to other Ministries / provincial political authorities /Sectors / Media Advocacy for strengthening curative care in every level in relation to NCD management Review of district operational plan and district level NCD activity Development of communication strategy and surveillance system for NCD Strengthen health Promotion in all settings Initiate formulation of a National Cancer Control Strategic Plan Strengthen of the tobacco and alcohol programme Production of master trainers for NCD programme / tobacco & alcohol programme District level capacity building Training of MO/NCD, MOH, PHI, PHM & officers in other relevant sectors Mobilizing youth and community leaders towards prevention of NCD Multidisciplinary Research effort with agreed research agenda Review of pilot projects & NATA (JICA / Nirogi Lanka / PEN / Bloomberg ) Revision of NATA legislation for Tobacco Control to: - Ban Point of Sales advertising - Ban Smoking in all Public Places (Instead of “enclosed” spaces) - Amend to a conisable offence - Inclusion of Pictorial Health Warnings Incorporation of NCD prevention into existing school curriculum Establishment of “Nutrition Clinics” in tertiary care institutions Development of master trainers in trauma managements Consultative meeting to finalize injury policy and strategic plan Establishment of i steering committee for injury prevention Development of operational plan for poison prevention in districts Development of information system for injury surveillance Development of operational plan for rehabilitation

Challenges in Implementing National NCD Programme

Challenges in the System : Lack of adequate NCD /risk factor surveillance system Quality improvement in clinical care based on standard guidelines Maintaining coordination between all sectors & stakeholders Behavioral change among the public Lack of adequate Monitoring & Evaluation system Lack of Policy decision on model of primary health care set up Multinational company involments

Challenges in Human Resources: HR constraints for providing optimal care for NCDs Gaps in recruiting and training of staff for NCD care at primary and secondary care Capacity building in central / district level Lack of policy decision on involvement of field officers (PHI & PHM) for community level health promotion, basic screening and follow up for NCDs

Challenges in Funding: Lack of funding for development of district level NCD implementation units Lack of funding for district level activities Lack of funding for social marketing campaign

lessons learnt over the last 5 yrs Priority on Iry prevention but IIry prevention also needed Need dedicated leadership Intersecoral coordination and collaboration is a must

Thank You