Current status of NCDs in Maldives Second International Seminar on Epidemiology and Public Health Aspects of Noncommunicable Diseases, Lausanne, 10-18 August 2010 Current status of NCDs in Maldives Ubeydulla Thoufeeq Deputy Director and Head, NCD Division Center for Community Health and Disease Control Ministry of Health and Family Maldives.

Contents Health system The problem The response The lessons The future

Maldives Island nation state 1900 islands 198 inhabited islands 33% under the age of 15 years and 5.1% over 65 years old. Life expectancy at birth increased dramatically 58 years in 1990 to 73 years in 2007

Health care institutions (service delivery & regulatory) Health System MoHF CCHDC MFDA DDPRS Health care institutions (service delivery & regulatory) NSPA DGFPS Private HC inst Tertiary Care Secondary Care Primary Care IGMH Hospital Grade 1,2,3 Health center Grade 1,2,3 Referral system

The problem- Epidemiological Magnitude and spread- STEPS survey 2003, Demographic Health surveys,2009, indicates High Smoking prevalence Multi Indicator Cluster survey ….indicates low exclusive Breast feeding Malnutrition <5yrs persistently high

Mortality due to NCDs

Burden of NCD risk

The problem- Social Economic Determinants Widening income disparities The underlying factors. Social determinants, behavioral determinants Migration to capital to seek jobs. Families left behind. Urbanization: 198 inhabited islands. 33% of population on one island

The problem- Health systems Benefits of economies of scale not achieved at island level. Hence, cost of providing health care is much higher High referral/ transport costs Current reform: regulatory and service delivery demarcations with formation of Health care corporations

The Problem-Challenges in delivery of Primary Health care Changing role of community health workers assuming more managerial functions with formation of Healthcare corporations Weak working links between Center for community Health and Public health units at atoll levels

The problem-Additional health system issues Historically no guidelines for managing NCDs NCDs a domain of the “specialists” Difficult to institutionalize good practices due to reliance on non-local doctors and their high turnover Lack of access to essential medicines due to absence of pharmacies in smaller islands Lack of trained human resource and funds

The response Policies- 7th National Development Plan, Health Master plan 2006-15, MDP Govt Manifesto, NCD Strategic plan Health system development Infrastructure ++ Human resources –few public health specialists Programs: Implementation at Central and atoll levels Civil society involvement-mixed success

Recent changes to the health system Government has called for revitalization of primary healthcare in Maldives. ? Motivated by difficulty in sustaining the current medical oriented model Introduction of a National social protection scheme Introduction of user fees under Health corporations Telemedicine NCD project in 4 atolls

The lessons Belated recognition of NCD burden Mismatch between service development and needs…HR, as well as services Difficult to sell ‘prevention’. Lost momentum in key areas Tobacco control Not tackling Burden of substance abuse Social determinants and disparities …MSDH report: needs shift from focus on the overall national health improvements to close in equity gaps within and between communities Need gate keeping, referral systems and care standards

The future Policy to revitalize primary health care Safety net including free health care for the elderly New treatment and rehabilitation for drug users Protocols and standards of care [WHO PEN] Tobacco Law passed. Institutional mechanisms for NCD P&C being strengthened Networking mechanism strengthened. [NTobCCte, Health PromotionNet ]

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