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

3. 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 ** Survey General’s Department 1988
*** Department of Census and Statistics **** Population census 2006
***** Demographic Survey 1994

4. 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
**Registrar General’s Department
***Medical Statistical Unit 2006
****Demographic and Health Survey 2006/07

5. Situational Analysis
Sri Lanka

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

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

9. Mortality by major Disease category

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

11. Morbidity – Prevalence of major NCDs

12. Present situation of major risk factors
Male
Female
Source- WHO

13. 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

14. Provincial level structure
Community
Volunteers / Volunteer organizations
PHNS
PHM
PHI

15. 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

16. 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, and Annual Health Bulletin 2007& Ministry of Finance

17. Existing Measures in NCD Prevention & Control

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

19. 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

20. 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

21. 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

22. 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.   

23. 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.

24. 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

25. 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

26. 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

27. 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

28. 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

29. Funding Agencies
World Bank
JICA
WHO

30. 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

31. 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

32. 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

33. 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

34. Future Plans

35. 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

36. 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

37. Challenges in Implementing National NCD Programme

38. 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

39. 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

40. 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

41. 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

42. Thank You