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Prof K Srinath Reddy President, Public Health Foundation of India Bernard Lown Professor of Cardiovascular Health, Harvard School of Public Health. Vision in a World of NCDs. Sir John Wilson Lecture. (Why) are NCDs (Finally) receiving policymaker attention at Global Level? - PowerPoint PPT Presentation

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Vision in a World of NCDsProf K Srinath ReddyPresident, Public Health Foundation of IndiaBernard Lown Professor of Cardiovascular Health, Harvard School of Public Health

Sir John Wilson Lecture {1QUESTIONS THIS TALK WILL ADDRESS(Why) are NCDs (Finally) receiving policymaker attention at Global Level?

Why is Eye Health not part of the UN/WHO NCD package?

How will Ageing and NCDs impact on Eye Health in the 21st Century?

How should Eye Health position itself in the broader Health System framework and Rights discourse?

Global Challenge of NCDs

APATHY (2000)ATTENTION (2011)ACTION ?

Is NCD a global crisis? YES!

Source:

Beaglehole R, Bonita R, Alleyne G, et al for the Lancet NCD Action group. UN HLM on NCDs: Addressing four questions.Lancet 2011POL June 13 2011Cardiovascular disease(Age-standardized death rate per 100 000, males)Yach D., 2009723-1030347-390391-426

391-426427-464542-722723-1030

138-205206-281282-346347-390391-426427-464465-541542-722723-1030No Data

Projected global numbers of deaths by cause for high, middle and low incomecountries (WHO, 2008)Is NCD a development issue? YES!(and the case for investment is strong)NCDs are a cause and consequence of povertyNCDs entrench poverty-cycle of debtCosts of loss of productivity and care will increase as the burden risesInaction will pose problems on fragile health systemsAnd action on NCDs will contribute to progress for other global priorities, e.g. MDGs NCDs: Economic ImpactNCDs accounted for five of the six top causes of economic loss in 2008Heart disease : $752bnStroke: $298bnDiabetes: $204bn

NCDs cost developing countries up to 6.77% of GDP; this economic burden is more than that caused by Malaria (1960s) or AIDS (1990s) - IOM Report 2010NCDs will lead to a loss of 30 Trillion Dollars globally up to 2030 representing 48% of global GDP in 2010 Harvard + WEF Study 2011Are affordable cost-effective interventions available? YES!

Source: Cecchini M, Sassi F, Lauer J et al. Tackling unhealthy diets, physical inactivity and obesity: health effects and cost-effectiveness. Lancet 2010UN ADOPTS NCDs!UNHLM September 2011 (New York)

Political Resolution Adopted

Global Target Set For 2025 25% Reduction in NCD Related Mortality Below 70 Yrs. 25 By 25What are NCDs?Why Only Four? (CVD; DM; Cancer: COPD)Linked by Common Risk FactorsWhat About:-Mental Health?-Oral Health?-Eye Health?-Renal Diseases?-Genetic Disorders?

Where Do Injuries and Disabilities Fit In?

UN Political Resolution 2011:Disease Burden & DeterminantsHigh and Rising Health BurdenAdvancing in LMICPreventable Premature DeathsCommon Risk Factors : PrevalenceSocial Determinants Recognized Economic Cost of Neglect : HugeRisk FactorsTobaccoUnhealthy DietPhysical InactivityHarmful Use of Alcohol

Others Mentioned:- Indoor Smoke - Breast Feeding - InfectionsGlobal causes of blindness due to eye diseases, excluding refractive errors (2002)Source: Eggleston K and Tuljapurkar S. Aging Asia The Economic and Social Implication of Rapid Demographic Change in China, Japan and South KoreaHow will vision fare in the 21st century?AgeingNCDsInjuriesClimate ChangeSILVER TSUNAMIGLOBAL GRAYING VERY ELDERLYELDERLYDEMOGRAPHIC TRANSITION

AGEING

Global Ageing Trends (2012)0 to 910 to 1930 or over25 to 2920 to 24Per centage 60 or over

Global Ageing Trends (2050)

By 2050, 80% of older people will live in LMIC

Chile, China and Iran will have a greater proportion of older people than USA.

By 2050, 400 million persons over 80 years; 100 million in China aloneAgeing in LMIC Cataract Age Related Macular Degeneration Vitreous Degeneration GlaucomaAge Related Eye ProblemsRisk Factors: Tobacco Use on the Rise in Developing Countries

2424Smoked Tobacco And The EyeCataract3 fold higher risk (nuclear cataract) Kelley et al 2005AMD

GlaucomaR.R. of 2.2 (95% CI, 1.4 3.5) for current smokers

O.R. of 2.9 (95% CI, 1.3 6.6) Cheng et al 2000Smokeless Tobacco And The Eye Raju et al (2006) O.R. for Nuclear Cataract = 1.67 (9.5% CI, 1.16 2.39)

Iyamu et al (2002) SLT Raises Intra Ocular Pressure

CountryPrevalence in 2010 (%)China9.7India 7.1Japan7.3Republic of Korea9.0Malaysia10.9Singapore12.7Thailand7.7Vietnam2.9United States12.3Prevalence of Diabetes in Asia-Pacific Countries Source: For China, Yang et al. 2008. For all other countries, International Diabetes Federation Diabetes Atlas, www.diabetesatlas.org/content/regional-dataRising Prevalence of Diabetes in Urban IndiaMohan et al, Diabetologia, 2006; 49: 1175Ramachandran et al, Diabetes Care, 2008; 31: 893Over 14 years, DM prevalence increased by 72.3% Prevalence rate age standardized for Chennai Census 1991NUDS CURESThe TOP 10

Diabetes And The EyePeople with Diabetes Are 25 Times More Likely To Go Blind From Diabetic Retinopathy And Cataract Than Those Without Diabetes

- Patel and Ireland (Sightsavers) Blood Pressure and EyeHypertensive RetinopathyInteraction Between HBP And DiabetesInteraction Between HBP And TobaccoCVD WITH OCULAR EFFECTS

Stroke/ TIA Arrhythmias Vasculitis Drug Effects

B. COMORBIDITIES

Assessment of surgical riskCVD and EyeTumours

PrimaryMetastatic

Treatment

SteroidsRadiotherapyCancer and EyeHEALTH SYSTEMPEOPLESOCIAL DETERMINANTS (OF HEALTH & NUTRITION)SocietalPersonalWaterIncomeSanitationEducationFood SystemOccupationEnvironmentSocial StatusSocial StabilityGenderDevelopmentNetworksWorkforceInfrastructureDrugs, Vaccines & TechnologiesFinancingInformation SystemsGovernance

ClinicalChanging SpectrumIncreased Caseload

Public HealthServicesContinuity of CareWorkforceAwareness

PolicyIntegrationFinancingImplications for the Health SystemShould Eye Health..Remain a Vertical ProgrammeBe part of a Horizontal Integration of many Programmes?Seek a Diagonal Approach?Primary Care:PhysiciansNon Physician Health Care ProvidersTask ShiftingTask SharingOutreach Services (IT enabled)Secondary Care:Ophthalmologists + Allied Health ProfessionalsOther PhysiciansTertiary Care:SpecialistsReferral ServicesSupportive Supervision Health Workforce

Universal Health CoverageSustainable Development Health SystemEquityRightsSocial DeterminantsHuman ResourcesEconomy21st Century

The Global Path to Universal Health CoverageBismarck Model 1883Beveridge Model, 1942Japan, 1938New Zealand, 1938UK, 1948 (NHS)

Scandinavia: Norway, 1912; Sweden, 1955; Denmark, 1973;NHIF, Kenya, 1966Canada, 1966 Spain, 1986; Brazil, 1988; Columbia, 1993South Korea; 1989Rwanda, 2003;

Ghana, 2004

South Africa, 2011/12Philippines, 1995; Taiwan, 1995;Thailand,2002; Vietnam, 2009INDIA, 2012Chile, 1952Australia, 1975, Italy 1978 Mexico, 2001Germany, 1941Sri Lanka, 1950Presentation slide for courses, classes, lectures et al. 40UNIVERSALITYCOVERAGEEQUITYBRIDGING GAPSHORIZONTALVERTICALBREADTHDEPTHUniversal Health Coverage Based On People Centric Primary Care- Margaret Chan, DG of WHO (2012)20th Century Health CareClinician CentredFocus on Benefits of TreatmentIncrease QualityPatient as Passive ComplierGood Care for Known PatientsHospital as FocusOperates Through BureaucracyDriven by FinanceHigh Carbon UsageChallenges met by Growth

21st Century Health CarePatient-CentredFocus on Prevention of Disease and HarmReduce Waste and Increase ValuePatient as Co ProducerEquitable Care for PopulationsFocus on systemsOperates Through NetworksDriven by KnowledgeLow Carbon UsageChallenges met by Transformation

-Sir Muir Gray (2007)How Do we then gather more strength

In our advocacy for adoption andadvancement of policies for eye health?A Framework for Determinants of Issue Attention in Global Health

The collective strength of the actors mobilising around an issue; The ideas they use to portray and position the issue;(iii) The issue characteristics that pertain to inherent features of the issue; and (iv) The nature of the political context or features of the environment that individuals confront as they seek to advance attention of the issue, including other actors who do not work on the issue (Jeremy Shiffman, 2010)

The Economic Argument

Cause and Consequence of PovertyProductivity LossesCost-Effective Treatments (Best Buys)

Global cost of Visual Impairment and Blindness = USD 3 TrillionPatel and Ireland (Sightsavers)

Vision Impairment is the 6th largest cause of DALY loss (3%)- WHO

How is Vision Loss weighted for estimation of Disability?- Perspective of Physicians- Perspective of Patients- Perspective of People

Quality of Life is an important message to conveyValue of VisionWhy Do We Need A Rights ArgumentEconomic arguments work BUT there are competing demands (within and beyond the Health Sector)Voice of Patients and Civil Society needed - e.g. HIV-AIDS, Tobacco Control

HEALTH EQUITY: PHILOSOPHICAL CONSTRUCTCapability Right

Utilitarian JusticeBentham RawlsSenA well ordered society would ensure that all individuals have the capability to be healthy and at a level that is commensurate with human dignity in the modern world, which is their right - Sridhar Venkatapuram. Health Justice; Polity (2011)WHAT NEXT?Post 2015 UN Agenda: Sustainable Development Goals (SDH)Four Pillars- Inclusive Economic Development- Inclusive Social Development- Environmental Sustainability- Peace and Security

Nine Thematic Working GroupsInter-Governmental Leadership Group