By Datuk Dr Lokman Hakim

1. 4/15/2013
1
Keynote Address:
Multi-Sectoral Approach (MSA)
to Prevent
Non-Communicable Diseases
Lokman Hakim S, MD, PhD
Deputy Director General of Health (Public Health)
Ministry of Health, Malaysia
NSM NCD Conference 2013
26 March 2013
Kuala Lumpur
lokman.hakim@moh.gov.my
Ministry of Health
Malaysia
The Causation Pathway For
Non-Communicable Diseases
Underlying
Determinants
•Globalization
•Urbanization
•Population
Ageing
Common Risk
Factors
•Unhealthy diet
•Physical Inactivity
•Tobacco & Alcohol use
•Age (non modifiable)
•Heredity
(non modifiable)
Intermediate
Risk Factors
•Overweight/obesity
•Raised blood sugar
•Raised blood
pressure
•Abnormal blood
lipids
Source: Adapted from Preventing Chronic Disease: A Vital Investment. Geneva, WHO 2005.
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2. 4/15/2013
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There are Four Major Groups of Non-
Communicable Diseases;
Four major lifestyles related risk factors
Modifiable causative risk factors
Tobacco use
Unhealthy
diets
Physical
inactivity
Harmful
use of
alcohol
Noncommunicablediseases
Heart disease
and stroke    
Diabetes
   
Cancer
   
Chronic lung
disease 
3
8.3
14.9
20.8
6.5
9.5
10.7
1.8
5.4
10.1
4.3 4.7 5.3
0
5
10
15
20
25
NHMS II (1996) NHMS III
(2006)
NHMS 2011
Prevalence(%)
Prevalence of Diabetes,
≥30 years (1996, 2006 & 2011)
Total diabetes
Known
Undiagnosed
IFG
Source: National Health & Morbidity Surveys (NHMS)
32.2 32.7
12.8
19.8
0
5
10
15
20
25
30
35
NHMS III (2006) NHMS 2011
Prevalence(%)
Prevalence of Hypertension,
≥18 years (2006 & 2011)
Total HPT
Known
Undiagnosed
20.6
35.1
8.4
26.6
0
5
10
15
20
25
30
35
40
NHMS III (2006) NHMS 2011
Prevalence(%)
Prevalence of Hyper-cholesterolaemia,
≥18 years (2006 & 2011)
Total HChol
Known
Undiagnosed
4
TRENDS IN NCD RISK FACTORS

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16.6
29.1 29.4
4.4
14.0 15.1
0
5
10
15
20
25
30
35
NHMS II
(1996)
NHMS III
(2006)
NHMS 2011
Prevalence(%)
Prevalence of Overweight & Obesity,
≥18 years (1996, 2006 & 2011)
Overweight
Obesity
PrevalenceofAbdominalObesity,≥18years
(2006&2011)
19.6
28.6
33.6
44.7
48.0
51.0
55.7
62.8 63.2
61.4
63.2
56.2
50.4
10
20
30
40
50
60
70
18-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+
PREVALENCE(%)
AGE GROUPS (years)
30.1
37.1
47.1
54.1
20
30
40
50
60
NHMS 2006 NHMS 2011
PREVALENCE(%)
MALES FEMALES
Prevalence of Abdominal
Obesity by age groups
(NHMS 2011)
5
BurdenofDiabetesinMalaysia:
(Adultsage18 years&above)
6
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
4,500,000
5,000,000
0
5
10
15
20
25
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Estimatedpopulation
Prevalence(%)
Year
Est. population, 2006 Est. population, 2011 Prevalence projection, 2006 Prevalence projection, 2011
Current
projection

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AdmissionstoMOHHospitalsdueto
CirculatoryDiseases&Cancer
7
y = 130995e0.0208x
R² = 0.7959
y = 53166e0.0523x
R² = 0.8716
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
200,000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Circulatory diseases Malignant neoplasms Projected, Circulatory diseases Projected, Cancer
PrimaryRenalDiseases
8
y = 314.5x + 1735.7
R² = 0.9634
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
New dialysis patients
New dialysis patients Projected new dialysis patients
Since 2003, diabetes
accounted for > 50%
of the primary renal
disease of new dialysis
patients

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9
2000
2003
2004
2008
Global Strategy for the Prevention and Control of
Noncommunicable Diseases
Global Strategy on Diet,
Physical Activity and Health
Action Plan on the Global Strategy for the
Prevention and Control of NCDs
2010
2009
2011
Global Strategy to
Reduce the Harmful
Use of Alcohol
WHO Global Status
Report on NCDs
Political Declaration on NCDs
WHO's global road map to prevent and
control NCDs
2012+ Realizing the commitments made in the Political Declaration
UNSecretary-General:
NCDsindevelopingcountriesarehidden,
misunderstoodandunder-recorded
A rapidly rising epidemic in developed and
developing countries…
… with serious socio-economic impacts,
particularly in developing countries.
Workable solutions exist to prevent most
premature deaths from NCDs and mitigate the
negative impact on development.
The way forward: These solutions need to be
mainstreamed into socio-economic development
programmes and poverty alleviation strategies.
10

6. 4/15/2013
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11
UN High-levelMeeting on NCDs
(New York, 19-20 September 2011)
High-levelMeeting
113 Member States
34 Presidents & Prime
Ministers
3 Vice-Presidents and
Deputy Prime Ministers
51 Ministers of Foreign
Affairs & Health
11 Heads of UN
Agencies
100s of NGOs
PoliticalDeclaration
Establish multisectoral
national plans by 2013
Integrate NCDs into
health-planning
processes and the
national development
agenda
Promote multisectoral
action through health-
in-all policies and
whole-of-government
approaches
Build national capacity
WhatWHOisdoing
Develop a Global
Monitoring Framework
and targets
Develop a global
implementation plan
2013-2020
Provide technical
support to developing
countries
Identify options for
partnerships
Coordinate work with
other UN Agencies
Measure results
World Health Assembly in May 2012:
Decided to adopt a global target of a 25% reduction in premature mortality
from NCD by 2025
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Highlights:UN PoliticalDeclaration
Heads of States and Governments and representatives committed to:
• Establish/strengthen, by 2013, national multisectoral policies and
plans for NCDs, taking into account the Global Strategy for NCDs and
its Action Plan;
• Integrate NCDs policies and programmes into health-planning
processes and the national development agenda of each Member
State;
• Develop national targets and indicators based on guidance provide
by WHO and give greater priority on surveillance;
• Accelerate implementation of the WHO FCTC, the Global Strategy on
Diet, Physical Activity and Health, and the Global Strategy to Reduce
the Harmful Use of Alcohol;
• Strengthen health systems that support primary care, prioritise early
detection and treatment, and improve access to affordable essential
medicines for NCDs.
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What is Multi-SectoralApproach?
• Working together across sectors to improve health and
influence its determinant
• A number of other terms are used, often inter-changeably,
for engaging sectors outside of health. These include:
• Inter-sectoral action for health.
• Multi-stakeholder action.
• Whole-of-government.
• Health-in-all policies.
• Healthy public policies.
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Why MSA?
• Governments can make substantial achievements in reducing
the burden of NCDs through MSA.
• Forging new collaborations and partnerships are critical in
making progress in addressing the NCD epidemic.
• Partnership occurs at different levels:
• Individuals, families and communities.
• Government, communities and NGOs.
• Government, development partners (within countries), civil
society and, as appropriate, the private sector.
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‘Whole-of-Government’ and
‘Whole- of-Society’approach
• ‘Whole-of-Government’ denotes
public service agencies working
across portfolio boundaries to
achieve a shared goal and an
integrated government response
to particular issues
• Responsibility for health and its
social determinants rests with
the whole society, and health is
produced in new ways between
society and government.
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Social Determinants of Health
17
Challengesin operationalising Multi-
sectoral Approach (MSA)
• No or ineffective multisectoral mechanism at national level;
• No high-level commitment and support for coordinated
operation;
• No or low level representation from different sectors in MSA
mechanisms;
• No mandate, agreed roles and responsibility of sectors;
• No joint plan with agreed target, indicator approach, and
inputs; and
• No auditing and valid reporting mechanism.
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NCD Targets & MSA
• 25% relative reduction in NCD mortality (between 30-70
years) has been adopted as a global target during the 65th
World Health Assembly in May 2012.
• A set of global targets and indicators has been decided in a
Formal Meeting with Member States in November 2012, and
will be presented for adoption in the 66th World Health
Assembly (WHA in May 2013).
• The Global Monitoring Framework on NCDs consists of 25
indicators, with 9 voluntary global targets.
• Having targets and indicators will provide clear direction for
MSA and facilitate identifying the role and responsibility and
accountability for the different sectors. 19
What is new?
"Best buys" interventions to address NCDs
Population-
based
interventions
addressing
NCD
risk factors
Tobacco use - Excise tax increases
- Smoke-free indoor workplaces and public places
- Health information and warnings about tobacco
- Bans on advertising and promotion
Harmful use
of alcohol
- Excise tax increases on alcoholic beverages
- Comprehensive restrictions and bans on alcohol marketing
- Restrictions on the availability of retailed alcohol
Unhealthy
diet and
physical
inactivity
- Salt reduction through mass media campaigns and reduced salt
content in processed foods
- Replacement of trans-fats with polyunsaturated fats
- Public awareness programme about diet and physical activity
Individual-
based
interventions
addressing
NCDs in
primary care
Cancer - Prevention of liver cancer through hepatitis B immunization
- Prevention of cervical cancer through screening (visual
inspection with acetic acid [VIA]) and treatment of pre-
cancerous lesions
CVD and
diabetes
- Multi-drug therapy (including glycaemic control for diabetes
mellitus) for individuals who have had a heart attack or stroke,
and to persons at high risk (> 30%) of a cardiovascular event
within 10 years
- Providing aspirin to people having an acute heart attack
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11. 4/15/2013
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Tobacco
use
Harmful
use of
alcohol
• Excise tax increases
• Smoke-free indoor workplaces and public places
• Health warnings
• Bans on advertising and promotion
• Excise tax increases on alcoholic beverages
• Comprehensive restrictions and bans on alcohol
marketing
• Restrictions on the availability of retailed alcohol
• Salt reduction through mass media campaigns and
reduced salt content in processed foods
• Replacement of trans-fats with polyunsaturated
fats
• Public awareness programme about diet and
physical activity
HEALTHY CITIES AND ISLANDS SETTINGS SUCH AS SCHOOLS, WORKPLACES
ADVOCACY, HEALTH IMPACT ASSESSMENT  HEALTH IN ALL POLICIES
MSA, ‘Best Buys’ and Sectors
MSA
Unhealthy
diet and
physical
inactivity
Ministries including
• Health
• Agriculture
• Finance
•Transport
• Trade and Industry
• Education
• Labour
• Urban planning
• Justice
Other stakeholders including
• Industry
• Civil society
• NGOs
• Academia
MINISTRIES
 Health,
 Agriculture,
 Finance,
 Transport,
 Trade and Industry
 Education,
 Labour,
 Urban planning,
 Justice
OTHER STAKEHOLDERS
 Civil society,
 NGOs,
 Academia,
 Private sector,
 Donor, development
partners
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Examplesof bestpractices and
effectiveapproachesfor MSA
- Tobacco Control
• Tobacco taxation and Health
Promotion Foundations in
Australia, Lao PDR, Korea,
Malaysia, Mongolia, Tonga,
Viet Nam
• Plain packaging- a path
breaking approach in Australia
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Examples of best practices and effective
approaches for MSA
- Promoting Healthy Diet
• Healthier foods in Singapore-Hawker Fare
• Salt reduction in China and Mongolia
• Eat smart restaurants (700+), Hong Kong
(China)
• Eat smart @ school (400), Hong Kong
(China)
23
Examplesof best practices and
effectiveapproachesfor MSA
-Promoting Physical Activity
• Exercise equipment in public parks
in Lao PDR, China, Korea
• Walk paths, and cycling tracks in
Cambodia, Korea, China, Malaysia
• Community physical exercise groups
clubs in Seongbuk, Korea and Shanghai,
China
• Walking days in Dalin, Seongbuk, Xiamen
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Examples of best practices and effective
approaches for MSA
- Tobacco Control & Reducing Harm from
Alcohol
• The Mongolia’s President initiative in
alcohol control, non- alcohol in
government’s function and new alcohol
legislation.
• Development of legislation: drinking and
driving, use of helmet, blood testing:
China, Cambodia, Philippines, Vietnam.
• Regulating informal alcohol
control in Vietnam. 25
Examples of best practices and effective
approaches for MSA
-Healthy Cities
• Smoke-Free Cities:
• Harbin, QingDao, China.
• Makati and Marikina, Philippines.
• Luang Prabang, in Lao PDR.
• Siem Reap, Cambodia .
• Environmentally sustainable healthy urban
transport (ESHUT) in 5 Asian cities:
• Promote walking, cycling.
• Public transport system.
• Reduce use of private vehicles.
• Smoking ban.
• Promoting health and hygiene.
• Barrier-free transport environments.
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Examples of best practices and effective
approaches for MSA
-Healthy Settings: Health Promoting
Schools and Work Places
• Health Promoting schools for multiple
health interventions - Singapore, Hong
Kong, Macao (China).
• Healthy workplaces - Shanghai, Hong
Kong, China.
27
MSA-Entry Points
National multi-ministerial forumNational
• Effective only with commitment at the highest level,
need a good driver, Health in All Policies
City/District/Village levelSubnational
• More feasible, leverage local government, collective
voice of community, government closer to the
community, local ordinances
Tobacco/Alcohol/Physical ActivityRisk factor
• Facilitators-activism, pressure groups, champions,
international agreements (FCTC), global reporting,
more palpable interventions, common good /common
enemy
Inter
ministerial
Local
Government
Cross sector
working groups 28

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MSA – Accountability and Reporting
• Experiences from MDG 4 and 5 in accountability framework.
• Agreed national targets and indicators.
• Sector-specific roles, responsibility, target, inputs and outputs.
• Joint statement and joint plan.
• Across sectors audit, evaluation.
• Public reporting.
29
Rio+20:
“NCDsconstituteoneofthemajorchallengesfor
sustainabledevelopment”
“We understand the goals of
sustainable development can only
be achieved in the absence of a
high prevalence of debilitating
communicable and NCDs, and
where populations can reach a
state of physical, mental and social
well-being.” [paragraph 138]
“We acknowledge that the global
burden and threat of NCDs
constitutes one of the major
challenges for sustainable
development in the 21st century.”
[paragraph 141]
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UNSystemTaskTeamonthepost-2015UN
DevelopmentAgenda:
NCDsisapriorityforsocialdevelopmentand
investmentsinpeople
“The MDGs did not adequately address
… increase in NCDs. ” [paragraph 19]
“Priorities for social development and
investments in people would include:
… NCDs. Access to sufficient nutritious
food and promotion of healthy life
styles with universal access to
preventive health services will be
essential to reduce the high incidence
of NCDs diseases in both developed
and developing countries.” [paragraph 67]
31
National Strategic Plan for
Non-Communicable Diseases
(NSP-NCD)2010-2014
• Presented and approved by the Cabinet on 17
December 2010
• Provides the framework for strengthening NCD
prevention & control program in Malaysia
• Adopts the “whole-of-government” and “whole-of-
society approach”
Seven Strategies:
1. Prevention and Promotion
2. Clinical Management
3. Increasing Patient
Compliance
4. Action with NGOs,
Professional Bodies & Other
Stakeholders
5. Monitoring, Research and
Surveillance
6. Capacity Building
7. Policy and Regulatory
interventions
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Strategy 7: Policy & Regulatory
Interventions
• Main thrust of NSP-NCD
• Health promotion and education will increase
awareness and knowledge
• However changes in behaviour is strongly influenced
by our living environment
Awareness Knowledge
Behavioural
Change
Supportive living
environment
Health promotion & educations
Policies & regulations
33
CabinetCommitteeforAHealthPromoting
Environment
• To support the implementation of NSP-NCD, the Cabinet on 17 December 2010
approved the establishment of a Cabinet-level committee, chaired by the Right
Honourable Deputy Prime Minister, and comprises of 10 members
1. Minister of Health
2. Minister of Education
3. Minister of Information, Communications, Arts & Culture
4. Minister of Rural & Regional Development
5. Minister of Agriculture and Agro-based Industry
6. Minister of Youth & Sports
7. Minister of Human Resource
8. Minister of Domestic Trade, Co-operatives and Consumerism
9. Minister of Housing and Local Governments
10. Minister of Women, Family and Social Affairs
Main TOR: To determine policies that creates a living
environment which supports positive behavioural changes
of the population towards healthy eating and active living
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Challengesfor Malaysia
• The main challenge in policy and regulatory interventions
remain that they are mostly under the responsibilities of
ministries and departments other than Ministry of Health
• Ministry of Health needs to take leadership role.
• Need to find a win-win solution – “mutuality of interest”.
• Economic and “political” consideration remains paramount
and needs to be acknowledged.
• For Malaysia, the establishment of the Cabinet Committee was
an important initial step to achieve the “whole-of-government
approach”.
• The health sector needs to play a strong advocacy role.
35
Summary
• Preventing and controlling NCD is an urgent priority for all
countries.
• Most of the drivers of NCDs and their risk factors lie outside
the control of the health sector.
• MSA is required to create enabling environments, so that
healthy choices are the easy choices.
• MSA is also required to break the cycle of poverty and NCDs.
• The prevention and control of NCDs and their risk factors
have a positive impact not only on health, but also on
productivity and economic and social development.
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Thank you
37