Public health Solutions for prevention of Non communicable diseases

1. Public Health Solutions for Prevention and
Control of Non-communicable Diseases
Pooja Karki
MPH 2021
School of Public Health and Community Medicine
17August, 2021

2. Outline of Presentation
1. Introduction
2. Global Scenario
3. Activities being carried out globally
4. NCD burden among the poorest billion
5. SEAR Scenario
6. Scenario of Nepal
7. Guiding principles to address NCDs in Nepal
8. Public Health Initiatives in Nepal
9. Basic NCD services in Nepal
10. Challenges in the current public prevention and control programs
11. Evidences on Public health approaches for prevention and control of NCDs
12. Recommended Public Health Solutions for Prevention and Control of NCDs 2

3. Non-Communicable Diseases(NCDs) :
Introduction
• Non-communicable diseases (NCDs), also known as chronic diseases,
are of long duration, generally slow progression and do not transmit from
one affected individual to another.
• NCDs are the result of a combination of genetic, physiological,
environmental and behavioral factors.
[WHO]
3

4. Non-Communicable Diseases(NCDs) :
Introduction
Chronic conditions are characterized by the following:
Do not result from an (acute) infectious process
Are “not communicable”
Cause premature morbidity, dysfunction, and reduced quality of life
Usually develop and progress over long periods
Often initially insidious
Once manifested there is usually a protracted period of impaired health
4

5. Non-Communicable Diseases and Injuries
(NCDIs): Extended Definition
 NCDs are also referred as NCDIs and also include:
• Chronic mental illness
• Injuries, which have an acute onset, but may be followed by prolonged
convalescence and impaired function.
5
[CDC]

6. Risk factors
6

7. Non-Modifiable Risk Factors
Risk factors that cannot be reduced or controlled by intervention, for
example:
• Age
• Gender
• Race
• Family history (genetics) etc.
7

8. Modifiable behavioral risk factors
• Tobacco use : More than 8 million deaths every year
• More than 7.2 millions deaths - First hand smoke
• Around 1.2 millions deaths - Second hand smoke
• Physical inactivity: Annual 1.6 million deaths.
• Unhealthy diet: Excess salt/sodium intake contribute to 4.1 million annual deaths
• Harmful use of alcohol: Annual deaths of 3.3 million attributable to alcohol use.
• More than half of these alcohol attributable deaths are from NCDs, including
cancer.
8
[WHO]

9. Metabolic risk factors
• Raised blood pressure: Leading metabolic risk factor. 19% of global deaths
attributable.
• Overweight/obesity: As of 2016,1.9 billion adults overweight. More than 1% annual
rise in High BMI from 1990-2019.
• Hyperglycemia :
• Annual increase in risk exposure of Fasting Plasma Glucose (>1%) over past two
decades.
• Third leading metabolic risk factor in terms of attributable deaths.
• Hyperlipidemia : Stagnant risk exposure for LDL cholesterol over the past decade.
9
[GBoD study 2019,WHO]

10. Environmental risk factor
• Air pollution : Around 8 million annual deaths attributable.
• Ambient particulate matter pollution : Attributed 4.2 million deaths annually. Largest
increase in risk exposure in past two decades.
• Household air pollution : Attributed 3.8 million deaths annually.
Substantial decrease in household air pollution
The poorest billion still at high risk.
• Prevalence of biomass fuels use among them : 98% . [NCDI poverty commission]
• Other occupational risks and living environment: Arsenic in water, occupational
carcinogen, high noise levels, stressful working environment etc.
• Environmental factors linked with 23% of global deaths.
10
[WHO]

11. Fig 1 NCD tree :Relation of Social determinants, Risk factor, metabolic factor and diseases
Social economic
status and political
situation
Urbanization
Business and
market
Globalization and
Information technology
Hidden
Causes
Obesity, HTN, Glucose,
Cholesterol in Blood
Risk Behaviour
Metabolic
Factors
NCDs
11
[WHO PEN]

12. Fig 2: 5×5 approach 12
[UNHLM 2018]

13. Fig 3:Tip of the iceberg phenomenon 13

14. NCDs: Tip of the iceberg phenomenon
• Analogy of an iceberg is used to describe the disease pattern in the community or the
population.
• The tip of the iceberg represents what the clinicians see.
• The submerged part is explored and made visible by the epidemiologists.
• Tells the progress (pathogenesis and spread) of a disease from its sub-clinical stages
to apparent disease state.
• The large hidden part constitutes the mass of unrecognized disease in the population
and determines the fate of any disease control program.
14

15. Global scenario of NCDs
• Accounts to 71% of all deaths globally, kills 41 million people each year.
• In 2019, 7 of the 10 leading causes of deaths were NCDs which accounted for 44% of all
deaths or 80% of the top 10.
• 77% of all NCD deaths and 85% of premature NCD deaths are in low- and middle-
income countries.
• Cardiovascular diseases account for most NCD deaths, or 17.9 million people
annually, followed by cancers (9.3 million), respiratory diseases (4.1 million), and
diabetes (1.5 million).
These four groups of diseases account for over 80% of all premature NCD deaths.
15
[WHO]

16. Global scenario of NCDs
• NCDs constitute almost all top ten leading causes of DALYs in 2019,among the age
over 50 years old.
• Ischemic heart disease and stroke were the top-ranked causes of DALYs in both the
50-74 year and 75-years and older age groups.
• Among the top ten causes, large declines in DALY rates for ischemic heart disease,
stroke, COPD, cirrhosis, and road injuries in age groups over 50 years between 1990
and 2019 , but increased in DALY rates for diabetes and chronic kidney disease.
16
[GBoD,2019]

17. Fig 4: Top 10 leading causes of global deaths
17

18. Activities being carried out globally for reducing
NCDs
Global Strategy for the Prevention and Control of Non-Communicable Diseases 2000.
WHO Framework Convention on Tobacco Control 2003.
Global Strategy on Diet, Physical Activity and Health 2004.
Global Strategy to Reduce the Harmful Use of Alcohol in 2010
Global Hearts Initiative
UN high level meeting on NCDs 2018
WHO Package of Essential Non communicable Disease Interventions (WHO PEN)
WHO Global action plan for the prevention and control of NCDs 2013-2020
Global Action Plan on Physical Activity 2018-2030 18

19. NCDs included in the 2030 Agenda for Sustainable Development
Fig 5: Sustainable Development Goals 19

20. • Change in the disease profile from communicable diseases to NCDs resulted in the
inclusion of NCDs in the 2030 agenda for sustainable development.
• It recognizes NCDs as a major challenge for sustainable development.
• By 2030:
• Target 3.4: Reduce by one third premature mortality from NCDs by prevention,
treatment and by promoting mental health and well-being.
• Target 3.a: Implement the WHO tobacco treaty
• Target 3.5: Reduce the harmful use of alcohol
• Target 3.6: Halve the number of global deaths and injuries from road traffic
accidents
2030 Agenda for Sustainable Development
20

21. NCDI burden among the poorest billion
• Poorest billion: About one billion people in low-income and lower-middle-income
countries (LLMICs) categorized on the basis of Multidimensional Poverty Index.
• NCDIs are an important, yet an under-recognized and poorly-understood
contributor to the death and suffering among these populations.
• This NCDI burden among poorest billion is also collectively known as NCDI
poverty.
• NCDI responsible for nearly 800,000 deaths every year among people aged
younger than 40 years that amounts to more under 40 deaths than caused by HIV,
tuberculosis, and maternal causes combined.
21
[The Lancet NCDI Poverty Commission,2020]

22. NCDI burden among the poorest billion
• 49% NCDI Poverty burden is avoidable resulting in 2·4 million avoidable
deaths and 93·8 million avoidable disability-adjusted life-years (DALYs) every
year.
• NCDIs account for around 35% of all-age DALYs.
• Nearly 5 million (22%) of the Nepalese population would be part of this poorest
global billion.
Central Terai and Mid-western Hill have the highest number of the poorest
billion.
22
[The Lancet NCDI Poverty Commission,2020]

23. South-East Asia Region (SEAR) Scenario
• Non communicable diseases (NCDs) mainly cardiovascular diseases, chronic
respiratory diseases, diabetes and cancer are top killers in the South-East Asia
Region, claiming an estimated 8.5 million lives each year.
• Of the projected global increase of 15% NCD deaths between 2010 and 2020 (44
million deaths) ,10.4 million deaths was estimated to occur in South-East Asia.
• 48% of all NCD deaths in SEAR are premature deaths (below the age of 70 years.)
23
[WHO]

24. Scenario of Nepal
• The deaths due to NCDs (Cardio-Vascular Disease, diabetes, cancer and respiratory
disease) have increased from 60% of all deaths in 2014 to 66% in 2018.
• In 2017 NCDs contributed to 59%, largest proportion of total DALYs in Nepal.
• Among all DALYs, 37.9% of NCDS and 79% from injuries occur before the age of 40.
• Injuries contributed to 10% of total DALYs in 2017.
• Almost 14% of deaths are attributable to high systolic blood pressure, 13% to smoking,
10% to high blood glucose levels, and 7% to ambient air pollution.
24
[WHO, NBoDstudy 2017, The Nepal NCDI Poverty Commission 2018]

25. Scenario of Nepal
• Global targets in NCDs largely focus on four major diseases , however 60% of death
and disability from NCDIs in Nepal are due to other conditions.
• In the year 2076/77 , 89.69 % NCDs were reported in outpatient consultation.
• Among the cases admitted to hospital ,there were nearly five times as many non-
communicable disease deaths as communicable disease deaths.
• Hypertension, Gastritis , falls and injuries, musculoskeletal pain were among the top
ten causes of outpatient consultation.
25
[The Nepal NCDI Poverty Commission 2018,Annual report 2076/77]

26. Fig 6: Top 10 causes of DALYs in Nepal by all-age, percentage of total DALYs for both sexes and percent change from 1990 to 2017 26

27. Health expenditure and Out of pocket
expenditure
• Domestic general government health expenditure was 25% out of current health
expenditure in 2018.
• Out of total health expenditure in Nepal, 50.8% was from out of pocket in 2018.
• Slightly more than half of total Out of Pocket (OOP) expenditure goes for NCDs.
(2018)
• As per the data of 2014 ,the government health spending on NCDIs was only
6.4%.
27
[The World Bank, The Nepal NCDI Poverty Commission 2018]

28. WHO 2018
COUNTRY PROFILE
Fig 7: Proportion of mortality due to NCDs in Nepal
28

29. Guiding principles to address NCDs in Nepal
Policies
• National health policy 2076
• National mental health policy 2053
• National oral health policy 2071
• The regulation of Tobacco Products (Control and Regulatory) Act 2011
Strategies
• Global Strategy on Diet, Physical Activity and Health (2004)
• Action Plan for the Global Strategy for the Prevention and Control of Non communicable
Diseases (2008- 2013)
• Global Strategy to Reduce the Harmful Use of Alcohol in 2010
• WHO Framework Convention on Tobacco Control 2011 29

30. • National Health Sector Strategy -NHSS (2016-2020)
• Multi Sectorial Action Plan for Prevention and Control of NCD (2014-2020)
• Standardized treatment protocol for top 10 common cancers in Nepal
• Standard treatment protocol for emergency health package 2078.
• National mental health strategy and action plan 2077
Primary health care related programs
• Package of Essential Non Communicable Disease (PEN) Intervention
• MhGAP (mental health gap action program) for Mental Health
Guiding principles to address NCDs in Nepal
30

31. Commissions
• The Nepal NCDI Poverty Commission
• Periodic (studies)
• Global burden of disease Study 2017
• STEPS survey 2019
• Global Youth Tobacco Survey
• Global School Health Survey
• National Mental Health Survey 31
Guiding principles to address NCDs in Nepal

32. Public health initiatives in Nepal
Free health care policy
Impoverished Citizen Treatment Fund (Bipanna Nagarik Ausadhi Upachaar Cosh)
Mental Health Activities
Anti-drink and drive campaign against road traffic accidents
 Dialysis
Tobacco Control Program- Nepal
Package of Essential Non-communicable (PEN) Disease Interventions for Primary Health
Care
म स्वस्थ; मेरो देश स्वस्थ अभियान
32

33. Free health care policy (FHCP)
Free health care policy (FHCP) was introduced in 2007 under the second long
term health plan 1997-2017 (SLTHP).
The free Essential Health Care Services (EHCS) comprised of free registration,
available basic health service and the free essential drugs.
The NCD drugs were included in the free essential drug list in 2011.
Now these services along with some additional services is being provided through
Basic Health Services Package 2075.
However, the availability of medicines for NCDs is low.
33

34. Impoverished Citizen Treatment Fund (Bipanna
Nagarik Ausadhi Upachaar Cosh)
A fund was established in 2013 to support the poor (up to USD 1000) who otherwise
would not be able to access services.
Conditions for provision of Treatment Support (8 diseases):
• Cancer, Renal diseases, Cardiac treatment, Parkinson’s, Alzheimer’s disease,
Sickle cell anemia, Spinal Injuries, and Head Injuries.
 Recently added three conditions
• Thalassemia, Liver transplant, Bone marrow transplant
34

35. (Children Assistance Program-CAP) and
(Senior Citizen Program-SCP)
Provision of free cardiac care
• Under 15 years of age (Children Assistance Program-CAP)
• Above 75 years of age (Senior Citizen Program-SCP).
The age group in between 15 and 75 years receives up to one lakh Nepalese
rupees from the Bipanna Nagarik Aushadhi Upachaar Cosh.
 Provision of free treatment for Rheumatic heart disease and free valve
replacement in Shahid Gangalal National Heart Center and Manmohan Cardio
Vascular Thoracic and Transplant Center for the Rheumatic Heart Disease.
35

36. Mental health actions
• Significant improvement since the year 2011.
• Establishment of NCD and mental health section on EDCD under the multi-sectoral
action plan.
• Increment of the total number of mental health workforce with mental health beds of
1.5 per 100,000 population.
• Initiation of the community based basic and integrated mental health services under
the five year mental health action plan 2077.
36
[Nepal mental health strategy 2077,The Nepal NCDI Poverty Commission 2018]

37. • However ,only limited specialist are available in mental health services.
• No counseling and the psychotherapeutic services available in the primary health
care level.
• The mental health policy framework needs to be implemented to the Zonal or
District level .
• Out of 75 districts only 7 districts provide mental health services.
Mental health actions
37
[Nepal mental health strategy 2077,The Nepal NCDI Poverty Commission 2018]

38. Anti-drink and drive campaign against road
traffic accidents
• Started in December 2011 under “The vehicle and transport management” act 2049.
• The traffic police have the authority to fine USD 10 and compel the offender to take
the Traffic awareness classes.
• The breathalyzer is used to estimate the blood alcohol content (BAC) from the breath
sample.
• More effective in decreasing the injuries.
• The injuries caused by alcohol drinking have decreased by more than 50% in the
Kathmandu valley. 38

39. Dialysis
• Estimated 3000 people develop kidney failure every year.
• The cost of dialysis ranges from NRs 1,20,000 to 2, 40,000 per year depending on the
service center.
• Currently 45 hemodialysis centers in Nepal
Services providing free hemodialysis in Nepal is 30.
(11 in valley and 19 out of the valley).
• Patients can receive treatment equivalent to $1000 for hemo-dialysis and peritoneal
dialysis and $2000 for the renal transplant.
• For those undergoing renal transplantation, $1000 is provided for the medication for one
year. 39

40. Tobacco Control Program- Nepal
Implementation of health warnings on tobacco products
 Prohibition of smoking in public places :
Workplaces and on public transport
Declaration of Smoke-free places
Levying health tax from tobacco industries for the treatment of diseases caused by
tobacco use
Allocation of funds to disseminate information and conduct education
Communication activities on the harmful effects of tobacco use
Enforcement of ban on tobacco advertisements through hoardings
40

41. MPOWER policy package in Nepal
• The NHEICC as the national focal point for tobacco control is implementing its
activities in line with these six policies :
• Monitor tobacco use
• Protect people from tobacco smoke
• Offer help to quit tobacco use
• Warn about the dangers of tobacco
• Enforce bans on tobacco advertising and promotion
• Raise taxes on tobacco products.
41

42. Package of Essential Non communicable
disease (PEN)
• To scale the essential NCD services even in resource constraint settings , WHO
has developed cost effective PHC intervention known as Package of Essential Non
communicable disease (WHO-PEN).
• Diseases and risk factors addressed through PEN approach (4 × 4 framework)
• 4 NCDs Major 4 Risk Factors
42

43. Smoking Unhealthy diet
Physical
inactivity
Harmful Use of
Alcohol
Cardiovascular
Diseases    
Cancer    
Diabetes    
COPD 
Risk factors
(4 disease X 4 modifiable shared risk factors = 80 % minimize the risk)
43

44. Aims to cover 77 Districts within FY
2078/79
44
Fig 8 : Implementation Status : PEN Nepal

45. Protocol 1: Prevention of Heart Attacks, Strokes and Kidney Disease through
Integrated Management of Diabetes and Hypertension
• Assessment, Routine management of hypertension, Diabetes Mellitus and screening
targeting specific population and referral as required.
Protocol 2: Health Education and Counseling on Healthy Behaviors
• Education and counseling using 5A’s and 5R’s for
Physical activity
Healthy diets
Attending regular medical follow-up, adherence to treatment
Cessation of smoking and harmful use of alcohol
PEN Protocols
45

46. WHO PEN Protocol 3:
3.1Management of Asthma
3.2Management of Management of Chronic Obstructive Pulmonary Disease
• Assessment of severity
• Treatment
• Advice
46
PEN Protocols

47. Protocol 4:
4.1 Assessment and referral of women with suspected breast cancer
4.2 Assessment and referral of women with suspected cervical cancer
• Assessment of signs and symptoms (i.e. history, intensity, duration, progression)
• Identification of relevant risk factors
• Referral as required
47
PEN Protocols

48. Essential instruments and tools and Core list of
medicines for PEN
Instruments= Glucometer, Sphygmomanometer , Measurement tape , Peak flow meter,
Meter Dose Inhaler
 Tools=Evidence based clinical protocols, Medical information register etc
• And the core list of medicines are:
Insulin
Aspirin
 Salbutamol
Metformin etc
48

49. Best Buys Approach
• Investing 1.27 US dollar per person per year, low and middle income
countries can adopt Best Buys.
• Each nation by investing 1 US $ can help getting back at least 7 US $
back, it could reduce 15% premature death.
• Helps in prevention of
17 million ischemic heart and stroke
cases.
49

50. मेरो वर्ष: म स्वस्थ, मेरो देश स्वस्थ अभियान
50
Fig 9: Mero barsha abhiyan

51. Basic NCD Services in Nepal
51

52. Level of consultation NCD basic services
Community Health Unit (CHU)  NCD, Mental health counselling
 Substance abuse, legal and GBV counselling)
 Growth monitoring, HTN and BMI screening
 Acute exacerbation of COPD and
 Asthma emergency management
Health Post (HP)  Screening for visual and hearing impairment
 Screening for hypertension and Diabetes
 (Clinical) Screening for pelvic organ prolapse, obstetric
fistula, cervical cancer (VIA)
 Urine dip-stick test (albumin and sugar)
Primary Health Care Center (PHCC)  Minor procedures such as simple fracture reduction
 Biochemistry: Sugar and Urea
District Hospital (DH)  Treatment of Epilepsy
 Treatment of Schizophrenia, bi-polar disorders
 Treatment for depression and anxiety
 Physiotherapy services
52
[NCDI commission]

53. Fig 10 Implementation of Task Sharing at Primary Health Care Setting
•Screening and referral by paramedic
•Refilling of drugs
HP
District
Hospital
PHCC
•Diagnosis and treatment by Medical Officer
•Referral
•Diagnosis and treatment by Medical Officer
•Referral
Tertiary
Hospitals
•Diagnosis and treatment by Medical Officer
•Referral
Referral for Refilling
of Drugs
High risk only those person who
visited in HF with suspected
disease
No specific management
of referral and protocol
program for this level not
developed
Team based care
53

54. Challenges in current prevention and control
programs
• Loopholes in NCDs implementation of policies and plans.
Government programs focuses on communicable diseases.
• Difficulty in priority-setting.
• Impact of economic, commercial, and market factors.
• Insufficient technical, operational capacity and resources for the effectiveness of
implemented programs.
• Insufficient (domestic and international) financing to scale up national NCD
responses.
54

55. Challenges in current prevention and control
programs
• Focused on changes in human behaviors only.
• Inadequate resources available for the poor to be properly nourished, live safely, and
to access health care.
• Information and education interventions generally less effective than regulation, fiscal
policies, and public investment in reaching the disadvantaged group.
• Lack of political will, commitment, capacity, and action.
• Lack of accountability.
55

56. Evidences on Public Health Approaches
for Prevention and Control of NCDs
56

57. 57

58. 58

59. 59

60. 60

61. Recommended Public Health Solutions for
Prevention and Control of NCDs
61

62. 1.Prevention of Risk Factors in Different
Levels of Prevention
62

63. Primordial Prevention
Methods Activities
Health education  Health information and warnings
 Public awareness through mass media campaigns on diet
and physical activity, tobacco and alcohol use
 Life style modification.
 Healthy diet.
 Discouragement of harmful habits.
63
[Best Buys approach]

64. Primary prevention
Methods Activities
Health
Promotion
 Tobacco and Alcohol:
• Raise in tobacco and alcohol taxes and restrict access to retailed tobacco and alcohol
• Strengthen enforcement of smoke-free indoor workplaces and public places and laws on
ban on advertising, promotion and sponsorship
• Screening for misuse of Tobacco, Alcohol, Prescription medications, and other
Substance [TAPS].
• Sustain and scale up drink driving enforcement programs at provincial and local levels.
• Review and set up programs for underage drinking prevention and control.
• Establish community-based approaches to curb the use of locally brewed alcohol in
selected communities
64
[Best Buys approach,,MSAP]

65. 65
Methods Activities
Health
promotion
 Unhealthy diet
• Reduced salt intake
• Replacement of trans fat with polyunsaturated fat
• Promote healthy diet- increased consumption of fruits and vegetables.
• Addressing informal sector food sellers, vendors on food safety and healthy diets.
• Settings (school) based actions to promote healthy diets
 Physical activity promotion :
• Projects for urban walkable/cycling/community-park environment.
• Setting-based physical activity (work places, schools and institutions) and health
promotion activities including yoga, meditation.
• Maintenance of healthy body weight.
Primary prevention
[Best Buys approach, MSAP]

66. 66
Methods Activities
Health
promotion
 Cancer
• Hepatitis B and HPV immunization to prevent liver and cervical cancer
 Air pollution
• Improvement of living conditions.
• Initiatives to replace solid biomass fuels with best alternatives and prevent
ambient air pollution.
• Strengthening capacities of cities to monitor their air quality.
• Monitoring industrial pollution.
• Enforcement of laws to ban old vehicles.
• Promoting public transport and walking for short distance.
Primary prevention
[Best Buys approach]

67. Secondary Prevention
Methods Activities
Early diagnosis and treatment  Screening and treatment of precancerous lesions to
prevent cervical cancer.
 Multidrug therapy for people with a high risk of
developing heart attacks and strokes including those
with established CVD.
 Treatment of heart attack with aspirin
 Proper treatment and care for NCDs.
67

68. 68
Methods Activities
Prevention of disability  Adherence to treatment and healthy life style.
 Regular follow up and monitoring of blood
pressure, glucose and lipid levels
 Rehabilitation
 Support groups
Tertiary Prevention

69. 2.Prevention and management of NCDs with
small and large-scale human cooperation
69

70. Fig :11 Prevention at different scale human cooperation
70

71. Fig 12 : Role of government in promoting health 71
[UNHLM 2018]

72. Fig 13 : Role of people in promoting health
72
[UNHLM 2018]

73. 3.Recommended Intervention
approaches for NCDs for low resource
settings
73

74. Expansion of priority NCDI conditions and
relevant interventions
• The priority of NCDI should be expanded from globally targeted major diseases
focus to wider aspect on NCDs which require priority attention.
• Expanded set of NCDIs particularly those affecting women and children, mental
health disorders, injuries, and conditions requiring surgery, rehabilitation, or
palliative care.
• Tailored approach should be introduced to prioritize and intervene conditions.
74

75. Multi sectoral interventions :
• Addressing behavioral, environmental, and other NCDI risks like regulation and
taxation to discourage consumption of unhealthy products.
• Investments to fortify foods and to make fruits, vegetables, healthy carbohydrates,
and proteins more available should be emphasized.
• Targeted investments to improve housing and household energy among the poorest
to address household air pollution.
75

76. Ministry/agency Potential roles in NCD prevention and control
1. Office of Prime Minster and Council
of Ministers/Chief Secretary
Coordinate for annual National Steering Committee meeting and circulate guidance of the
committee to the stakeholders, monitor progress on MSAP
2. Ministry of Education • Health education on NCD prevention in schools through curricular or non-curricular
approaches ,
• Enforcement of ban of unhealthy food, consumption of alcohol and tobacco within and
around school premises
• Mandate implementation of physical activity guidelines
• Form alliance with schools and college associations to promote healthy diet and increase
physical activity
3. Ministry of Youth and Sports Promotion of national guidelines for physical activity and diet.
4. Ministry of Home Affairs Enforcement of tobacco, alcohol, road and traffic regulations
5. Ministry of Agriculture Development • Promote/ subsidize production of fresh vegetables to improve access
• Monitor food safety
• Strengthen capacity of central DFTQC and Regional food labs for testing and monitoring the
content of trans fat, sugar and processed foods with excessive salt
6. Ministry of Information &
Communication
Regulate ban on advertisement, promotion and sponsorships of alcohol, tobacco and unhealthy
food
76

77. 7. Ministry of Finance Pricing and taxation of tobacco, alcohol and unhealthy food products
• Increase tobacco taxation substantially (WHO recommends tobacco excise tax
should account for at least 75% of retail price of tobacco products)
• Increase taxation of alcohol and sugar sweetened beverages
8. Ministry of Federal Affairs and Local
Development
• Promote healthy lifestyle to prevent NCDs with local government budget.
• Awareness campaigns in communities involving consumer groups, farmers,
Citizen awareness Centers, Ward Citizens forums
9. National Planning Commission • Prioritize NCDs in budget allocation
• Involve CSOs, Academia, Private sector and Development partners in expanding
the NCD agenda
• Monitor progress of MSAP
• Support implementation of the plans in line with MSNP and Nutrition and Food
Security Action Plan to promote affordability, availability and acceptability of
healthier food products
11. Ministry of Urban development • Road safety
• Public transport
• Tobacco, alcohol, unhealthy diet control
77
Source :MSAP 2014-2020

78. Cost effective and highly equitable interventions
• Low cost, chronic medical treatment for several of the lethal or highly disabling
severe conditions in children and young adults (eg: type 1 diabetes, epilepsy,
rheumatic heart disease, and sickle cell disease).
• In settings where sickle cell disease is a public health concern, universal newborn
screening (For example in Tharu community in Nepal).
• Secondary prophylaxis with penicillin for rheumatic fever or established RHD.
• Treatment of acute pharyngitis to prevent rheumatic fever.
• Low-cost medical treatments that address acute and life-threatening manifestation of
chronic conditions (such as, acute heart failure and myocardial infarction).
78

79. Strengthening of Existing programs
• Scaling up of already existing NCDs programs by analyzing their potential role
and contributions when implemented on full fledged capacity.
• Implementing measures to increase efficiency, effectiveness and accessibility of
disadvantaged groups.
• Monitoring the progress and targets.
79

80. Contribution of Strengthening PEN implementation to Health
System Building Blocks
Leadership/governance • Assess needs/gaps in NCD services
• Facilitate use of available resources for NCD efficiently and equitably.
Financing • Prioritize NCD interventions to support raising of adequate funds for universal coverage
Medical products &
technologies
• Define prerequisites for integrating a core set of essential NCD interventions into primary care
• Develop an affordable list of essential medicines and appropriate technologies
Health information
system
• Provide templates (paper-based or electronic) to gather reliable information of people
Health workforce • Provide training material to enhance knowledge and skills for NCDs prevention
• Audit performance
Service delivery • Improve access to essential preventive and curative NCD medicine
• Provide equitable opportunities for early detection
• Define core set of cost-effective NCD interventions
• Provide tools for implementation of NCD interventions
• Improve quality of care
• Improve gate keeper function of primary care
• Reduce cost due to hospital admissions and complications
People • Develop tools for community engagement and empowerment of people for self-care
• Improve health outcomes
80

81. Life-course approach
Maternal health, including preconception, antenatal and postnatal care and
maternal nutrition.
Proper infant feeding practices, including promotion of breastfeeding.
Health promotion for children, adolescents and youth.
Promotion of a healthy working life.
Healthy ageing in later life.
Continuum of care for people with NCDs.
81

82. Fig 14 : Continuum of care
82
[Journal of Global health]

83. Health services strengthening
• Enhancing capacity of health providers through additional training.
• Emphasis on provision of essential medications and services at all levels of health
facilities.
• Strengthening existing services and resources for well recognized conditions, such
as type II diabetes, hypertension, heart disease and stroke, asthma and COPD
require greater resources.
83

84. Governance for NCDI response
• Decentralization of services to local level and integration with other existing services.
• Adequate resource allocation from government budget for NCDs.
• Reorientation for donor funds to include NCDIs.
• Engagement of all stakeholders for joint effort.
• Introduction of Disease-specific policies and programs for high-cost conditions.
• Palliative care should be integrated in primary health care.
84

85. Financial protection
• NCDIs on poorer portion has more lethal effect. Relief schemes should be adopted
for specific conditions for the poor.
• The social health insurance should reach to all the people and focus on poor .
• The insurance schemes should cover high priority NCDIs.
85

86. Focus on vision to invert the pyramid
Hospitals are taking a
high load of complicated NCDs
MI, strokes, dialysis cases
Primary health care is not
proactive in prevention , promotion and
early detection
Vision
Primary health care is
proactive in prevention ,
promotion and early detection
Existing
Fig 15 : Pyramid of Health service delivery
[WHO PEN]
86

87. 87
Organization of
proposed interventions
under Federal structure
Source : NCDI Commission

88. Conclusion
The burden of NCDs is a agenda of growing concern and a major public health issue
for our country. It is the leading cause of deaths.
The rise of NCDs is partly due to the changing age structure and lifestyle changes
such as increasing sedentary behavior, tobacco use, changes in eating habits, and
harmful use of alcohol.
Investment in health from an equity and cost effective perspective is essential to
yield better outcomes.
Individual, family, community, government and non government organizations should
make joint and long term efforts to tackle with NCDs.
88

89. References
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90. References
12. A systematic analysis for GBD 2019 Risk Factors Collaborators
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DISEASES 2013-2020
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91. 91