Non-communicable diseases (NCDs), particularly cardiovascular diseases (CVD) and diabetes are increasing dramatically in many low and middle income countries. The main reasons for this are an increase in major risk factors, particularly increasing obesity [as a consequence of changes in nutrition and decreases in physical activity], and high levels of tobacco use. In the Mediterranean partners involved in this project (Palestine, Syria, Tunisia, Turkey), obesity levels are particularly high among women, and tobacco use common in men.
Globalisation, urbanisation and an ageing population are contributing to this trend. A common misperception is that NCDs are diseases of affluence, but in fact they are common amongst poorer sectors of populations, and age-specific disease rates can be higher in developing countries than in industrialised settings. Health services in these countries, developed to tackle acute infectious diseases, are often not ideally organised to promote effective care and prevention for NCDs.
To be able to make recommendations about the policy initiatives, both within and outside the health sector, likely to be the most effective and cost-effective in reducing the burden of CVD and diabetes mortality and morbidity in each country.
MedCHAMPS used a mixed methods approach to identify potential policy initiatives in each of the four countries. We combined quantitative epidemiological modelling and economic evaluation, with situation and context analysis, to derive policy options and implementation plans in each country. Our research project coincided with tumultuous political upheaval in 2 of the 4 partner countries. Data collection for the situation analysis took place in 2010 and would have been inconceivable just a few months later.
Epidemiological modelling (IMPACT CHD mortality model): First, detailed epidemiological risk factor data required to populate quantitative models of coronary heart disease mortality, diabetes and stroke was collected and interpolated where needed. Key findings were a rise in BMI of 1-2kg/m2 over the previous 15 years; with diabetes prevalence increasing by 40%-50% in men and women in all four countries. Regional smoking prevalences were high in men, and persisting in Syria but decreasing in Tunisia, Palestine, and Turkey. Age adjusted CHD mortality rates ROSE by 20% in Tunisia and by 65% in Syria, and fell by 12% in Palestine and 17% in Turkey.
Adverse risk factors trends explained approximately 75% of the observed mortality rise in Tunisia and more than 90% of the increase in Syria. In Palestine risk factor changes explained more than 65% of the overall mortality fall with treatments accounting for approximately 30%. In Turkey, risk factor improvements explained approximately 60% of the overall mortality fall with treatments accounting for the remaining 40%.
Diabetes projection and policy modelling tool: We have developed and validated a new diabetes model, enabling us to project trends for a time period of 30 years in each country. The model has been tested in each of the 4 partner countries, as well as the US, UK and Saudi Arabia, and is now being used to explore the impact of prevention policies.
Stroke modelling: We developed a novel stroke model to explore policy questions regarding the prevention and treatment of ischemic strokes. We have first developed the model using high quality Dutch data, for testing and validation purposes, and are now testing it using data from Palestine and Tunisia.
Situation and context analysis: Work Package 5 (WP5) undertook a situation analysis of current CVD and diabetes policy in the four partner countries and analysed the contexts in which health systems manage CVD and diabetes in these countries, at a regional and sub-regional level. Three distinct ‘levels’ of data collection were carried out: documentary analysis; key informant interviews; and clinic fieldwork.
There is a formal recognition about the increased burden of non-communicable diseases in the partner countries. However, they are placed differentially in terms of planning and managing this emerging situation. While Turkey and Tunisia have developed some policies and strategies concerning CVD and Diabetes, Syria is lagging well behind in this regard. Despite the unique political context, Palestine is making good progress in this regard. However, it is also apparent that none of these countries has developed a comprehensive, multi-sectoral, well defined policy to deal with non communicable diseases.
The health management system was found to be highly centralized in all the partner countries and there is a lack of coordination between different departments. There is a major lack of information on CVD and Diabetes in all the four countries, as well as a shortage of skilled and specialist health personnel to manage these NCDs. Although the supply of medicine and equipment did not appear as a key problem, there is evidence of unequal distribution between regions, as well as between urban and rural areas.
While the degree varies between countries, our research shows that awareness regarding the risks of NCDs among patients is patchy and incomplete everywhere. At the same time, health facilities and treatment processes were generally experienced by patients as unfriendly (though this was much less the case in Palestine), with widespread complaints about the time given by health staff to explain the causes and consequences of their condition, and the reasons for the steps stipulated to manage it. Controlling NCDs is a complex challenge and it demands interventions both within and outside the health sector.
Policy options were short listed by the research team based on results from the quantitative epidemiological modelling and situation / context analyses, and the literature. Country specific policies were then selected by each country team and evaluated by key stakeholders (5-7) based on predefined criteria.
Policies were ranked based on their importance in relation to the policy makers’ input and 5 policies for each country were identified as top priority. Ten different policies were identified and action plans are being developed: 4 on the health system level addressing human resources, health information services, collaboration between stakeholder and strengthening the primary health care; 3 on the population level through raising awareness, reducing salt intake and reducing BP though screening; 2 as treatment interventions by increasing the uptake of metformin and secondary prevention for MI; and 1 on high risk groups with a focus on primary prevention for hypertensive patients using antihypertensive medications (beta blockers and diuretics).
Three policies to reduce population dietary salt intake were chosen for economic evaluation: a health promotion campaign, labelling of food packaging and mandatory reduction of salt content in processed food. All three of these policy options were evaluated separately and in combination. The costs of implementing each of the policies were estimated using a combination of existing evidence from comparable policies and expert opinion.
The total cost of implementing the policy and the associated health care costs were calculated and compared against the current baseline (i.e no policy). In all countries the majority of the evaluated policies were cost saving compared with the baseline. The combination of all three policies together resulted in estimated cost savings of; $235,000,000 and 6455 life years gained (LYG) in Tunisia; $39,000,000 and 31674 LYG in Syria; $6,000,000 and 2682 LYG in Palestine and $1,3000,000,000and 378439 LYG in Turkey.
Although each country has come up with specific recommendations to combat these challenges, the following were common: population-based intersectoral, comprehensive policies to control NCD risk factors by legislative, regulatory and health promotion measures; steps to improve staff numbers, staff accessibility and staff training; and empowering the public in the clinic treatment context as a necessary means to strengthen patients’ self management.
We have also identified key areas for improvement in data collection systems particularly for cause of death data. A lack of understanding of the differences between strategies, policies, action plans and guidelines was demonstrated by key informants working in health care settings. There was evidence that lifestyle and preventive interventions have been relatively neglected from key strategies, particularly interventions at a population level.
National partnerships formulated as a result of this project (including establishing the Project Management and Advisory Committee or ProMac, and contact with stakeholders and key informants) is also providing a novel foundation for the active engagement of academia and policy makers to improve CVD and DM health in each of the four Mediterranean partner countries. These new avenues for communications can be vital to advancing population health in the future, especially given the scarcity of such partnerships in the Eastern Mediterranean region at the moment.
Involving stakeholders and customers at various junctions of the health care system moreover is also helping to display the discrepancies between policy and reality, and is already drawing attention to the CVD and DM health needs of the underprivileged in these countries. Significant capacity development for junior researchers has also taken place during the project, particularly training in undertaking qualitative and using mixed research methods for understanding the social determinants of NCDs.