Increasing Burden of NCD in Malaysia: Challenges in resource allocation

Increasing Burden of Non-Communicable Diseases in Malaysia:Challenges in Resource Allocation

Feisul Idzwan Mustapha MBBS, MPH, AM(M)Public Health Physician, NCD Section, Disease Control Division

Ministry of Health, Malaysia

Payor Network Initiatives 201411 September 2014

Kuala Lumpur

[email protected]

Ministry of Health Malaysia

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

Noncommunicable diseases

Heart disease and stroke

Diabetes

Cancers

Chronic lung disease

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Proportional mortality, Malaysia (% of total deaths, all ages, both sexes)

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Premature mortality due to NCDs, Malaysia

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The probability of dying between ages 30 and 70 years from the 4 main NCDs is 20%

DALYs attributable to risk factors

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10.8%

10.7%

9.0%8.3%

5.2%4.3%

3.1%0.7%

0.1%

10.8%

0.7%11.4%

12.1%

5.1%0.9%

4.3%0.7%

0.1%

15.0% 10.0% 5.0% 0.0% 5.0% 10.0% 15.0%

High BP

Tobacco

Diabetes Mellitus

High BMI

High Cholesterol

Alcohol

Physical Inactivity

UnderweightPoor Water & Sanitation

Male Female

Burden of Disease Study Malaysia, slide courtesy of Dr Mohd. Azahadi Omar, Institute for Public Health

19.4%

15.7%

8.5%

7.3%

7.0%

5.0%

2.3%

0.2%

0.1%

22.8%

1.2%

9.1%

8.1%

8.2%

7.1%

0.3%

0.2%

0.1%

25% 20% 15% 10% 5% 0% 5% 10% 15% 20% 25%

High BP

Tobacco

Diabetes Mellitus

High Cholesterol

High BMI

Physical Inactivity

Alcohol

Underweight

Poor Water & Sanitation

Male Female

Deaths attributable to risk factors

Burden of Disease Study Malaysia, slide courtesy of Dr Mohd. Azahadi Omar, Institute for Public Health

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Sub-analysis of NHMS 2011 data

• At least 15% (18 years and above) already with known NCD risk factors (diabetes, hypertension or hypercholesterolemia).

• Undiagnosed high blood sugar, high blood pressure or high cholesterol: 42.1% (18 years and above).

• Or, if include obesity: 48.3% (18 years and above).

• Therefore our high risk and at risk population: 63.3% (18 years and above)

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Source of icons: World Heart Federation Champion Advocates Programme

Global NCD Targets

Cost effective NCD interventions…

• What works, what can we afford, and what should we adopt?• The challenge? Identify interventions that:

• are effective;• can lead to measurable declines in NCD death rates quickly (e.g.

over 10 years);• are affordable; and• can easily be implemented and sustained.

The Lancet. December 8, 2007 Volume 370:Gaziano T, Galea G and Reddy K. Scaling up interventions for chronic disease prevention: the evidence. pp 1939-1946.

The Lancet. December 15, 2007. Volume 370:Asaria P, Crisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. pp 2044-2053.Lim S, et. al. Prevention of cardiovascular disease in high-risk individuals in low-income and middle-income countries: health effects and costs. pp 2054-2061.

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Cost effective 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 interventionsaddressing 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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UN Secretary-General:NCDs in developing countries are hidden, misunderstood and under-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. 12

Non-Communicable Diseases:Socio-economic Impact• Macro-economic impact:

• World Economic Forum estimates high risk and likelihood of negative economic impact from NCDs.

• Heart diseases, stroke and diabetes alone estimated to reduce GDP between 1-5% in developing countries.

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ChallengeREDUCED ECONOMIC GROWTHThen how to initiate or sustain UHC?

Non-Communicable Diseases:Socio-economic Impact• Impact at household level:

• World Bank estimates that one-third of people living on US$1-2 a day die prematurely of NCDs.

• People in developing countries die younger from NCDs, often in their most productive years.

• Low-income households suffer from the cost of long term treatment and the cost of unhealthy behaviours:

• Cost of caring for a family member with diabetes: 20% of low-income household income

• Poorest households spend more than 10% of their income on tobacco

• Cost of essential drugs to treat and cure cancer makes them unaffordable for the poor

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Economic Burden of Diabetes

• Chronic diseases place a substantial economic burden on society. Estimates for the United States place the costs of chronic illness at around three-quarters of the total national health expenditure (Hoffman et al. 1996).

• Some individual chronic diseases, such as diabetes, account for between 2% and 15% of national health expenditure in some European countries (Suhrcke et al. 2005).

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Challenge WHERE IS OUR DATA?We need Malaysian data

Cost of Diabetes in Malaysia

• People diagnosed with diabetes have access to diabetes care and treatment in Malaysia.

• Diabetes costs are estimated to account for 16% of the national Malaysian healthcare budget.• placing Malaysia among the top 10 countries in the world in

terms of percentage of healthcare budget spent on diabetes.• In 2010, an estimated RM 2.4 billion was spent on diabetes-

related healthcare.

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Zhang P. et al. Global healthcare expenditure on diabetes for 2010 and 2030. Diabetes researchand clinical practice. 2010; 87: 293– 301.

Cost of Diabetes in Malaysia

• Cost of managing diabetes in Malaysia: ~RM19,000.00 per patient per year• Conservative estimate from a study we did in 2007• Not ideal treatment

• Data from NHMS 2011 estimates about 1.1 million patients are on follow up at MOH hospitals and clinics• 1.1 M x RM 19k = RM 20.9 billion!!

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ChallengeQUALITY OF CARE?Dichotomy between public – privateIncreasing number of patients in public health facilities

Complications drive costs!

• While there are no studies in Malaysia that outline the breakdown of diabetes costs, a study (CODE II) shows that up to 73% of diabetes-related healthcare costs result from hospitalisation and ambulatory care, as a result of complications due to poor blood sugar control.

• Only 7% of the total diabetes-related healthcare cost is spent on anti-diabetic drugs.

18Jonsson B. Revealing the costs of type 2 diabetes in the EU and findings from 8 EU countries.Diabetologia 2002;45:S5–S12.

Financing NCD prevention and control programmes• Policy & regulatory interventions do not require a huge

budget.• What is more crucial is the political leadership and commitment.• Support from civil society is also essential.

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Summary• The issue is not should we spend more money (GDP) for

health• We already have universal health coverage• We subscribe to cost-effective treatment

• The question remains that if we were to spend more money (GDP) on health NOW, how are we assured that especially for NCDs, we will get our money’s worth.

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Thank you

[email protected]

Facebook: Feisul Mustapha

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