Integration of Waqf and Islamic Microfinance for Poverty Reduction
Integration Science” for NCDI Poverty
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“Integration Science” for NCDI Poverty DGHE CVD Program in Global NCDs and Social Change Harvard Medical School Fundamentals of Global Health McGill University 10 November 2020 Gene Bukhman, MD, PhD
Transcript of Integration Science” for NCDI Poverty
“Integration Science”for NCDI Poverty
DGHE CVD
Program in Global NCDs and Social Change Harvard Medical School
Fundamentals of Global Health McGill University
10 November 2020
Gene Bukhman, MD, PhD
What are NCDs
Daar$et$al.$Nature.$2007$
NCD(I)s in GBD and in GHE include: CVD, Neoplasms, CRD, Diab, Endocrine, Uro, Renal, GI, MSK, MNS, Sense Organ, Skin, Congenital, Heme, Oral + Injury
https://www.knowablemagazine.org/article/health-disease/2018/finlands-bold-push-change-heart-health-nationhttps://www.sevencountriesstudy.com
https://www.knowablemagazine.org/article/health-disease/2018/finlands-bold-push-change-heart-health-nation
Box1:HistoryofNCDcategoryatWHO
Since the 1980s, WHO has tried to simplify this complexity by focusing on small number of diseases and their shared risk factors. By the time of the 2011 HLM this was distilled down to 4 diseases and 4 shared modifiable risk factors: 4 x 4
Reduction Target
Age of Population
1 Death fromCVD, Cancer, Diabetes, Lung Disease
25% age 30-70
2Harmful
Alcohol Use10% 15+
3 Physical Inactivity 10%10–19;≥18
4 Salt 30% ≥18
5 Tobacco 30%10–19;≥18
6High
Blood Pressure25% ≥18
7 Diabetes and Obesity ≥ 0% 10–19;≥18
National System Response
8 Treatment for Cardiovascular Risk50%
coverageage ≥ 40 +
10-yr risk ≥ 30%
9 Medicines and Technologies 80% availability
The Problem:
The Global Framework for NCDsis not designed specificallyfor Low-Income Countries
or the Poor in Middle Income Countries
September, 2011
UN GATHERING ON NON-COMMUNICABLE DISEASES CONSIDERS WAYS TO COMBAT SCOURGENew York, Sep 20 2011 10:05PMDelegates at a United Nations high-level conference on non-communicable diseases (NCDs) today considered strategies to combat the preventable, mostly lifestyle- and diet-related illnesses that have become major killers across the world.Participants at the two-day meeting, hosted by the General Assembly, yesterday adopted a declaration calling for a multi-pronged campaign by governments, industry and civil society to set up by 2013 the plans needed to curb the risk factors behind the four groups of NCDs – cardiovascular diseases, cancers, chronic respiratory diseases and diabetes.
Steps range from price and tax measures to reduce tobacco consumption to curbing the extensive marketing to children, particularly on television, of foods and beverages that are high in saturated fats, trans-fatty acids, sugars, or salt. Other measures seek to cut the harmful consumption of alcohol, promote overall healthy diets and increase physical activity.
The overall annual death toll from NCDs is estimated at 36 million worldwide, which means it comprises more than 60 per cent of the broader total of 57 million.
$11.4 billion per year
Scaling up action against noncommunicable diseases: How much will it cost? Geneva: World Health Organization; 2011
What has been the Global Ask?
What has been the Global Ask?
• $11.4 billion per year ($1/capita in LICs, $1.5/capita in LMICs, and $3/capita in UMICs)
• $2 billion for population-based interventions
– tobacco, alcohol, salt, public awareness re: diet and physical activity
• $10 billion for individual-based interventions
– VIA for cervical cancer, multi-drug therapy (e.g polypill for < 30 10 year cardiovascular risk), glycemic control for DM
Scaling up action against noncommunicable diseases: How much will it cost? Geneva: World Health Organization; 2011
~ 90% of global ask for individual treatment focused on vascular disease
Reduction Target
Age of Population
1 Death fromCVD, Cancer, Diabetes, Lung Disease
25% age 30-70
2Harmful
Alcohol Use10% 15+
3 Physical Inactivity 10%10–19;≥18
4 Salt 30% ≥18
5 Tobacco 30%10–19;≥18
6High
Blood Pressure25% ≥18
7 Diabetes and Obesity ≥ 0% 10–19;≥18
National System Response
8 Treatment for Cardiovascular Risk50%
coverageage ≥ 40 +
10-yr risk ≥ 30%
9 Medicines and Technologies 80% availability
Trends in Development Assistance for Health (1990-2014)
Source: IHME. http://vizhub.healthdata.org/fgh/
**
*
UN High-level meeting on NCDs
UN General Assemblyon HIV/AIDS
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This strategy might be effective e.g. in Russia and elsewhere,
where ischemic heart diseaseand stroke are dominant.
Ischaemic)heart)disease)
Cerebrovascular)disease)
Other&uninten*onal&injuries&
Alcohol&use&disorders&
Poisonings&
Road&traffic&accidents&
Unipolar)depressive)disorders)Violence&Self:inflicted&injuries&
Cirrhosis&of&the&liver&
Tuberculosis&Hearing&loss,&adult&onset&Osteoarthri*s&Falls&
Inflammatory&heart&diseases&(k)&HIV/AIDS&Nutri*onal&Deficiencies&Lower&respiratory&infec*ons&Trachea,&bronchus,&lung&cancers&Stomach&cancer&Congenital&anomalies&Chronic&obstruc*ve&pulmonary&
disease&Diabetes&mellitus&Drownings&Drug&use&disorders&Refrac*ve&errors&Colon&and&rectum&cancers&Breast&cancer&Alzheimer&and&other&demen*as&Fires&Bipolar&disorder&War&Schizophrenia&Hypertensive&heart&disease&Rheumatoid&arthri*s&Macular°enera*on&and&other&(j)&Asthma&Obsessive:compulsive&disorder&Maternal&condi*ons&Neonatal&infec*ons&and&other&condi*ons&(i)&Panic&disorder&Migraine&Pep*c&ulcer&disease&Pancreas&cancer&Leukaemia&Cataracts&Prematurity&and&low&birth&weight&Nephri*s&and&nephrosis&Cervix&uteri&cancer&Corpus&uteri&cancer&Glaucoma&Mouth&and&oropharynx&cancers&Skin&diseases&Birth&asphyxia&and&birth&trauma&Epilepsy&Ovary&cancer&Dental&caries&Insomnia&(primary)&Rheuma*c&heart&disease&Post:trauma*c&stress&disorder&Liver&cancer&STDs&excluding&HIV&Endocrine&disorders&Oesophagus&cancer&Lymphomas,&mul*ple&myeloma&Bladder&cancer&Diarrhoeal&diseases&Meningi*s&Edentulism&Parkinson&disease&Prostate&cancer&Mul*ple&sclerosis&Upper&respiratory&infec*ons&Benign&prosta*c&hypertrophy&Melanoma&and&other&skin&cancers&Other&neoplasms&Hepa**s&B&(g)&Appendici*s&O**s&media&Hepa**s&C&(g)&Periodontal&disease&Childhood:cluster&diseases&Tropical:cluster&diseases&Malaria&&:&&&&
&1,000&&
&2,000&&
&3,000&&
&4,000&&
&5,000&&
&6,000&&
&:&&&& &10&& &20&& &30&& &40&& &50&& &60&& &70&& &80&& &90&&
DALYs)
Rank)
Rank)Ordering)of)Burden)of)Disease)by)CondiAon)in)Russia)(2004)GBD)esAmates)in)DALYs))
This strategy is unlikely to be effective in the poorest populations …
Mathers et al. Global Burden of Disease. 2004 Update. WHO. 2008
Poorest Billion People by Multidimensional Poverty Index in 2011
… where NCDIs are part of the long tail of disease burden distribution
Generated for the Lancet NCDI Poverty CommissionMap by Benjamin Hennig www.viewsoftheworld.net
Data by Gisela Robles, Oxford Poverty and Human Development Initiative
WHO GCM/NCD Dialogue on NCDs, Poverty, and Development (April 20–21, 2015)
Meeting Objectives and Agenda Report Process and Timeline
Boston Meeting 3 October, 2017
NCDIPOVERTYCommission
THE LANCET
Reframing Noncommunicable Diseases and Injuries for the Poorest Billion
www.ncdipoverty.org
Objectives of the Commission
• Assess the nature of the NCDI Burden among the poorest billion people in the world
• Work with a group of countries to develop actionable pro-poor pathways for expansion of NCDIs interventions
• Assure that sustainable financing is not a bottleneck to just NCDI treatment and prevention among the world’s poorest
• Expand the NCD movement and the global health agenda to urgently address the lived realities of NCDIs among the poorest billion
Two Intersecting Dimensions of the Project
Global Messages:
Global Working Groups
Country Impact:
16 National NCDI Poverty Commissions/
Groups
Health-sector interventions scored for cost-e!ectiveness and equityHighly Equitable and Cost-E!ective Interventions
All Interventions Scored for Cost-E!ectiveness and Equity
High Equity – Very High Cost-E!ectiveness
Very High Equity – High Cost-E!ectiveness
Very High Equity – Very High Cost-E!ectiveness
High Equity – High Cost-E!ectiveness7
18
85
86
39
36
40
46
2
4
5
15
16
76
8182
89
90
70
98
68
120
49
50
51
53
74
124
54
72
112
31
100
114
115
116
125
150
151
152
153
156
157
137
Neoplasms82
89
Opportunistic screening for cervical cancer using visual inspection or HPV DNA testingand treatment of precancerous lesions with cryotherapySurgical treatment of early stage colorectal cancer
90 Treatment of early stage colorectal cancer with generic chemotherapy, with curative intentMental, neurological, and substance abuse disorders
69 Management of depression and anxiety disorders with psychological and generic antidepressant therapy
Injuries162
162
Urgent, de!nitive surgical management of orthopedic injuries
Other noncommunicable diseases31 Childhood vaccination series (hepatitis B)
100 Childhood vaccination series (rubella)114 Cataract extraction and insertion of intraocular lens115 Repair of cleft lip and cleft palate116 Repair of club foot125 Surgery for trachomatous trichiasisInjuries137 Basic skin grafting
CardiovascularManagement of acute critical limb ischemia with amputation as a last resort7Use of percutaneous coronary intervention for acute myocardial infarctionwhere resources permit18
Neoplasms76
81
School based HPV vaccination for girls
Early detection and treatment of early-stage cervical cancer
Diabetes, urogenital, blood, and endocrine disorders
120Treatment of congenital endocrine or metabolic disorders that have highincidence rates and for which management is feasible in limited resource settings
Other noncommunicable diseases72 Management of osteomyelitis, including surgical debridement for
refractory cases
112Provide iron and folic acid supplementation to pregnant women, as well as food/caloric supplementation to pregnant women in food insecure households
Cardiovascular
Diabetes, urogenital, blood, and endocrine disorders
Neoplasms
Mental, neurological, and substance abuse disorders
Other noncommunicable diseases
Injuries
Provision of aspirin for all cases of suspected acute myocardial infarction2
4
5
15
36
39
85
86
40
46
16
49
50
51
52
53
74
124
Medical management of acute, decompensated heart failureMedical management of heart failure with diuretics, beta-blockers, ACEi, and mineralocorticoid antagonistsSecondary prophylaxis with penicillin for rheumatic fever or established RHD
Treatment of acute pharyngitis to prevent rheumatic fever
Surgical treatment of early stage breast cancer with curative intent
Treatment of early stage breast cancer with generic chemotherapy, with curative intent
70
98Provision of harm reduction services to people who inject drugsManagement of epilepsy using generic anti-epileptic medications and psychosocial treatment
In settings where sickle cell disease is a public health concern, universal newborn screening
Management of Type 1 Diabetes
Relief of urinary obstruction by catheterization or suprapubic cystostomy
Prophylaxis against bacterial infections and malaria for those with sickle cell disease
Shunt for hydrocephalus
Combination therapy for individuals with moderate to severe rheumatoid arthritis
Repair of perforations (e.g., perforated peptic ulcer)
Management of bowel obstruction
54
Colostomy
Hernia repair, including emergency surgery
Removal of gallbladder, including emergency surgery
Appendectomy
181
182
183
Trauma-related amputations
Trauma laparotomy
184
187
188
Tube thoracostomy
Placement of external !xator and use of traction for fractures
Irrigation and debridement of open fractures
Fracture reduction
52
High Equity Very High Equity
Very
High
Cost-
E"ec
tiven
ess
High
Cost-
E"ec
tiven
ess
Cost-
e"ec
tiven
ess c
atego
ry
Equity category
4
3
2
1
1 2 3 4
No data
Does notapply
Does not apply
Cardiovascular diseaseDiabetes, urogenital, blood,and endocrine disorders
NeoplasmsChronic respiratory disorders
Other and unspeci!ed NCDsMental, neurological, andsubstance abuse disorders
InjuriesCross-cutting services (rehabilitation,palliative care
Cause groups
Cost-e"ectiveness data from Disease Control Priorities, Third Edition1 with additional equity analysis by this Commission. All interventions are identi!ed and described in more detail in Appendices 2.B and 2.C.1 Jamison DT, Gelband H, Horton S, Jha P, Mock CN, Nugent R. Disease Control Priorities, Third Edition (Volume 9). Washington, DC: World Bank Publications, 2018.
ReferralHospital
HealthPromotion
Prevention Chronic Care CurativeTreatment
First-level(District)Hospital
HealthCenter
Community
ReferralHospital
HealthPromotion
Prevention Chronic Care CurativeTreatment
First-level(District)Hospital
HealthCenter
Community
Global Action Plan “Best Buys”Interventions Prioritized
by National NCDI Poverty Commissions
4 x 4 conditions associated with behavioral risks (Category 1)4 x 4 conditions NOT associated with behavioral risks (Category 2)
4 x 4 conditions associated with multiple causal factorsother NCDs and injuries (Category 3)
Global Action Plan “Best Buys” and Interventions Prioritized by National NCDI Poverty Commissions – a Complementary Agenda
Condition categories addressed by interventions
Referral Hospital
Health Center
++
Prospective Integrated Care Teams (ICTs) at di!erent levels of the health system
Cardiothoracic Surgical TeamCritical and Palliative Care Team
Gynecologic Surgical TeamInternal Medicine Inpatient Team
Ophthalmic Outpatient Care TeamOrthopedic Surgical Team
Pediatric Inpatient Care TeamSpecialized Surgical Team
Interventional Cardiology Team
First-Level HospitalAdult Inpatient Care Team
Complex ID Outpatient TeamEmergency/High Dependency Team
General Surgical Team
Ophthalmic Outpatient Care TeamRehabilitation Service Team
Severe Mental Health Outpatient TeamSevere NCD Outpatient Team
Women’s Health Outpatient TeamNewborn Screening Team
Acute/Women’s Care Team Dental TeamChronic Care Team
Severe NCD Outpatient Team(PEN-Plus)
Chronic Care Team(PEN)
First-Level Hospital
Health Center
++
Screening and management of diabetes among at-risk adultsManagement of epilepsy, including long-term management with generic anti-epileptics
Management of depression and anxiety with psychological and antidepressant therapy
Long term management of ischemic heart disease, stroke, and peripheral vascular disease Prophylaxis against bacterial infections and malaria for those with sickle cell diseaseProvision of harm reduction services to people who inject drugs
Provide iron and folic acid supplementation to pregnant women, as well as food/caloric supplementation to pregnant women in food insecure households
Psychosocial support and counseling services for individuals with serious health problems and their caregivers
Low-dose inhaled corticosteroids and bronchodilators for asthma and COPD Essential palliative care and pain control measures
Secondary prophylaxis with penicillin for rheumatic fever or established RHD
Screening and management of albuminuric kidney disease
Management of post-valve replacement patients requiring warfarinInhaled corticosteroids and bronchodilators for severe, persistent asthma and COPDManagement of stable breast cancer requiring tamoxifenManagement of chronic myeloid leukemia requiring imatinib therapy
Cardiac surgery for children and young adults with rheumatic heart diseaseCardiac surgery for children and young adults with correctable congenital heart disease
Management of advanced malignancies and other end-stage NCDs with pain and palliative care
Medical management of chronic heart failureManagement of type 1 diabetes
Combination therapy for individuals with moderate to severe rheumatoid arthritis
General Surgical Care Team
Management of acute critical limb ischemia with amputation as a last resortRelief of urinary obstruction by catheterization or suprapubic cystostomyAppendectomyRemoval of gallbladder, including emergency surgeryHernia repair, including emergency surgeryColostomyManagement of bowel obstructionRepair of perforations (e.g., perforated peptic ulcer, typhoid ileal perforation)Management of osteomyelitis, including surgical debridement for refractory cases
Fracture reductionIrrigation and debridement of open fractures
Placement of external !xator and use of traction for fracturesTube thoracostomyTrauma laparotomy
Trauma-related amputations
Burr hole to relieve acute elevated intracranial pressure
ICTsInterventions prioritized by national NCDI Poverty Commissions* Additional highly equitable and cost-e!ective NCDI interventions**
Referral Hospital
Specialized Surgical TeamCardiovascular diseaseDiabetesNeoplasmsChronic respiratory disorders
Other and unspeci!ed NCDsMental, neurological, and substance abuse disorders
InjuriesCross-cutting services (rehabilitation, palliative care)
Cause groups
Examples of selected ICTs at di!erent levels of the health system
Projected health !nancing capacity vs. essential Universal Health Coverage (EUHC) costsin low-income Poorest Billion countries, 2017-2030
$0
$20
$40
$60
$80
$32
$84
$100
20302029202820272026202520242023202220212020201920182017
EUHC cost for all conditions including NCDs and injuries
EUHC cost for infectious, maternal, child, and reproductive health
Per c
apita
healt
h !na
ncing
capa
city (
US$)
NCDI
EUHC
gap
range of projected health !nancing capacity with constant revenue generation and government expenditures on health at current levels
range of projected health !nancing capacity with linear increasesin revenue generation and government expenditures on health 3% per year annual per capita GDP growth
4% per year annual per capita GDP growth6% per year annual per capita GDP growth
3% per year annual per capita GDP growth4% per year annual per capita GDP growth6% per year annual per capita GDP growth
0
1000
1990 1995 2000 2005 2010 2015
2000
3000
4000
5000
6000
7000Poorest Billion
Countries
Other andUnspeci!ed
Countries
HIV
Milli
ons o
f 201
7 US d
ollars
0
1000
2000
3000
4000
5000
6000
7000 M
illion
s of 2
017 U
S doll
ars
0
1000
2000
3000
4000
5000
6000
7000
Milli
ons o
f 201
7 US d
ollars
0
1000
2000
3000
4000
5000
6000
7000
Milli
ons o
f 201
7 US d
ollars
1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015
Maternal & Child Health
PoorestBillionCountries
Other and Unspeci!ed Countries
Other and Unspeci!ed
Malaria
“Poorest Billion”Countries
NCDs
“Poorest Billion” Countries
Other andUnspeci!ed
Countries
DAH to “poorest billion” and other countries by condition – 1990–2016
Prioritize conditions and interventions
Phase 1Situation analysis
and priority-setting
Develop models for integrated delivery of priority interventions
Phase 2Delivery Model
Design
Establish training sites and national operational plans
Phase 3Initial
Implementation
partnerships to support scale-up
Phase 4National Scale-up
Tanzania
Ethiopia
AfghanistanNepal
Chhattisgarh
KenyaDemocraticRepublicof Congo
Zambia
Malawi
Rwanda
UgandaSierra Leone
Liberia
Haiti
GuatemalaBurkina Faso
Ghana
Benin
CameroonNigeria
Zimbabwe
Madagascar
Mozambique
Cambodia
Namibia
Lesotho
Phase 4 – National scale-up
Phase 2 – Delivery model design
Phase 1 – Situation analysis & priority-setting
Application to initiate pending
Phase 3 – Initial implementation
NCDI Poverty Network Participation and Interest – September 2020
https://www.afro.who.int/publications/who-pen-and-integrated-outpatient-care-severe-chronic-ncds-first-referral-hospitals
