Download - Addressing the Challenge of NCDs in LAC: Brazil Country Case Study Isabella Danel Christoph Kurowski
Addressing the Challenge of NCDs in LAC:Brazil Country Case Study
Isabella Danel
Christoph Kurowski
Brazil Country Case Study
To inform policy dialogueLessons learned from developed countries and the
potential applicability of the most CE strategies in BrazilPotential impact of expanding health promotion and
improved NCD management on health outcomesCosts and returns from expanding health promotion and
improved NCD management activities
To inform current and future health project (VIGISUS 2 and 3, FHP)
To develop and pilot a model for assessing NCD prevention and control issues in other countries
Objectives:
Brazil Overview
Largest country in LAC Population 186 million; 80% urban Large health disparities Universal health system since 1990 Decentralized Family Health Program % of GDP spent on health: 7.6 Basic health indicators:
• LE: 69 / aging population• TFR: 2.2 • IMR: 30 (48 in 1990)• HALE at birth: 57/62 (male/female)
Burden of Disease by Major Disease Groups, Brazil 1998
0
5,000
10,000
15,000
20,000
25,000Communicable,Maternal, Perinatal,and NutritionalConditionsNon-CommunicableDiseases
Injuries
Source: BOD study 2002
Thousands of Disability-Adjusted Life Years
24%21%
55%
Burden of Disease, Brazil 1998
0
5,000
10,000
15,000
20,000
25,000
Communicable, maternal,perinatal, nutritional
Non-communicable Injuries
Disability,YLDs
Deaths,YLLs
Source: BOD study 2002
Thousands of Disability-Adjusted Life Years, Divided into YLLs and YLDs
Comparison of Years of Life Lost Among Several Diseases
Thousands Years of Life Lost due to Premature Mortality
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
Ischemic heartdiseaseCerebro-vasculardiseaseChronic ObstructivePulmonary DiseaseLung cancer
HIV
Source: BOD study 2002
Avoidable DALYs: Brazil compared to Amer-A*
Brazil Ameri-A
Causes Rate / 1000 Rate / 1000
ALL 270 142
Communicable Maternal Perinatal, Nutritional
Infectious, parasitic
Respiratory infection
Maternal
Perinatal
Nutritional
65
32
8
5
15
5
10
4
1
<1
2
1
Non-communicable
Cancer
Diabetes
Neuro-psychiatric
Cardiovascular
Chronic respiratory
Other
148
15
13
38
31
18
34
118
17
4
42
21
9
25
Injuries
Unintentional
Intentional
56
45
11
14
9
5
* Very low child and adult mortality: Canada Cuba, USA
Prevalence of risk factors in Brazil
Study on nutrition / obesity data is national; all others are smaller studies
Behavioral Risk Factor Survey in most capital cities has been completed – data not yet available
Multiple studies showing wide ranges:Tobacco – 35-50% for men; 20-33% for women Inactivity – 45-60% in men; 60-80% in womenObesity – 10% in adults in ’89 (national survey)Hypertension – 20-30% in adults; higher among lower SES
TendenciesObesity increasing: 6% among adults in ’75; 10% in ’89; also increasing among the poor: 3.6% for lowest female
tercile in ’75, 9.7% in ’89Diabetes increasing: 7.6 / 100,000 for < 15 years old in ’93
(SP); 12.7 in ’98
The challenge of NCD’s in Brazil
Preliminary results of an economic evaluation
Objectives
For a subset of largely preventable NCDs, to estimate the financial costs of treatment and care; estimate the future burden of disease; estimate the future financial and economic costs; and estimate the financial costs of health promotion in
comparison with the financial and economic benefits.
Model (I)
Diabetes mellitus
Ischaemic heart disease
Ischaemic stroke
Chronic obstructive pulmonary disease
Cancer (trachea, bronchi, lungs)
Physical inactivity
Arterial hypertension
Smoking
Current costs of treating a subset of NCD’s [2002/03]
Risk factor Sec. Disease USD 2000 [billion]
Physical inactivity IHD, CVD*, DM 3.4
Arterial hypertension
IHD, CVD 3.2
SmokingIHD, COPD, “lung” cancer
3.5
Total 10.2
Future burden of disease 2005/2010
2005 2010 2015 2020
LE
Future burden of disease – selected conditions by risk factor: 2005 to 2010
Risk factor Sec. Disease BoD 05-10 [DALY, million]
Physical inactivity IHD, CVD*, DM 4.9
Arterial hypertension
IHD, CVD 12.6
SmokingIHD, COPD, “lung” cancer
3.7
Total 21.2
Future costs due to NCD’s 2005/2010
Future costs (status quo persists): Financial costs:
Costs of treating secondary diseases Economic costs:
Financial costs plusproductivity losses due to disability and premature mortality
Future economic costs due to NCD’s: 2005/2010
Risk factor Sec. Disease Economic costs 05-10 [ USD, 2002, billion]
Physical inactivity IHD, CVD*, DM $130.0
Arterial hypertension
IHD, CVD $215.2
SmokingIHD, COPD, “lung” cancer
$122.0
Total $467.2
Model II
Physical inactivity
Arterial hypertension
Smoking
Scaling up of AGITA SAO PAULO
Treatment of 25% of population c hypertension
10% increase in prices of cigarettes
Medical counseling for 25% of smokers
Scaling up of AGITA SAO PAULO
Intervention: Expansion of program to 25% of population
Financial costs of providing intervention
131 million
DALY’s averted 127,000
Financial costs in care of secondary diseases averted
572 million
Losses in productivity averted 452 million
Benefit cost ratio 7.8
Costs in USD 2000
Benefit cost ratios
Scaling up of AGITA SAO PAULO
Treatment of 25% of population c hypertension
10% increase in prices of cigarettes
Medical counseling for 25% of smokers
7.8
1.2
2.9
0.1
Conclusions
NCDs consume a large share of Total Expenditure on Health
Future economic costs accruing over the period of 2005/2010 equal approximately 70% of GDP in 2002
Effective interventions to prevent NCD’s exist. Some are financially and economically highly attractive.
Ministry of Health Response to Health Transition
Fragmented national policies: National policy to reduce injuries and violence National anti-tobacco and anti-drug policy National Food Security policy National and State Cancer Control policies National and State Occupational Health policies
Policies not yet operationalized in national / state / municipal health plans
Health Muncipalities project, 2002, UNSP
Ministry of Health Structure
Executive Secretariat responsible for establishing health promotion policies and coordinating cross-cutting program
Fragmented national structure: No one unit responsible for health promotion
activities Four secretariats involved
Greater activity in some states e.g. Sao Paulo
Ministry of Health:primary health care
Eight Family Health Program priorities include: Control of hypertension and diabetes Health promotion
National plan and guidelines available for hypertension and diabetes detection and control, but not health promotion
Plan has been implemented through training, IEC campaigns, community work
Performance measures on hospitalization and mortality; none for risk factors or HP activities
In process of defining policies to promote healthy lifestyles, health promotion and risk prevention.
Interventions in tobacco
National Tobacco Control Program established, 1987 Advisory Board on Tobacco Use Control established,
1987 Warning on cigarettes, 1988; bolder in 2001 Restricted tobacco advertising, 1994 Smoking banned in MOH, 1998 Tobacco considered drug and regulated by ANVISA,
1999 Various media campaigns Tobacco advertising only at point of sale, 2000 Tobacco use education and control programs in the
workplace, schools, and health units
Next steps
National health promotion plan -- involvement of multiple sectors; address issues at various levels
Clearly defined priorities and targets Commitment to financing Structure that facilitates action Scale up cost-effective interventions shown to
work in Brazil Piloting interventions found to be cost-effective in
other countries based on priorities HP performance measures include in pactos Information systems to monitor impact and trends