ChaisriSupornsilaphachai
DepartmentofDiseasesControl; MOPH;Thailand
PresentedinMeetingtheChronicDiseaseChallenge
High‐LevelRegionalWorkshop
Jakarta,Indonesia
June20‐21,2011
IntegratedDiseaseManagement
What is “Integrated Diseases Management” ?
Why is it important ? What have we already
developed How about the role of
partnerships ? What next ?
‐International
‐ThaiContext
What is “Integrated Diseases Management” ?
The word ‘integration’ stems from the Latin verb integer, that is, ‘to complete.’
The adjective ‘integrated’ means ‘organic part of a whole,’ or ‘reunited parts of a whole.’
It is mostly used to express the bringing together or merging of elements or components that were formerly separate.
The idea of comprehensiveness overlaps with that of integration
“Integration” is used by different people to mean different things.
Combined with the fact that this is an issue which arouses strong feelings,
there is clearly much scope for misunderstanding and fruitless
polarization.
World Health Organization
World Health Organization
The meaning implied in the WHO quotation … “Integrated”, “Integrated health service”, “Integrated Service”, “Integration” ….can be summarized as:
“The management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the
health system.”
Characters of Chronic conditions in Chronic Diseases
People with chronic conditions (risks, illnesses and disabilities)
often have a mix of acute and long-term care needs that require multiple providers, organizations, and systems of
care to address.�
“Chronic disease prevention and management consists of a group of coherent interventions, designed to prevent or manage one or more chronic conditions using a community wide, systematic and structured multidisciplinary approach potentially employing multiple treatment modalities.
“The management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system.”
Key questions under this definition are:
• What interventions should be packaged together? • How are management support systems best organized to service these interventions?
toidentifypersonswithoneormorechronicconditions,
topromoteself‐managementbypatients
toaddresstheillnessorconditionsaccordingtodiseaseseverityandpatientneedsandbasedonthebestavailableevidence,maximizingclinicaleffectivenessandefficiencyregardlessoftreatmentsetting(s)ortypicalreimbursementpatterns.
toallowroutineprocessandoutcomemeasurementsforfeedbacktoallthoseinvolved,aswellastoadapttheprogramme.
TheGoalofChronicDiseasePreventionandManagement:
- Rapid growing threat and impact of chronic diseases
- The natural course of chronic diseases
- How to start and mobilize our health system to response
Why is it important?
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Source: Bureau of Health Policy and Plan, MOPH
Source:Thai Burden of Disease (BOD) Study
Health Status : Lower Mortality Middle Income country
TrendofDiabetesandHypertensionPrevalence
WhyPreventionmoreFocused
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• 1998
Suspected Case • HT ∼ 6+ million • DM ∼ 1.9 million
HT 5+ Million times DM 2+ Million times
HBP, HT
HBS, DM
Stroke/Renal Failure/ISHD
2 from 3 of HT and DM suspected population Is in working population
Stroke/Renal Failure/ISHD
BNCD/Chai/27-9-48
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• 2004
Suspected Case • HT ∼ 9+ million • DM ∼ 2+ million
HT 8+ Million times DM 4+ Million times
HBP, HT
HBS, DM
Stroke/Renal Failure/ISHD
2 from 3 of HT and DM suspected population Is in working population …. children
Stroke/Renal Failure/ISHD
BNCD/Chai/27-9-48
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Million Baht percentage
Productivity loss from 12 BOD Male Female Total Male female Total
- Premature death 175,028 33,259 208,287 80% 15% 95%
- Absenteeism OP 7,422 2,414 9,836 3% 1% 4%
- Absenteeism IP 1,123 314 1,437 0.5% 0.1% 1%
Total 183,573 35,987 219,560 84% 16% 100%
% of GDP in 2548 3.1%
% of total health expenditure 2548
88.5%
Total productivity loss from 12 BOD = 219,560 million baht
~ 3.1% of GDP in 2005
Note: GDP in 2548 = 7,104,228 million baht
Productivity loss from 12 BOD Estimated in 2005
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Ratio of Doctors in 1,000 Population; Compared among the countries in the near economic level
Country GDP/Capita Physician/1000 Latin America & Caribbean
6950 1.4
Europe & Central Asia
6900 3.1
Malaysia 8500 0.7
Thailand 6890 0.4
Phillippine 4450 1.2
Vietnam 2300 0.5
Why Prevention more Focused Source: World Development Indicator 2004
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Sritara P et al. Why Prevention more Focused
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Population with Specific Important Risk Factors
2004-2005 Risk Factors ** MiIllions
Low fruits and vegetable Diet 38
Physical Inactivity 19
Tobacco Consumption 10.7
Heavy Alcohol Consumption 1.7
Overweight and Obesity 16.1
Hypertensive Diseases ~ 7.4
Diabetes ~ 3.3
แหล่งข้อมูล: สํานักโรคไม่ติดต่อ (ฉ.2549) คาดประมาณจาก ‘*’ TBRFSS2548 ‘**’ TNHEXAM2546
Why Prevention more Focused
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Table: Percentage of Population who have Risk Factors by Age, Sex, Numbers of Risk Factors
Numbers of Risk Factors
Age (Year) 15-29 30-44 45-59 60-6
9 70-79 80+ ทุก
อายุ Male (N=18934)
1 Risk Factor 42.8 48.0 39.2 40.6
41.6
46.1 43.7
2 Risk Factors 10.8 20.7 28.4 28.2 29.9
26.7 20.0
3 Risk Factors 3.1 6.7 11.9 12.0 9.1 7.2 7.1 >= 4 Risk Factors
0.3 1.8 3.4 3.4 1.6 0.9 1.7
Female (N=20356) 1 Risk Factor 21.4 37.2 36.6 32.4 35.2 44.4 32.0 2 Risk Factors 5.4 12.4 24 25.5 27.3 22.6 14.7 3 Risk Factors 0.6 3.7 11.2 14.7 10.7 0.7 5.6 >= 4 Risk 0.1 0.3 2.1 3.3 2.2 1.4 1.0
RiskFactors:Hypertension,Hypercholesterolemia,Diabetes,Overweight,RegularSmoker
แหล่งข้อมูล: TNHEXAM2546
N.B. : a Treatment of infectious disease can lead to prevention of further cases if it interrupts transmission. An example: Distal socioeconomic causes include income, education and occupation, all of which affect levels of proximal factors such as
inactivity, diet, tobacco use and alcohol intake; these interact with physiological and pathophysiological causes, such as blood pressure, cholesterol levels and glucose metabolism, to cause cardiovascular disease such as stroke or coronary heart disease. The sequelae include death and disability, such as angina or hemiplegia.
ประยุกต์280151
เสนอประชุมพัฒนาชุดการวิจัยเบาหวานความดันฯ
Lifestyles Modification Intervention
Health and Disease Continuum
Information and Environmental Supports for Primary
Prevention Early Diseases
Detection Diseases
Management
Risk Screening and risk management and Information support
Care for Health
Population level Individual level
Social and Economic Environm
ent Health care System:
Family health, Health Learning, Health services, Social Services Ph
ysic
al E
nviro
nmen
t
Healthsystemrelatedbefore2004
Whatwehavealreadydeveloped2004‐2009
What have we already developed ?
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Service Problems in NCDs Prevention and Control before 2004
• Overload ……Huge burden in Thai commuinties • Expensive service for treatment • Acute care management can not solve chronic
care problems • Unclear for prevention and control model
– Confusion in every level – Not effectiveness for prevention and control service – Difficult to determine resources to support efficiently Etc.
Health Reform
Reform Government System
Decentralization
Civil society Policy
Thailand Provincial and
local government Policy NCD
Universal Coverage Insurance
Thai Health
Foundation Fund MOPH
National NCD Program Move to Department of Diseases Control in 2003
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Acute Chronic / Subacute /Acute
Vertical Program
Comprehensive and Integrated Program
Monitoring and
Control
Monitoring and
Support
Normal.Disease/Sick Individual level
Normal.Risk.. Disease...Sick
Population Average
Disease Treatment and Care Disease and Risk Prevention and Control
Separated Service activities
System and coordinated
group of Service activities
Consulting/ Collaboration and cooperation/ Monitoring and support/Regional evaluation
Development of social and
campaign process
Services System Quality
Development
DDC.. With Other Depts,
Cen
tral
and
R
egio
nal S
yste
m
Social mobilization and campaign For awareness and risk reduction
Development needed Mechanism for prevention and control
Hlth Provincial Office
CEO and Provincial
Managerial Organization
Are
a
20
Law Development
and Enforcement Surveillance
and Information Development
Development & Research HMR Development Policy and Plan Development
National Goal/Strategic Outline/Main Strategic Collaboration
(Disease Control System: quality/ standard/ strength/transparency etc.) C
ount
ries
Social Organization
Health care net
Support for quality of prevention and control (focused on risk reduction and qulity improvement process)
Regulation and Law enforcement for protection from risk
BNCD
ODC
PCU/CHC
ปรับ2547
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Review, Rethink and Reestablish 3 Main Activities of Diseases Control Process
• Surveillance Activities – surveillance for community situation – Warning back to community – Suggestion for community measures for risk reduction
• Prevention Activities – Focused on risk prevention and control and risk
opportunities • Control Activities
– Disease Control for prevention repeated attack and complication and consequences prevention
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Input Resources (1) 1. Comprehensive concept and preliminary outline of prevention and
control activities and roles at every levels of provincial health care system
2. Natural course of diseases; paradigm and service delivery targets of 3 main prevention and control activities
3. Essential contents, suggested technique, examples of expected characteristic and innovation and designs for adding and adjusting in the model such as information service for risk reduction etc
4. Continuous quality improvement process and how to connect and integrate with existing standard services and knowledge in the community
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Input Resources (2) 5. Informing about the factors that influence services arrangements,
service adaptation and development.
6. Informing how important it is for evaluation for services development
7. Forum for learning together
8. Monitoring, supporting and consultation
9. Seeding money for innovation, quality improvement process and evaluation
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Many Challenges 1. Knowledge, technique and guide
2. Population and community characteristics such as local culture, proportion of migration population in the area etc
3. Information system that support surveillance and management
4. Inadequate needed resources
5. Other supporting system
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Study of Community’s information
Paradygm shift in health workers
Information of NCDs’ situation
Floor to conclude lesson learned Provincial level
Learning from work
and success
Project introduction for civil society
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other supporting system (Health guide, CPG)
Finance (Universal coverage insurance, social insurance, local budget, etc)
Level of service units/ age specific
Settings, local specific population and area target
Consequence Results in PHC: Financial support for
- Stroke risk screening service
- risk reduction service
Stroke Fast Track
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Hypertension & Diabetes Mellitus
Screening
Non- pharmacologic
Care
Hypertension Awareness
Quality Standard HT & DM
Screening
Stroke Awareness & Comprehensive CVD Screen
Increase Communication Thru Salt Net
Trend of Crude Death rate (per 100,000) in Thailand from Stroke and Key activities in 1995-2007
Source: BNCD (ฉ.2006) and edited in 2009 Start CBI for Comprehensive risk reduction Start National Exercise Campaign
World Health Organization
50
ปรับทิศ&เป้าองค์กรสุขภาพ ระบบข้อมูลดูแลสุขภาพเรื้อรัง
ระบบสนับสนุนการตัดสินใจ
ระบบบริการและจัดบริการ
สนับสนุนจัดการตนเอง
สร้างนโยบาย สุขภาพ สาธารณะ
เสริมสร้าง สมรรถนะ ชุมชน
ลดวิถีชีวิตเสี่ยง ลดการเกิดโรค ลดการเข้าอยู่ในโรงพยาบาล ลดความพิการ
ป้องกันการเพิ่มขึ้นของ ประชากรที่มีปัจจัยเสี่ยง
ป้องกันการเกิดโรค ในกลุ่มเสี่ยงสูง
ป้องกันและชะลอการดําเนินโรคสู่ ภาวะแทรกซ้อนและการเป็นซ้ํา
สร้างเสริมสุขภาพ ในวิถีชีวิตและสิ่งแวดล้อม
การ ป้องกันโรค 3 ระดับ
ประชากรทั้งหมด
เสริมกลไกจัดทรัพยากร &สภาพ
แวดล้อมชุมชน เสริมกลไกจัด สภาพแวดล้อมสนับสนุน
ทีมพร้อม ปฏิบัติการ
ผู้ป่วยรับข่าวสาร และตระหนักจัดการ
เพิ่มคุณภาพชีวิต
ทีมปจรรท.ร่างปรับ290251
Informed, Activated Patient
Productive Interactions
Prepared, Proactive Practice Team
Improved Outcomes
Delivery System Design
Decision Support
Clinical Information
Systems
Self- Management
Support
Health System Resources and Policies
Community Health Care Organizations
Source:BureauofPolicyandStrategy,MoPH
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Trends of major physiological /behavioral risk factors (Aged >= 15 Yrs)
Prevalence (%) – NHES
Male female Total III IV III IV III IV
Obesity* 22.5 28.4 34.4 40.7 28.7 34.7
Waist circumference** 15.4 18.6 36.1 45.0 26.1 32.1
Regular Smokers 45.9 38.7 2.3 2.1 23.3 19.9
Alcohol consumption (harmful)
16.6 13.2 2.1 1.6 9.1 7.3
Fruit & Vegetable Low Intake*** 80 83.1 76.4 81.5 78.1 82.3
Physical Inactivity 20.7 16.8 24.2 20.2 22.5 18.5
* BMI >25Kg/M2 ** >90,80 cm in male , female *** <5 servings/D Source : NHESII ,III , IV
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Diabetes
Hypertension
Hypercholesterolemia
Health Status , Thai Population aged 15+
NHES III
(2004-5)
NHES IV
(2008-9)
Prevalence 6.9% Prevalence 6.9%
Prevalence 22.0% Prevalence 21.4%
Prevalence 15.5% Prevalence 19.4%
Awareness 43.4%
Awareness 68.8%
Awareness 28.6%
Awareness 49.7%
Awareness 12.9%
Awareness 27.3%
Control
28.5% Control 12.2%
Control
8.6%
Control 20.9%
Control 6.2%
Control 14.8%
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Resource availability and allocation
“The Universal Health Care Coverage Policy” for entire population
Total expenditure on health (% of GDP) -3.5% GDP in 1994 and reached 4.0% in 2008
The share of public financing sources - 74.0% of THE
• The role of partnerships
• What next ?
How about the role of partnerships ?
Awareness, Support self management & prevention &
care, sustainable health care system
Awareness, environment and resources support, Competency Community for risk & diseases reduction
Awareness, Self Management (Risks & Disease & Increase QOL)
แผนภูมิ กงล้อความร่วมมือขับเคลื่อนการบูรณาการนโยบายและสมรรถนะสู่ความสําเร็จ
การพัฒนาระบบการป้องกันและจัดการโรคเรื้อรังไทย • มุ่งเน้นจัดการปัจจัยสาเหตุการเกิดและการดําเนินโรคต่อเนื่อง
• การป้องกันปฐมภูมิเป็นพื้นฐานสําคัญ • การนําการป้องกันสู่ทุกระดับการบริการและการเข้าถึงการดูแล
• การจัดการความเสี่ยงในระดับการดูแลปฐมภูมิ • การปฏิบัติตามแนวปฏิบัติทั้งโดยไม่ใช้ยาและใช้ยา • การสนับสนุนปรับวิถีชีวิต/การจัดการตนเอง • ความต่อเนื่อง ความครอบคลุมภาพรวม และ การประสานการดูแลสุขภาพ
• การขับเคลื่อนหน่วยบริการสาธารณสุขให้ตอบ- สนองโรคเรื้อรังอย่างมีคุณภาพ
Prevention
Policy
• เป้าประสงค์และคุณค่าร่วมกัน • เน้นที่ปัจจัยกําหนดสุขภาพ • ภาวะผู้นํ , หุ้นส่วน และ การลงทุน • โครงสร้างภายในและความสามารถด้านสาธารณสุข / การดูแลพื้นฐาน / ชุมชน
• การบูรณาการการป้องกันโรคเรื้อรังและการจัดการ • การกํากับติดตาม การประเมินผล และการเรียนรู้
Success Factors
Family Individual
Community
Local government
Federal government
Public Health System
Health Service Network
Primary Health Care
ฉ.๐๕๐๑๕๓
58
“ตาสว่างเดินหน้า”
ในการประชุม “วันพรุ่งนี้กับการจัดการเบาหวานและความดันโลหิตสูง.วันที่ 30 มิถุนายน 2552