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