NCDs POLICY BRIEF - MALDIVES February 2011 The World Bank, South Asia Human Development, Health Nutrition, and Population NON-COMMUNICABLE DISEASES (NCDS) 1 – MALDIVES’ MAJOR HEALTH CHALLENGE This policy brief is based on the World Bank’s recent publication: Capitalizing on the Demographic Transition: Tackling Non- communicable Diseases in South Asia (2011). It assesses the NCD burden and develops policy options at both country and regional levels.  Maldives have reached a stage of quick population aging. The proportion of the population 65 years and older will double, from 3.5% in 2000 to 6.3% in 2025 (Figure 1). Older populations are more likely to be affected by NCDs. Thus, the health burden from NCDs will rise in parallel with aging. Figure 1: Age structure of Maldives, 2000 and 2025 Female Male 80-84 Femal Male 80-84 Age group e Age group 60-64 60-64 40-44 40-44 20-24 20-24 0-4 0-4 -15 -5 5 15 -15 -5 5 15 Percentage, 2000 Percentage, 2025 Source: U.S Census Bureau. www.census.gov/ipc accessed July 1, 2010  NCDs already imposes the largest health burden in Maldives. In terms of the number of lives lost due to ill-health, disability, and early death (DALYs),2 NCDs (inclusive of injuries) account for 78% of the total disease burden. Only 22% of the DALYs come from communicable diseases, maternal and child health, and nutrition issues all combined (Figure 2).  Maldives’ major NCDs are Mental Health (neuropsychiatric conditions), Injuries, Cancers, and Cardiovascular diseases (CVD) (Figure 2). Road accidents are one of the main sources of injuries; they account for 4% of all NCD DALYs lost.  Smoking, a major risk factor for NCDs, is among the highest in South Asia, with a prevalence of 45% for males and 12% for females.  Another NCD risk factor, obesity is important for Maldives, particularly among women. Prevalence in the female population reaches 17% - against 9% for males. Prevalence increases with age: approximately 50% of women over 35 years are overweight and/or obese. Figure 2: Pattern of overall DALYs (age standardized) and NCD related DALYs in Maldives, 2004 100% CDs, maternal, 90% perinatal & nutritional, Others, 24% 80% 22% Diabetes, 3% 70% CVD, 12% 60% NCDs Respiratory diseases, 4% 50% Cancers, 14% 40% (inclusive of 30% injuries) , Injuries, 19% 20% 78% 10% Neuropsychiatric (Mental Health), 24% 0% Total DALYs NCD DALYs Source: World Health Organization, Global Burden of Diseases http://www.who.int/healthinfo/global_burden_disease/estimates_country/en/index.html Page 2 NCDs Policy Brief: Maldives February 2011 MALDIVES’S RESPONSE TO NCDS POLICY AND LEADERSHIP efforts. The Center for Community Health and Disease Control (formerly the Department of Maldives have acknowledged NCDs as a top Public Health) is mandated to deliver preventive health priority. The country developed a Health health care programs. The Center’s work is Master Plan (HMP) 2006–2015, which states that, clustered around two major divisions - Disease among NCDs, CVD, diabetes, renal diseases, COPD, Control and Health Promotion. Under the Disease and selected cancers will be given the main focus. Control Division, the Non-Communicable Diseases The plan includes specific national targets for Section leads health promotion activities, these diseases by 2015, with nine NCD-related advocacy efforts, and conducts workshops with indicators. Thalassaemia and mental health also technical cooperation from WHO. In terms of receive priority attention. Services for the human resources, the NCD division is still prevention and rehabilitation of physical and understaffed. The current staff also requires more mental disabilities will be developed in training. partnership with social services and the private sector. In addition, Maldives has developed the HEALTH SERVICES DELIVERY Non-Communicable Diseases Strategic Plan 2008–2010. The plans intend to combine private Government’s current policy is to move service and public sector efforts in the management and delivery from the public toward the private care of priority NCDs. sector, through public-private partnerships. The health system in Maldives consists of primary, Maldives is making progress on tobacco control. secondary, and tertiary care layers. The regional, However, progress has been limited due to lack of atoll hospitals and health centers are located legislation. Maldives ratified the WHO Framework strategically among the islands to minimize access Convention on Tobacco Control in 2004. The time. The public infrastructure is supplemented by enabling national legislation (Tobacco Control Act) the private sector. In the private sector, there is was passed and ratified in August 2010. As per the one major tertiary hospital and approximately 50 stipulations of the Act, a national advisory body different clinics throughout the country. (Tobacco Control Board) has been formed and is currently formulating tobacco control regulations. Under new policy, health care services are being corporatized at the provincial level. However, In parallel, the Center for Community Health and oversight remains with Ministry of Health and Disease Control, in collaboration with national Family. stakeholders, is conducting awareness and advocacy activities targeted to the general Despite efforts to circumvent geographic population and to policy makers. constraints, access to NCD diagnostic and services remains an issue. Patients with NCDs are treated Despite these recent efforts, Maldives has the primarily at regular out-patient departments. highest prevalence of tobacco use in South Asia. Tobacco products are widely available and However, the full range of tests and medications comparatively low-priced. Also progress towards are not available at all clinic sites. There is no effective policy (e.g. taxation, supply control) is formal policy for the referrals which hinders hindered by the strong lobbying from the tobacco quality and continuity of care. In addition, industry. important NCD-related tertiary services that cannot be accessed in Maldives include The institutional structures for NCD prevention oncological services, cardiac bypass, and invasive and control are adequate but key posts and diagnostic procedures. positions remain unfilled limiting implementation Page 3 NCDs Policy Brief: Maldives February 2011 Telemedicine and e-health services are under SURVEILLANCE development and expected to be available in 2011. Care guidelines and standard treatment The current information on NCDs is insufficient to protocols for the major NCDs have been guide decision-making. Systematic data collection developed and are undergoing dissemination and for NCD morbidity and the economic burden is implementation. limited, and there is no cancer registry, making it hard for the country to track the NCD burden and Access to essential NCD medications is limited in risk factors. A subnational NCD Risk Factor Survey remote areas and among the poor. was conducted in 2004 and another subnational Pharmaceutical products are imported by the Survey is planned for mid 2011. Global Youth private or public sector. The private sector imports Tobacco Survey was conducted in 2003 and 2007. and distributes to private pharmacies in Male and A Global School Health survey was conducted in throughout the country. With few exceptions the 2010. Demographic Health Survey conducted in government health facilities only stock 2009 also contained modules on NCD. medications for hospital and institutional use. Drugs for persons with NCD are purchased by patients from private pharmacies. The National FINANCE Social Insurance scheme (Madhana) covers cost of medicines. A pilot is now underway to develop Maldives’ health financial system still leaves community pharmacies on less populated islands. individuals bearing a large share of health costs. Under the recently introduced universal social A high reliance on expatriate health professionals insurance scheme, MADHANA, services can be has proved a constraint to care efficiency. The sought from private institutions, hospitals, clinics, number of physicians and nurses increased and pharmacies linked to the scheme. However significantly between 1990 and 2005 (40 to 379 the scheme is still in its early stages and is likely to physicians, 137 to 974 nurses) due to the face challenges with long term financial expansion of health system and the opening of the sustainability. Indira Gandhi Memorial Hospital. However, the high dependence on short term expatriate Pharmacies do not existing on most small islands, providers (approximately 73 %) reduces continuity limiting benefits from these schemes. of care, an important factor in NCDs management. POLICY OPTIONS FOR MALDIVES The World Bank’s recent publication: Capitalizing on the Demographic Transition: Tackling Non-communicable Diseases in South Asia (2010) introduces a policy framework for identifying NCD-related policy options. The options below follow this framework. COORDINATE NATIONAL EFFORTS With the relevant legislation now available, In 2008, the government created a separate NCD efforts to control tobacco should shift to unit in the Center for Community Health and implementation and enforcement. This would Disease Control, which has since been upgraded require early formulation of regulations including to a section. It would now be necessary to build the needed enforcement capacity across the the section’s capacity and provide sufficient implementing agencies. resources and authority to meet its objectives. In order to address social, economic and environmental determinants that underlie NCDs, cross-sector collaborative mechanisms will be needed. STRENGTHEN TOBACCO CONTROL POLICIES Page 4 NCDs Policy Brief: Maldives February 2011 DEVELOP COMPETENCY OF WORK FORCE TO other unhealthy goods towards preventive health, should be explored. TACKLE NCDS In parallel with the introduction of the care guidelines and standard practices for NCDs, an TAKE AN ACTIVE ROLE IN REGIONAL assessment of human resource needs for the COLLABORATION current and future is needed. Human resource for Regional collaboration can be very effective for key areas, such as mental health, need to be preventing and controlling NCDs. Several addressed urgently. promising areas for regional cooperation have been identified. Actively participating in regional CREATE A NATIONAL NCD SURVEILLANCE collaboration on NCDs prevention and control would be beneficial. Activities include: SYSTEM The Center could work on the gradual creation of a national NCD surveillance system, to inform  Expanding and harmonizing tobacco advertising ban to reduce demand strategic planning and policy development. The system should include NCD mortality, morbidity,  Increasing and harmonizing tobacco taxation to reduce consumption health services utilization, and economic burden data (available from national health accounts). This  Harmonizing tobacco taxes and strengthening anti-smuggling measures information will be critical as decentralization evolves. Core public health institutions are needed  Standardizing and mandating food labeling policy to improve knowledge and awareness of food to provide technical support along with composition international institutions such as the WHO.  Collaboration on group purchasing of essential medications to increase their assess and CREATE CAPACITY TO EVALUATE PROGRAMS affordability AND POLICY  Establishing a regional health technology As more resources are committed to NCD efforts, assessment institution to improve the the government would benefit from developing a comparative effectiveness of interventions for capacity to evaluate policies and programs. NCDs and other conditions  Using regional education and training capacity to complement the national needs for human STRENGTHEN FINANCING FOR NCD CARE resources in order to improve both staffing and Progress has been made with the introduction of skill levels social health insurance. However, equity and access can be improved. The restructuring of the  Establishing a regional network of surveillance and burden assessment to improve national capacity health system should not compromise on the through knowledge sharing and experience public expenditure for health - especially exchange preventive health. New avenues for health financing , such as tax earmarks from tobacco and . Notes 1 Non-communicable Diseases (NCDs) are defined by World Health Organization to include chronic diseases, principally cardiovascular disease, diabetes, cancer, and asthma/chronic pulmonary disease (COPD), in addition to injuries and mental illness. 2 Disability Adjusted Life Years (DALYs) are defined by World Health Organization as “the sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability.”