National Strategy for Prevention and Control of Noncommunicable Diseases (NCDs), Injuries, Disabilities and Care of the Elderly & NCD National Action Plan 2014–2018

Objectives

Timor-Leste’s National Strategy for Prevention and Control of Non-Communicable Diseases, Injuries, Disabilities and Care of the Elderly, supported by the 2014–2018 National Non-Communicable Disease Action Plan, seeks to enable healthy, productive and dignified lives free from avoidable morbidity, disability and premature death. It aims to reduce preventable non-communicable disease (NCD) morbidity, disability, premature mortality, risk factors and associated costs, while supporting productivity, equitable development and community wellbeing.[1][2][3][4]The framework is founded on equity, community empowerment, the right to the best possible health care and respect for cultural diversity.[3]

• Lead a multisectoral response to major NCDs, particularly cardiovascular disease, cancer, diabetes and chronic respiratory disease, and to their behavioural, metabolic, infectious, environmental and commercial determinants.[5][6][3]
• Reduce tobacco use, harmful alcohol use, unhealthy diet, physical inactivity, overweight and obesity, raised blood pressure, raised blood glucose or diabetes, and household exposure to solid-fuel pollution.[7][8][9][10][11][12]
• Promote healthy settings and behaviours through healthy schools, workplaces and communities, breastfeeding support, nutrition guidance and labelling, food-marketing controls, physical-activity opportunities, cleaner cooking practices and public information.[7][13]
• Strengthen prevention, early detection, treatment, referral, rehabilitation, palliative care and continuing support across all health-system levels, including access to essential medicines, diagnostics, trained personnel and tertiary care.[14][15][16]
• Reduce injury-related mortality, morbidity and disability by improving trauma care and addressing road traffic injuries, suicide, violence, workplace injuries and other unintentional injuries.[17][18]
• Enable people with disabilities to live as independently and healthily as possible with dignity, equitable access to rehabilitation, assistive devices and specialised care.[19][20]
• Improve older people’s quality of life through age-friendly primary care, community and family participation, and services for people aged 60 years and over.[21][22]
• Establish sustainable surveillance, monitoring, evaluation and research systems to inform evidence-based policy and programme development.[3][23]

The action plan sets measurable NCD ambitions, including a 7% reduction in premature mortality from the four major NCDs by 2020 and a 20% reduction by 2025 relative to baseline.[24]It also sets targets for reduced tobacco use, physical inactivity, harmful drinking and raised blood pressure; maintaining or halting increases in overweight, obesity and diabetes; and improving coverage of cardiovascular preventive treatment, essential medicines and technologies, trained primary-care workers and hepatitis B vaccination.[8][9][24][25][26][27][12]

Implementation

Implementation combines population-wide prevention with individual care, delivered through a health-in-all-policies and primary-health-care model.[3][14]The Ministry of Health leads the response with other government sectors, communities, civil society, development partners, technical agencies, health providers and relevant private-sector actors.[6][4]Delivery is intended to be progressive across households, outreach services, health posts, community health centres, inpatient community facilities, referral hospitals and the national tertiary hospital.[15]

• Establish an Inter-ministerial Committee, chaired by the Prime Minister or a designated senior cabinet member, to provide stewardship of the multisectoral response.[28]
• Establish a multisectoral NCD Working Group chaired by the Director General of Health Services, clarify roles through memoranda of understanding, and strengthen the Ministry of Health NCD Unit to co-ordinate, implement and monitor the action plan.[28][4]
• Apply health impact assessment and policy action across trade, taxation, education, agriculture, urban development, food production and pharmaceutical production, initially focusing on tobacco, alcohol, diet and physical activity.[6][3]
• Implement tobacco and alcohol controls through legislation, taxation, smoke-free places, warnings, advertising restrictions, sales controls, cessation and treatment services, surveillance, mass-media campaigns and drink-driving enforcement.[28][7]
• Integrate a World Health Organization primary-health-care package for NCDs into routine services, supported by risk assessment, screening, counselling, standard treatment guidelines, home visits, self-care support, referral and continuity of care.[14][16]
• Ensure essential generic medicines and basic technologies through national lists, procurement and supply management, facility inventories and strengthened diagnostic capacity.[14][26][27]
• Build workforce capacity through training, curriculum revision and specialist service development, including cardiac, stroke, oncology, renal dialysis, trauma, geriatric, rehabilitation and mental-health care.[16][18][20][22]
• Deliver disability and healthy-ageing interventions through community-based rehabilitation, primary care, home visits, accessible facilities, transport and referral arrangements, and collaboration with the Ministry of Social Solidarity.[20][22]

Monitoring is to be integrated into national health information systems and the Ministry of Health Monitoring and Evaluation Working Group.[23]The framework contains 24 indicators, with targets for 12, covering mortality and morbidity, risk-factor exposure and health-system response.[23][8][9]Planned data sources include civil registration and vital statistics, medical certification using International Classification of Diseases 10th Revision coding, verbal autopsy for selected home deaths, hospital reporting, disease registries, five-yearly adult risk-factor surveys, school-based student health surveys and health-facility surveys.[23][4][16]

Financing measures include advocating increased regular government allocations for health and NCD prevention and control, allocating funds for essential medicines and technologies, and earmarking cigarette and alcohol tax or levy revenue for NCD care, particularly primary care.[28][4][16]The supplied material does not provide a total implementation budget or activity-level costing.[4][16]

Monitoring & Evaluation

The strategy establishes an integrated monitoring, evaluation and surveillance architecture for non-communicable diseases (NCDs), injuries, disability and healthy ageing. It combines population risk-factor surveillance, disease and mortality monitoring, health-system assessments, registries, research and institutional oversight, while recognising major baseline data weaknesses in vital registration, causes of death and hospital records.[2][23][16]

• Establish a national NCD monitoring framework containing 24 indicators across mortality and morbidity, risk-factor exposure, and health-system response; targets are specified for 12 indicators.[23]
• Use 2010 risk-factor data where available, or data generated in 2014-15, as baselines; obtain baseline information by 2015, assess a possible second data point by 2020, and review 2025 targets in 2020.[23][8]
• Reduce premature mortality from cardiovascular disease, cancer, diabetes and chronic respiratory disease by 7% by 2020 and 20% by 2025 relative to baseline.[24]
• Conduct nationally representative adult NCD risk-factor surveys, school-based student health surveys and health-facility surveys every five years; planned Demographic and Health Surveys in 2014 and 2020 are important data sources.[23][8][4]
• Strengthen civil registration and vital statistics, medical certification of cause of death using International Classification of Diseases, 10th Revision coding, and verbal autopsy for an adequate sample of deaths occurring at home.[23]
• Improve hospital reporting through stronger medical-record departments, information technology, staff capacity and feedback mechanisms; consider or establish hospital-based registries for major NCDs, including cancer and stroke.[23][16]
• Integrate NCD surveillance into national health information systems and the Ministry of Health Monitoring and Evaluation Working Group, and strengthen institutional and academic capacity for disease surveillance and research.[23]
• Monitor access to services, medicines and technologies through health-facility inventories, surveys and supportive-supervision checklists.[23][26][27]

Key NCD targets include a 20% reduction in adult tobacco use, a 30% reduction in adolescent tobacco use, 50% coverage of cardiovascular preventive drug therapy for eligible high-risk people by 2025, 80% availability and affordability of essential medicines and basic technologies, 80% training coverage among primary health-care workers, and 95% coverage for the third infant hepatitis B vaccine dose.[25][26][27][12]Adult overweight, obesity, and raised blood glucose or diabetes have no 2020 target and aim to halt further increases by 2025.[24]No national targets are specified for cancer screening, raised cholesterol, industrial trans-fat elimination, unhealthy-food marketing to children, salt intake or household solid-fuel use in the relevant sections.[11][25][27][12]

For injuries, monitoring is to use case records compiled into a database and community surveys, with impact indicators covering injury-attributable deaths and road-traffic mortality, and outcome indicators covering risk factors and pre-hospital trauma care.[17][18]For disability, indicators include disability-free life-years gained, assistive-device provision and disability prevalence and severity; for healthy ageing, they include disability-free life-years among people aged 60 and over, age-friendly facility standards, screening and health-system contact.[20][22]The plan assigns surveillance and implementation functions to the Ministry of Health, its NCD Unit, the Monitoring and Evaluation Working Group, the National Hospital, the University and research or statistical partners, supported by an inter-ministerial committee, a multisectoral NCD Working Group and partner memoranda of understanding.[28][16]

Costing & Financing

The plan presents NCD prevention, earlier primary-care management and strengthened domestic tertiary services as potentially cost-effective measures that may reduce productivity losses, household impoverishment and reliance on expensive overseas treatment.[6][2][25]It nevertheless provides limited quantified costing: no comprehensive implementation budget, activity-level costings, funding-gap estimate, financing schedule or economic assumptions are specified in the supplied sections.[2][4][16]

• Allocate a larger share of the regular government health budget to NCD prevention and control, including regular financing for essential medicines and technologies.[28][4][16]
• Earmark revenue from cigarette and alcohol taxes and levies for health care for people with NCDs, particularly primary health care, while raising tobacco and alcohol taxes and import duties as prevention measures.[28]
• Recognise that the Ministry of Health budgets US dollars 4 million annually for overseas referral of approximately 250 to 300 patients requiring high-end treatment, many of whom have NCDs.[2]
• Prioritise domestic primary and tertiary capacity to generate possible savings by managing NCDs earlier and reducing overseas referrals.[2]
• Provide adequate projected funding for ageing-related treatment and care; prevention and supportive policies may yield budgetary savings, but no monetary estimate is provided.[21]
• Recognise that reducing household air pollution from solid fuels requires action beyond the health sector and has substantial economic implications.[12]

Resource requirements identified without monetary values include trained health workers, essential medicines, diagnostic technologies, procurement and supply systems, hospital and referral capacity, registries, information systems, surveillance, research, rehabilitation, assistive devices and community-based services.[14][15][23][20]