Knowledge Brief 93389 Health, Nutrition and Population Global Practice THE ROLE OF THE PRIVATE SECTOR Tackling NCDIs in Cambodia: an opportunity for IN REPRODUCTIVE HEALTH inter- and SERVICESsynergies intra-sectoral IN BANGLADESH Ahmed Al-Sabir, Bushra Binte Alam, November 2014 and Sameh El-Saharty May 2014 KEY MESSAGES: Non-Communicable Diseases (NCDs) are a set of chronic diseases, including cardiovascular disease, cancer, chronic respiratory disease and diabetes that are on the rise in Cambodia. Meanwhile, injuries include those due to traffic accidents, which are becoming a major source of mortality and morbidity in Cambodia. NCDs are increasing in Cambodia as a result of smoking, unhealthy diet, harmful use of alcohol, and physical inactivity, all resulting in a sharp increase in the rates of obesity and high blood pressure. Cardiovascular disease, cancer, chronic respiratory disease and diabetes alone cause 46 percent of deaths in Cambodia. NCDs are affecting Cambodians in their productive years. Over half men and over a third of women dying from NCDs are younger than 60 years. The high cost of long-term health care and medicines, along with loss of income, pushes many Cambodian families deeper into poverty. It also overburdens the country’s health system, constraining efforts to improve maternal and child health and tackle infectious diseases. Because of the nature of NCDs, which are rooted in multiple causes, strengthening the health system alone will not reduce the burden of NCDs. Many of the actions needed to prevent and control these diseases require the participation of numerous ministries and government agencies, as well as the private sector. For Cambodians to continue enjoying the fruits of economic growth, a strong commitment by the Government, the people, and the international community is becoming increasing important. Introduction communicable diseases, and maternal, perinatal and Non-communicable diseases (NCDs) are chronic nutritional deficiencies. Cambodia’s history of conflict has diseases, such as cardiovascular disease, cancers, contributed to a high prevalence of mental health chronic respiratory diseases, diabetes and mental health disorders: a 2012 survey found that almost a quarter of disorders. Injuries include those due to traffic accidents, Cambodians suffer from anxiety, and about 16 percent which are also becoming a major source of mortality and reported symptoms of depression. The link between morbidity. WHO estimates that 53 percent of deaths in mental health and NCDs is strong and co-morbidity of Cambodia are from NCDs, with cardiovascular disease mental disorders with diseases, such as cardiovascular the main killer, followed by cancer, while 5 percent of disease, cancer and diabetes, is common. deaths are due to injuries and 42 percent are due to Page 1 HNPGP Knowledge Brief RISK FACTORS FOR NCDS cause of death and serious injury. Overall, 76 percent of fatalities are reported to have suffered from head injuries. The leading risk factors for NCDs in Cambodia are: alcohol, blood pressure, tobacco, underweight, overweight, cholesterol, low fruit and vegetable intake, indoor smoke from solid fuels, and iron deficiency, with Road traffic injuries and fatalities have an enormous the addition of raised blood glucose. To give some impact on the social and economic welfare of Cambodia examples, almost half of men are daily smokers, 10 times with an estimated annual cost of US$248 million, or 3 the proportion of women (5 percent). About 16 percent of percent of GDP. Road traffic injuries disproportionately men drink alcohol daily compared with 10 percent of affect the poorest and the most vulnerable sections of the women, with a third of male drinkers indulging in heavy population. More than 85 percent of the road traffic drinking in the previous 7 days. Based on a 2013 survey, casualties in Cambodia are from those motorcycling, average daily salt consumption is about 7.7g, more than walking and cycling, the primary means of transport used recommended by WHO (5g). by poorer people. NCDI POLICY AND REGULATORY FRAMEWORK There is evidence of links between maternal and child The National Health Strategic Plan (2008-15) includes NCDs as one of the key programs, and the progress on malnutrition, and development of NCDs such as coronary NCDs is reported in the Joint Annual Performance Review heart disease, hypertension, and insulin resistance reports. Specific strategies and action plans include the syndrome in later life. There is also evidence that for National Strategic Plan for the Prevention and Control of those with a relatively low birth weight, excess weight gain NCDs (2013-20); a Mental Health and Substance Misuse during childhood will lead to coronary heart disease in Strategic Plan (2011-15); a National Strategic Plan on adulthood. Chronic child malnutrition in Cambodia is one Education and Reduction of Tobascco Use (2011-15); of the highest in the region and, although underweight and a multi-sectoral National Road Safety Action Plan for 2011-20. and stunting have declined since 2000, they are still high at 28 percent and 40 percent, respectively, for children under five. Cambodia has ratified the Framework Convention on ROAD TRAFFIC INJURIES Tobacco Control (FCTC), and tobacco legislation. A sub- decree to regulate smoke-free environments has also Dramatic improvements in Cambodia’s road network in been approved. the past decade have sadly been accompanied by increased traffic-related injuries and deaths. According to the 2012 Road Traffic Accident and Victim Information System Report, 15,615 road crash casualties were Clinical guidelines or protocols exist for the management reported as a result of 4,250 crashes. There were 1,966 of some NCDs and the MoH is developiong the clinical fatalities and 5,349 severely injured. There were 13 guiidelines for out-patient consultation for NCDs. There fatalities per 100,000 people in 2012, and a strong are (2008) guidelines for cervical cancer screening, increasing trend. Over the past 8 years (2005-12), the prepared by the Preventive Medicine Department, number of fatalities has doubled. At the same time, the gynaecologists and oncologists. These guidelines will be number of registered vehicles has risen by 278 percent updated in 2015 following completion of a demonstration (82 percent of which are motorbikes). project in cervical cancer screening for all women aged 30-49 in selected operational districts in 2014. In 2009, the leading causes of road crashes, fatalities and injuries (potentially leading to disability) in Cambodia were FOCUSING ON AREAS FOR GREATEST HEALTH related to speed and drunk driving (70 percent of GAIN fatalities), in combination with low helmet wearing rates In view of the epidemiological transition and the “double- among passengers and children. Head injury is a key burden� of communicable and NCDIs in Cambodia, Page 2 HNPGP Knowledge Brief  priority should be given to reducing risk factors that are Models suggest that 70 percent coverage could reduce common, widespread and impact significantly on health. cervical cancer in Cambodia by half. Among NCDs, the leading cause of death is Early detection of cancer can be promoted through cardiovascualar disease. Substantial reductions have campaigns to: raise awareness of early symptoms of been achieved in coronary heart disease mortality in common cancers so that people are referred earlier for some countries through a combination of population-level treatment; and improved quality/coverage of low-cost and prevention approaches targeting individuals at high cervical screening. risk. Most benefits have been achieved by reducing cholesterol, systolic blood pressure (e.g., through reducing salt intake) and reducing smoking. This calls for Table 1 shows a cost-effective package of interventions strong control of tobacco and nutritional interventions, for low-resource settings aimed at NCDs. including salt reduction. Palm oil, which is widely used, may contribute to cardiovascular risk. Diabetes is higher Table 1: Priority interventions for NCDs than expected for the levels of adult obesity and may reflect earlier origins of disease. Risk Factor Intervention Tobacco use Accelerate implementation of the WHO Framework Convention on Tobacco Control Measures: In low/middle-income countries, cancers of the cervix, monitor tobacco use and stomach, liver, oral cavity and pharynx are common. One prevention policies; protect people quarter of these are caused by chronic infection, while the from tobacco smoke; offer help to proportion caused by tobacco is growing. For Cambodia’s quit tobacco; warn about the dangers of tobacco; enforce bans cancer profile preventable cancers are likely to be liver, on tobacco advertising, promotion, oropharynx and lung, cervical and stomach. Cervical and sponsorship; and raise taxes on cancer in particular can be cured if detected early by tobacco raising awareness of symptoms among women, using Dietary salt Mass-media campaigns and screening, and better referral and treatment pathways. voluntary action by food industry Prevention strategies include reducing transmission of to reduce consumption. infection (e.g., condoms and sexual health promotion), Obesity, unhealthy diet, Mass-media campaigns, subsidies, vaccinating for Human Papillomavirus (HPV), and tobacco and physical inactivity labelling, and marketing and alcohol control. restrictions. Harmful alcohol intake Tax increases, advertising bans, and restricted access. Common risk-factor approach Cardiovascular risk Combination of drugs for reduction individuals at high risk of NCDs, Given the NCD profile, the prevalence of risk factors and and reduced dietary salt through the additional disease burden, strategies should have mass media campaigns; regulation of food industry. high impact, low cost and maximize synergies with other programs. Source: Adapted from Beaglehole, R. and others 2010. Guidelines exist for assessing multiple cardiovascular risk Synergies with other health system factors. Measures for cancer prevention include: programs promotion of breast-feeding; promotion of safe sex; high coverage of Hepatitis B vaccination; and the consideration Given limited resources and the nature of NCDs, tackling of HPV vaccinations for cervical cancer prevention. them requires a ‘disease-inclusive’ approach. One Page 3 HNPGP Knowledge Brief chronic disease (such as diabetes) should be used as an tobacco. This could be spent on food, education, or health entry point for a more integrated approach (e.g., with care. Total annual spending on tobacco by households is cardiovascular disease), building on common risk factors. about US$69 million. To reduce the demand for tobacco, excise tax increases work well as part of an overall strategy of tobacco control. Studies find that a 10 percent Priorities for collaborating with maternal/child health cigarette price increase will reduce consumption by 4 programs could include: alleviating malnutrition and percent in high-income countries and by 8 percent in low- reducing smoking in pregnant women; increasing and middle-income countries, while contributing to breastfeeding uptake; monitoring birth weight; increasing increased government revenue. educational attainment of women; promoting health nutrition in families; identifying and managing hypertension and diabetes in pregnancy; and promoting Tobacco taxes are currently lower in Cambodia than in smoke-free homes. neighboring countries. The total tax on tobacco products in Cambodia is 20 percent of retail price for domestic and 25 percent for imported products, while in Vietnam it is Examples of collaboration with reproductive health and about 38 percent and in Thailand it is 73 percent for the sexual health programs promote condom use and safe- most sold brand. sex practices, and raise awareness of early symptoms of breast and cervical cancer. Tobacco taxation is a key component of the FTCC that has been signed by the RGC. To support policy decisions Collaboration on infectious diseases and immunization and serve as an input for policy deliberations, further programs includes improved access to HPV and/or analytical work on tobacco taxation could be conducted Hepatitis B vaccinations, and extension of palliative care by the MEF and MOH. The aim would be to simulate the programs from HIV/AIDS to cover other chronic diseases. revenue impact of gradual increases in tobacco excise tax Models already exist for collaboration with tuberculosis and cigarette retail prices, as well as the public health control programs to benefit patients with non-infectious impact. Such analysis could help build consensus in respiratory symptoms in primary care, e.g., asthma and government for implementing tax increases. obstructive pulmonary disease. In addition to tobacco taxation, it is important to enforce Examples of collaboration with environmental health and smoke-free public places, particularly in health facilities, transport include: reduction of air pollution; promotion of schools, hotels and restaurants. This measure, which smoke-free environments; promotion of walking and reduces the social acceptability of smoking, has been cycling through safe transport routes and healthy urban initiated as a gradual approach in 750 facilities, and an planning; enforcement of occupational health legislation; initiative for smoke free status in all public facilities was and reductions in environmental hazards and pollutants initiated in one provincial town in 2013. harmful to health. ROAD TRAFFIC SAFETY A priority in Cambodia is to reduce head injury related deaths and injuries due to motorcycle crashes through Beyond health systems: community-based programs to increase awareness, TOBACCO TAXATION emergency medical training, providing incentives for correct wearing of helmets, and better enforcement of In Cambodia, where 20.5 percent live below the poverty road safety laws. To ensure the sustainability of these line, lower-income households with at least one smoker interventions, a robust effort should be mounted and use about 9 percent of total household spending on geared to support the implementation of the 2011-20 Page 4 HNPGP Knowledge Brief National Road Safety Action Plan. Recommendations Particular emphasis should be placed on (i) strengthening the institutional management functions of the National The following are suggested ways of integrating Road Safety Committee; (ii) institutionalizing the approaches in order to achieve inter- and intra-sectoral Cambodia Road Crash and Victim Information System at synergies in tackling NCDIs: the Ministry of the Interior, MOH and National Road  Prevention and case management of NCDIs Safety Committee; (iii) enacting an amended Helmet Law require both intra- and inter-sectoral coordination, to mandate the wearing of helmets by all motorcycle examples of which are given in the note. drivers and passengers; and (iv) reforming emergency medical services, including both pre-hospital and in-  Coordination among the different programs needs hospital services. to be strengthened to implement the Health Strategic Plan 2008-15 priority areas, including maternal and child health, communicable diseases, health system strengthening, and Conclusion: Designing an integrated NCDIs. approach  The organization and functioning of the MOH-led It is imperative for the RGC to: (i) prioritize mapping the Task Force for NCDI (TF3) should be health profile of Cambodia; and (ii) focus on how the strengthened by reviewing its terms of reference NCDI agenda could develop synergies with other health and its membership. programs, particularly in maternal and child health, health system reform, and initiatives on tobacco and alcohol  A high-level coordination mechanism should be control and road traffic safety. This course of action on established at the MOH to integrate planning, NCDIs should be supported by the World Bank and other programming and operation of the separate MOH development partners to avoid creating an “unfunded task forces appointed to guide the implementation vertical program�, making more effective use of limited of the HSP2, including NCDIs. resources.  A proposed 12-24 month implementation action plan for tackling NCDIs should be agreed between the MOH and development partners. Improved coordination among all MOH task forces would maximize financial and human resources and help  Regular Health Program and Technical Working implement priority NCDI-related interventions as part of, Group for Health meetings would help to provide and not separate from, other ongoing programs. The a forum for advancing this policy dialogue in application of the proposed measures would benefit from NCDIs. clear procedures for joint planning, programming, budgeting, training, reporting, and M&E of all programs. The Health, Nutrition and Population Knowledge Briefs of the World Bank are quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, please contact Miguel Sanjoaquin, Health Economist (msanjoaquinpolo@worldbank.org) . Page 5