The Burdens of Cardiouascular Disease (Cvds) and Other Non Communicable Diseases (Ncds)

HEALTH SECTOR

Non-Communicable Diseases

Country Context/Health Status:

The burden of cardiovascular disease (CVDs) and other non-communicable diseases (NCDs) like cancer, chronic obstructive lung disease and diabetes is considerable. Good data on these conditions do not exist. The latest information available on NCDs if from 1999. These conditions were probably the first cause of morbidity and mortality prior to 1990. With the decline in social conditions in the 1990s, infectious conditions rose, with diarrhea and respiratory infections among young children becoming the top causes of death. If these conditions decline rapidly in the next few years, as is expected, then NCDs will again become the number one cause of death.

Control of NCDs suffered since 1990 through isolation from developments in the rest of the world and impoverishment of the medical care system. Usual sources of medicine supply and familiar doses disappeared, leading to an excessive focus on the provision of drugs in place of a focus on health. Most importantly, those aspects of the system that dealt with prevention and health promotion were most retarded during the country’s period of wars and economic sanctions.

The number of cancer cases registered is between 8000-9000 per year. The most frequently reported tumors are CA Breast (14%), Lung (10.6%), Bladder (7.5%) followed by CA of the Lymphatic system. Childhood Cancers constitute about 8% of total cancer in Iraq

The main determinants of NCDs are smoking, hypertension, diabetes, unhealthy diet and lack of physical activity. Of these, smoking is probably the single most important risk. The prevalence of smoking in males is 40% while in females 5%. A survey by FAO in 2000 determined that 40% of the adults are overweight. There is no routine surveillance system for NCDs risk factors.

Health Policy/ Management Structure:

Iraq was one of the first countries in the region initiate a population-based cancer registry and a national cancer control plan. The Ministry of Health chairs the Iraqi Cancer Board (ICB). Before the 2003 war it had14 provincial committees and subcommittees for smoking control, cancer registration, prevention and early detection, radiotherapy, chemotherapy and palliative cancer. Iraq was one of the first countries in the region to establish a unit for NCD control in MOH about 17 years ago . it is now part of the department of non-communicable disease and mental health.

MOH formulated a NCD prevention and control programme but implemented little of it. It organized several national workshops and training courses, produced health education materials and disseminated several treatment guidelines. It launched a national campaign for the early detection of breast cancer in 2001. It prohibited of all forms of tobacco advertising and imposed tariffs on imported tobacco.

Since the war the anti-smoking control program has been lost. The previous high tariffs on imports of cigarettes disappeared.

To address this situation there should be:  Re-activation of the Smoking Control Committee.  Empowering this committee to enable anti-smoking regulations.  Changes in the managerial structure of the NCDs program to better define different levels of the health care system and emphasize decentralization.

Health Care Service Patterns:

PHC physicians are inadequately trained in the management and follow up of NCDs.

A semi-private nation-wide network of public clinics was established after the embargo to ensure the availability of essential drugs to chronically ill patients. These clinics (which are more or less dispensaries in reality) were managed by a DG of public clinics and it offered better incentives to health workers, but operated only in evenings.

Specialists in internal medicine working in private/public clinics now treat people with NCDs. This form of health care delivery is loosely regulated and malpractice is not uncommon.

Pharmaceuticals

A national NCD Drug policy but during sanctions there were frequent shortages and interruptions of supply. Adherence to the formulated national drug policy was inconsistent, case management impaired and control of complications nearly absent. Most of the drugs for NCDs were subsidized.

Short Term Goals:

1. An effective National Surveillance System should be developed to monitor NCD risk factors strengthen mortality statistics and monitor the nutritional status of the population. Better equipment, more modern patient management approaches, improved referral systems, improvement in the referral and counter-referal of patients from PHCs may notably reduce mortality. 2. Establishing a primary prevention program based on integrated prevention of the major NCDs that share the same risk factors. 3. Developing a long term culturally specific health education strategy aimed at raising public awareness on the prevention of risk factors and promoting "self-care" and "self-monitoring". 4. Investments in interventions to change the KAP of the population should be sustained over extended periods of time to achieve optimal changes in risk factor levels and disease outcomes. 5. A national surveillance system for NCDs should be designed and built to be an integral part of the overall disease surveillance.

2 6. Create a special focus on housewives education that smoking inside the house hurts the whole family, including the children 7. Approaching the people through intensive media campaign designed to address the local community, for example interviewing victims of smoking to tell their story and /or people who where able to quit smoking specially the ones that are likely to influence the beliefs and behavior of people 8. Actively involving high profile religious leaders in the campaign against smoking would have an important impact on a society that highly respects these leaders and is willing to follow their example. 9. Perhaps one of the most effective anti-smoking activities was the global ban on smoking advertisement that was strictly enforced. This ban should be reasserted now

Medium Range Goals:

1. The chronic disease cards system provides opportunities to deliver evidence- based practice and improve the skill levels of clinicians specializing in one type of disease. Patient support groups and educational activities are also relatively easy to organize with this population-based system of specialized care. maintained because it offers every NCD patient with his or her monthly “ration” of drugs. The opportunities offered by this system to maintain a patient database and observe changes in treatment modalities is great.

I. When the public system of care for patients with NCDs improves, it will become possible for the medical association and DOH to begin monitoring quality of care in private practice. Malpractice reports can be followed up, perhaps a legislative body can be established that looks into lawsuits filed by victims of malpractice. Re-licensing of practice can be linked to attainment of continuing medical training points (on the job training).

II. Training is an essential tool that is needed to improve medical care standards. Continued medical training was used by MOH only occasionally. To correct this situation, it is suggested that performance be linked to scholarship for outside the country training and/or education opportunity.