Paper presented at a CME Session, held in conjunction with the NIH Research Week 2014, 26 November 2014 at the Institute for Health Management, Bangsar

1. Ministry of Health
Malaysia
Non-Communicable Diseases:
Malaysia in Global Public
Health
Feisul Idzwan Mustapha MBBS, MPH, AM(M)
Public Health Physician, NCD Section, Disease Control Division
Ministry of Health, Malaysia
NIH Research Week 2014, CME Session
26 November 2014
Kuala Lumpur
dr.feisul@moh.gov.my

2. Engagement of Non-State Actors
2
SharingValueAsia Summit,
9 October 2014, Singapore:
“Unlocking the Value of
Government: New Approaches
for Policymakers”
Photos courtesy of PublicAffairsAsia

3. Engagement of Non-State Actors
3
• What considerations should
government abide by when
collaborating with businesses?
• How do I expect multi-stakeholder
collaborations to change the role of
government in coming decades?
• How should collaborative
mechanisms best be insulated from
changes of government that may
affect policy? • Can Malaysia play an active role
Photos courtesy of PublicAffairsAsia
in global public health in the
context of WHO’s work in
engagement of non-State
actors?
• What can the private sector do
if governments are not
receptive to collaborative work?

4. 4
Global NCD
Targets
Source of icons: World Heart Federation Champion Advocates Programme

5. Proportional mortality, Malaysia
(% of total deaths, all ages, both sexes)
5

6. Premature mortality due to NCDs,
Malaysia
6
The probability of dying between ages 30 and 70 years
from the 4 main NCDs is 20%

7. DALYs attributable to risk factors
7
Poor Water & Sanitation
Underweight
Physical Inactivity
Alcohol
High Cholesterol
High BMI
Diabetes Mellitus
10.7%
10.8%
8.3%
9.0%
3.1%
4.3%
5.2%
0.1%
0.7%
12.1%
10.8%
0.1%
0.7%
11.4%
5.1%
0.9%
4.3%
0.7%
Tobacco
High BP
15.0% 10.0% 5.0% 0.0% 5.0% 10.0% 15.0%
Male Female
Burden of Disease Study Malaysia 2008, slide courtesy of Dr Mohd. Azahadi Omar, Institute for Public Health

8. Deaths attributable to risk factors
Poor Water & Sanitation
Underweight
Alcohol
Physical Inactivity
High BMI
High Cholesterol
Diabetes Mellitus
19.4%
15.7%
7.0%
7.3%
8.5%
5.0%
2.3%
0.1%
0.2%
22.8%
0.1%
0.2%
1.2%
7.1%
8.2%
8.1%
9.1%
0.3%
Tobacco
High BP
25% 20% 15% 10% 5% 0% 5% 10% 15% 20% 25%
Male Female
Burden of Disease Study Malaysia 2008, slide courtesy of Dr Mohd. Azahadi Omar, Institute for Public Health
8

9. 9
Global NCD
Targets
Source of icons: World Heart Federation Champion Advocates Programme

10. 10

11. 65th World Health
Assembly (May 2012):
Decided to adopt a global target of
a 25% reduction in premature
mortality from NCD by 2025.
66th World Health Assembly
(May 2013):
Adoption of the Global Action plan for
the Prevention and Control of NCDs
(2013-2020), including 25 NCD
indicators with 9 voluntary global
targets.
11

12. Outcome Document of the 2014 UN
General Assembly High-level Meeting
on NCDs
First High-level Meeting on NCDs (New York,
19-20 September 2011)
2011
Second high-level Meeting on NCDs (New York, 10-11
July 2014) to take stock of the progress made since
2011
2014
Third High-level Meeting on NCDs
to report on progress achieved
since 2014
2018
12
Slide courtesy of Dr Shin Hai-rim, WHO Western Pacific Region Office

13. 2014 UN Outcome Document on NCDs
(resolution A/RES/68/300)
• Bottom line:
Governments committed themselves
to intensify their efforts towards a
world free of the avoidable burden of
NCDs
• Moving forward:
Maps out a set of concrete national
commitments to be implemented
between 2014 and 2018, and
provides 3 new global assignments
• Towards the world we want:
Next milestone in 2018
13
Slide courtesy of Dr Shin Hai-rim, WHO Western Pacific Region Office

14. National commitments included in the
2014 UN Outcome Document on NCDs
By 2015, consider setting national targets for NCDs
By 2015, consider developing national multisectoral
policies and plans
Integrate NCDs into health-planning and national
development plans
By 2016, implement "best buys" to reduce risk factors
for NCDs
By 2016, implement "best buys" to enable health
systems to respond
Strengthen national surveillance systems
14
Slide courtesy of Dr Shin Hai-rim, WHO Western Pacific Region Office

15. Global assignments included in the
2014 UN Outcome Document on NCDs
By 2015, WHO to develop an approach to register and
publish contributions of non-State actors towards the 9
global NCD targets
WHA68: Framework for country action to mobilize
sectors beyond health
OECD/DAC: Purpose code to track development
assistance for NCDs
By 2017, WHO to submit a progress report to UN
General Assembly
By 2018, UN General Assembly to convene a third High-level
Meeting
15
Slide courtesy of Dr Shin Hai-rim, WHO Western Pacific Region Office

16. Global accountability framework for NCDs:
Milestones during the next three years
• WHO publishes global baseline
• WHO conducts third survey on national capacities
• WHO generates data
2015
• Progress report to WHA on 25 outcome indicators
• Progress report to WHA on 9 progress indicators 2016
• Independent evaluation (Global Action Plan)
• Progress report to the UN General Assembly 2017 16
Slide courtesy of Dr Shin Hai-rim, WHO Western Pacific Region Office

17. NCDs in the post-2015 development
agenda: Towards the world we want
• 10 September 2014: Member States
welcomed the report of the Open Working
Group of the UN General Assembly on
Sustainable Development Goals
• Next 12 months: Proposal shall be the
main basis for integrating sustainable
development goals into the post-2015
development agenda
• Target 3.4: By 2030 reduce by one-third
pre-mature mortality from NCDs through
prevention and treatment, and promote
mental health and well-being
17
Slide courtesy of Dr Shin Hai-rim, WHO Western Pacific Region Office

18. 18

19. Cost effective interventions to address
NCDs
Population-based
interventions
addressing
NCD
risk factors
Tobacco use - Excise tax increases
- Smoke-free indoor workplaces and public places
- Health information and warnings about tobacco
- Bans on advertising and promotion
Harmful use
of alcohol
- Excise tax increases on alcoholic beverages
- Comprehensive restrictions and bans on alcohol marketing
- Restrictions on the availability of retailed alcohol
Unhealthy
diet and
physical
inactivity
- Salt reduction through mass media campaigns and reduced salt
content in processed foods
- Replacement of trans-fats with polyunsaturated fats
- Public awareness programme about diet and physical activity
Individual-based
interventions
addressing
NCDs in
primary care
Cancer - Prevention of liver cancer through hepatitis B immunization
- Prevention of cervical cancer through screening (visual
inspection with acetic acid [VIA]) and treatment of pre-cancerous
lesions
CVD and
diabetes
- Multi-drug therapy (including glycaemic control for diabetes
mellitus) for individuals who have had a heart attack or stroke,
and to persons at high risk (> 30%) of a cardiovascular event
within 10 years
- Providing aspirin to people having an acute heart attack
19

20. Cost effective NCD interventions…
• What works, what can we afford, and what should we
adopt?
• The challenge? Identify interventions that:
• are effective;
• can lead to measurable declines in NCD death rates
quickly (e.g. over 10 years);
• are affordable; and
• can easily be implemented and sustained.
The Lancet. December 8, 2007 Volume 370:
Gaziano T, Galea G and Reddy K. Scaling up interventions for chronic disease prevention: the evidence.
pp 1939-1946.
The Lancet. December 15, 2007. Volume 370:
Asaria P, Crisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and
financial costs of strategies to reduce salt intake and control tobacco use. pp 2044-2053.
Lim S, et. al. Prevention of cardiovascular disease in high-risk individuals in low-income and middle-income
countries: health effects and costs. pp 2054-2061.
20

21. WHO Regional Response
2000
2001-03
2004-06
2008
2009-11
Healthy Islands Initiative
WPDD
Call for Action on Obesity Control
Regional plan for integrated CVD and
Diabetes Prevention 1998-2003
Regional Tobacco action plan
FCTC implementation
Regional NCD STEP Surveys
Healthy Cities Initiatives
addressing NCD and tobacco
NCD & Poverty: Pro-Poor Strategy 2006
Regional Action plans for NCD
Regional Strategy to Reduce
Alcohol related harm
Regional Initiative on multi-sectoral
intervention for NCD prevention: Obesity
Strategy & programme: Breast/cervical
cancer control
2012
National multisectoral plans
Marketing of foods/ NCD and
PHC/Surveillance
2013 Cancer Leadership and LeAd-NCD
Regional action plan (2014-2020)
2014
NCD knowledge net work
2nd Lead NCD
NCD surveillance
21
Slide courtesy of Dr Shin Hai-rim, WHO Western Pacific Region Office

22. National Strategic Plan for
Non-Communicable Diseases
(NSP-NCD) 2010-2014
• Presented and approved by the Cabinet on 17
December 2010.
• Provides the framework for strengthening NCD
prevention & control program in Malaysia.
• Adopts the “whole-of-government” and
“whole-of-society approach”.
• Diabetes & obesity are used as the entry
points.
Seven Strategies:
1. Prevention and
Promotion
2. Clinical Management
3. Increasing Patient
Compliance
4. Action with NGOs,
Professional Bodies &
Other Stakeholders
5. Monitoring, Research
and Surveillance
6. Capacity Building
7. Policy and Regulatory
interventions
22

23. Strategy 7 NSP-NCD:
Policy & Regulatory Interventions
• Main thrust of NSP-NCD
• Health promotion and education will increase awareness and
knowledge
• However changes in behaviour is strongly influenced by our
living environment
Awareness Knowledge
Behavioural
Change
Supportive living
environment
Health promotion & educations
Policies & regulations
23

24. The Great Prevention Debate
Personal choice
versus
government responsibility
24

25. Personal Choice is Important
25

26. BUT …
If we want people to make healthy choices we
have to make healthy choices available,
accessible and affordable
26

27. Prevention is BOTH a personal and
government responsibility
27

28. Current Approaches to NCD From Birth To Tomb
Pregnancy
Pre-conception
Intervention
Package
 Health
Promotion
Infant/
Toddler
First 1,000 Days
To reduce obesity and NCDs-birth weight
Lifestyle during pregnancy – fetal health
Pre-
School
School-going
Age
Garispanduan Pemasaran Makanan
& Minuman kepada Kanak-kanak
Garispanduan
Pengurusan Kantin
Garispanduan Penguatkuasaan
Larangan Penjualan Makanan &
Minuman Di Luar Pagar Sekolah
NCDP1M
School Setting
KOSPEN
Workplace / Community
Setting
Higher
Education Adults Elderly
AktivitiFizikal
Program Warga Aktif
Warga Produktif
Healthy Workplace
for Healthy
Workforce
Sihat
Amalan
Pemakanan Sihat
Hidangan Sihat
SemasaMesyuarat
Kafeteria Sihat
Garispanduan Perlaksanaan
Vending Machine Makanan &
Minuman Sihat dlm
Perkhidmatan Awam
Jom Mama
Initiatives
28

29. Strategy 7 NSP-NCD: Policy & Regulatory
Interventions, Progress thus far…
• Guideline on marketing of foods and non-alcoholic beverages to
children (Self-regulatory, August 2013).
• Strengthening implementation of the Framework Convention for
Tobacco Control (FCTC).
• Guideline on food and beverages sold in school canteens (revised
guideline, January 2012).
• Banning of sale of food & beverages by mobile vendors outside of
school perimeters (2012)
• Health-promoting workplaces in the public sector
• Healthy menus during meetings
• Healthy vending machines
• Healthy cafeterias
29
There is still much that needs to be done….

30. Other strategies under NSP-NCD,
Progress thus far…
• Continue to work with food and beverage industries to reduce the
content of salt, sugar and fat in processed food.
• Development of Salt Reduction Strategy
• Prioritising interventions to fight obesity
• “Komuniti Sihat, Perkasa Negara” initiative
• Involvement of PIBG to support implementation of health-related
programs in schools
30
There is still much that needs to be done….

31. National Systems Response to NCDs –
ASEAN Countries
BRN
CAM
IND
LAO
MAL
MYN
PHI
SIN
THA
VIET
Has an operational NCD unit/branch or department
within MOH ✓ ✓ ✓ ✗ ✓ ✗ ✓ ✓ ✓ ✗
Has an operational multisectoral & integrated national
policy, strategy or action plan ✗ ✗ ✓ ✗ ✓ ✓ ✗ ✗ ✗ ✗
Has an operational policy, strategy or action plan to
reduce the harmful use of alcohol ✓ ✓ ✓ ✗ ✗ ✓ ✓ ✗ ✓ ✗
Has an operational policy, strategy or action plan to
reduce physical inactivity ✗ ✓ ✓ ✗ ✓ ✓ ✓ ✓ ✓ ✗
Has an operational policy, strategy or action plan to
reduce the burden of tobacco use ✗ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Has an operational policy, strategy or action plan to
reduce unhealthy diet and/or promote healthy diets ✗ ✓ ✓ ✗ ✓ ✓ ✓ ✓ ✓ ✓
Has evidence-based national guidelines for the Mx of
major NCDs through a primary care approach ✓ ✗ ✓ ✗ ✓ ✓ ✗ ✓ ✓ ✗
Has an NCD surveillance and monitoring system in
place to enable reporting for the GMF ✗ ✓ ✗ ✗ ✓ ✗ ✗ ✓ ✓ ✓
Has a national, population-based cancer registry ✓ ✗ ✗ ✗ ✗ ✗ ✗ ✓ ✗ ✗
31

32. ASEAN Task Force for Non-
Communicable Diseases (ATFNCD)
• STRATEGY I: Revitalise and implement ‘ASEAN Healthy Life Style
2002
• Engage in advocacy opportunities at regional/international platforms
• Policy advocacy on NCD concerns that includes but not limited to:
• Labeling and standards for healthy low salt food
• Ethical advertising of food products for children
• Alcohol consumption reduction
• Strategy II: Facilitating enabling environment for ensuring
promotion of healthy lifestyle for the people of ASEAN
• Networking among ASEAN Cancer Data and Registry Information
System
• Key indicators on Healthy Lifestyle especially on 4 selected NCDs
• Regional Workshop to harmonize guidelines on physical activity in
collaboration with WHO
• Regional framework for NCD screening and management 32

33. Consultation on Overweight, Obesity, Diabetes
and Law in the Western Pacific Region, April 2014
• Co-organised by the International Development Law
Organisation (IDLO), University of Sydney (Faculty of Law and
Boden Institute of Obesity, Nutrition and Exercise) and WHO
WPRO.
• Several themes and areas for action were identified :
• Generating and sharing evidence for action
• Capacity-building: Strengthen the linkages between health and
the law, building the capacity of each profession to understand
and work with one another. Suggestions for achieving this
included:
• Training the legal and health workforces through changes to
academic curricula;
• Conducting workshops and forums to encourage greater dialogue
between government and civil society, and
• Developing a multidisciplinary group of public health law experts.
33

34. Consultation on Overweight, Obesity, Diabetes
and Law in the Western Pacific Region, April 2014
• Promising interventions: In-depth technical advice on specific
promising interventions, including
• Regulation and taxation of sugar-sweetened beverages;
• Restriction of marketing unhealthy food products and beverages to
children;
• Requirements for interpretative front-of-pack labelling on packaged
foods; and
• Legislation to facilitate environments that are conducive to physical
activity.
• Social mobilization: The support and participation of civil society is
crucial to the development, implementation and enforcement of
innovative legal approaches to overweight, obesity and diabetes.
• Actions to address industry interference: Clear guidelines are
needed to avoid conflicts of interest and to ensure that government
interactions with the food industry are transparent and constructive,
and do not jeopardise public health goals. 34

35. 65th Regional Committee Meeting for the
Western Pacific, 13-17 Oct 2014
• One of the main agenda items is Tobacco free initiative:
Regional Action Plan 2015–2019
• Malaysia made a strong statement on this issue
35
“I think it will be fool hardy
for us to expect that the
tobacco industry will not
interfere. By virtue of being
the Tobacco industry itself it
is their duty to interfere and
they will continue to
interfere”

36. 65th Regional Committee Meeting for the
Western Pacific, 13-17 Oct 2014
Malaysia’s stand:
• We cannot handle the issue of tobacco without looking at the
trade and economical aspects of tobacco
• Malaysia is quite consistent in this idea that we should try to
exclude tobacco in all forms of trade agreements e.g. in TPPA.
• Must address issue of illicit tobacco and transboundary
smuggling – need multisectoral involvement.
• Increasing excise duty.
• Need to gather further evidence to support policy
implementation.
36

37. 6th Session of the Conference of Parties (COP)
to the WHO Framework Convention on
Tobacco Control (FCTC) – 13-18 Oct 2014
37
• Malaysia continues to fight for carving out
tobacco from trade agreements and hosted
a drafting group.
• Met with strong opposition from several
countries.

38. Commission on Ending Childhood
Obesity
38
• Announced by Dr Margaret Chan at the 67th World Health Assembly 2014
• The Commission has been tasked with producing a report specifying
which approaches and combinations of interventions are likely to be most
effective in tackling childhood and adolescent obesity in different contexts
around the world.
• The Commission will deliver its report to the WHO Director-General so
that she can convey its recommendations to the World Health Assembly.
http://www.who.int/entity/end-childhood-obesity/about/en/

39. National Strategic Plan for
Non-Communicable Diseases
(NSP-NCD) 2010-2014
• Presented and approved by the Cabinet on 17
December 2010.
• Provides the framework for strengthening NCD
prevention & control program in Malaysia.
• Adopts the “whole-of-government” and
“whole-of-society approach”.
• Diabetes & obesity are used as the entry
points.
Seven Strategies:
1. Prevention and
Promotion
2. Clinical Management
3. Increasing Patient
Compliance
4. Action with NGOs,
Professional Bodies &
Other Stakeholders
5. Monitoring, Research
and Surveillance
6. Capacity Building
7. Policy and Regulatory
interventions
39

40. “My Body is Fit
and Fabulous”
An Implementation Research
(qualitative + quantitative approaches)
MyBFF@school MyBFF@home MyBFF@work
INTERVENTION PROGRAMMES
TO COMBAT OBESITY IN MALAYSIA
Slide courtesy of Dr Wan Nazaimoon, IMR; nazaimoon@gmail.com
40

41. JOM MAMA: Focus on pre-pregnancy for
prevention
41
Evidence base Pre-conception / young couples Malaysia
Nurul (25) &
Khairil (27)
Academia/Partners
Public-private partnership Implementation
Phase 1
Co-creatIon
Phase 2
Programme
development
Phase 3
Evaluation and
Evaluation
Slide courtesy of Priya Matzen, Novo Nordisk; pryn@novonordisk.com

42. JOM MAMA: Objective
42
What we want to do
To investigate if pre-pregnancy
interventions
improves young couples
health literacy and
women’s health
To assess if the
intervention improves
delivery and birth
outcomes.
Prevent/
reduce risk
of NCDs
Slide courtesy of Priya Matzen, Novo Nordisk; pryn@novonordisk.com

43. HOPE-4 Study
• Intervening the epidemiologic transition through innovative
means of controlling hypertension
• Collaboration between UiTM, NCD MOH, McMaster
University, Toronto University and London School of Hygiene &
Tropical Medicine
• Grand Alliance for Chronic Diseases, supported by Grand
Challenges Canada.
• 50 communities in Malaysia, Columbia, India and Sub-Sahara
Africa.
• Task shifting – non-physician healthcare workers under
supervision of doctors.
• Use of polypill.
43
Information courtesy of Prof. Dato’ Dr Khalid Yusoff, kyusoff@salam.uitm.edu.my

44. v
South East Asia Community Observatory
SEACO:
Research for a healthy community
D.D. Reidpath & P. Allotey
44

45. DHSS: A Research Platform
SEACO: A research platform
• A community-based sentinel surveillance system that
captures longitudinally, a fully enumerated population within
circumscribed geographical location.
• The data collection process explicitly captures information on
demography, morbidity and mortality from the individual,
within the context of the household, and the household
within the context of the community, as well as the physical,
social, geographical relationships between these.
Slide courtesy of Prof. Pascale Allotey, Monash University Sunway Campus; pascale.allotey@monash.edu
45

46. Lessons learned from the past and current
attempts to work with other sectors
• Go for the path of least resistance.
• Perhaps less impact, but at least establish the link and develop
trust.
• Compromise, find the “middle path”
• You cannot force the other sectors to go 100% your way.
• Be creative – think “out-of-the-box”
• Use other existing mechanisms not previously used to move the
NCD prevention and control agenda forward.
• Be sensitive to current global/national trends.
• Use any opportunity to move the NCD prevention agenda
forward.
46

47. threesteps
sir george
alleyne
mutuality of interest
specificity of purpose
identification of specific resources
47

48. Thank you
dr.feisul@moh.gov.my
Facebook: Feisul Mustapha
48