SheffWHO 2019: Winning Position Paper: NONCOMMUNICABLE DISEASES

Building on the hugely successful 2018 debut, SheffWHO explored the theme “Non-Communicable Diseases: A Crisis in Slow Motion” from 8-10 March 2019. As before, delegates represented WHO Member States, as well as Non-Governmental Organizations (NGOs), pharmaceutical companies and the media.

Contributing to interdisciplinary and experiential learning in global health, delegates from all disciplines (not just science/health) were encouraged to participate in this event. They discussed, co-operated, and negotiated with other stakeholders to produce resolution papers addressing the simulation theme, as an important global health priority.

The winning position paper was by Jowi Kryz Guillen.

For the SheffWHO 2019 simulation, Jowi was tasked to prepare a position paper for Pakistan as a delegate of the Eastern Mediterranean Regional Office (EMRO). This position paper addressed the conference theme of Non-Communicable Diseases (NDCs), which included details of mortality and morbidity due to NCDs and potential causal factors, such as diet, air quality and lifestyle. The main goal of the position paper was to propose alternative solutions to overcome prevalent NCDs in Pakistan, which are cost-effective and right-impact interventions that respects the political and cultural factors unique to Pakistan. Furthermore, the recommended actions enhances present healthcare platforms and complements the WHO agenda for combatting NCDs.

Jowi has just finished her MSc in Biomaterial and Regenerative Medicine at the University of Sheffield, where she is expected to graduate this January 2020 with distinction. She is currently taking a sabbatical and volunteering with the British Council (Generation UK - InternChina) in Chengdu, to teach English and work for a local orphanage. Her next goal is to start a PGCE in Biology/Chemistry at University College London in 2020.

Name: Jowi Kryz Guillen
Role: Member State Representative of Pakistan
Region: Eastern Mediterranean (EMRO)
Twitter: @jowikryz


Noncommunicable Diseases 

National Position Paper Pakistan


Pakistan has been named to be the 6th most populated country in the world, with over 200 million inhabitants contributing to 2.65% of the total world population1. Noncommunicable diseases, NCDs, and their shared risk factors (tobacco use, harmful use of alcohol, unhealthy diets and physical inactivity, as well as air pollution) represent an unacceptable blind spot in our collective path to sustainable development, causing far more deaths and disability than any other group of diseases2. NCDs and injuries are amongst the top ten causes of mortality and morbidity in Pakistan3; estimates indicate that they account for approximately 25% of the total deaths within the country4. NCDs contribute significantly to the premature mortality and morbidity, and impose a heavy economic burden on individuals, societies and health system5. In most cases, it is the economically productive workforce (age 30 to 70 years old), which bears the brunt of these diseases3,4,5.

NCDs currently share over a fifth of the disease burden in Pakistan, and 2.5% are disabled. The majority of such mortalities were caused by the four main NCDs, namely: cardiovascular disease, CVD (44% of all NCD deaths); cancer (22%); chronic respiratory disease (9%); and diabetes. Over the past 5 years, the proportion of underweight women has decreased (14% to 9%)6, yet the proportion of overweight or obesity women has increased by 12%6, where the rates are significantly higher than men, regardless of residence7. The coexistence of underweight in early life with obesity in adults presages both a higher prevalence and incidence for NCDs such as CVD and diabetes. Existing population-based morbidity data on NCDs in Pakistan show that 1 in 3 adult, over the age of 45 years, suffers from high blood pressure6, and the prevalence of diabetes is reported at 10%. The major contributing factors to these diseases are the combination of increasing urbanisation, changing lifestyles, reduced physical activity and higher energy density of diets with Pakistani cooking.

Pakistan is the only country to have been created in the name of Islam, therefore tobacco use and alcohol consumption would innately be at low incidences (0.3 litre consumption per capita and 36.7 prevalence of tobacco smoking; persons aged 15 and older),8 relative to other countries. However in 2016, the environmental issue of air pollution became apparent, where the mortality rate attributed to household and ambient air pollution was at 173.6 (per 100 000 population), inflicting 3.8 million deaths from chronic respiratory disease and 9.0 million deaths from cancer.8 Yet again women are at greater risk of suffering from cancer, namely ovarian and breast cancer, taking the lives of 40 000 women per year9,10. According to multiple studies, breast cancer occurs to 1 in every 9 Pakistani woman, which is one of highest incidence rates in Asia10 and is not sparing even the younger age groups 9,10.

Despite the magnitude of the threat posed by NCDs, the current health expenditure (CHE) of Pakistan is 2.7% (GDP, 2015; US $38 per capita); the total expenditure on health is US $18 per head10. The World Health Organisation (WHO) has criticized the country’s reluctant investment (inadequate by 0.4%, according to United Nations human development index) towards health11, and recommended the allocation of US $34 per head to fund a package of essential health service8. Furthermore, Pakistan was notoriously condemned for the vaccine-preventable diseases that caused half of all the deaths in 2008, based on the ‘Western sterilisation plot’12. Thereafter, Pakistan became the first country in the WHO Eastern Mediterranean Region to conduct joint external evaluation in 2016, impetus to the tripartite alliance between the Ministry of Health, Government of Pakistan, the WHO, Pakistan office and the NGO Heartfile13. A national action plan for the International Health Regulation (IHR) Global Health Security Agenda was developed, with the aim to fulfil the IHR requirements to prevent, detect and mound a comprehensive public health response to health threats.

Addressing NCDs in developing country such as Pakistan is a multidimensional challenge with implication at different levels that requires the implementation of cost-effective and right-impact interventions. These include institutional, community and public policy levels changes set within a long-term and life-course perspective. Therefore in congruent to the WHO Global Coordination Mechanism (GCM) for the prevention and control of NCDs, the following actions could aid Pakistan to fight against NCDs and, promote mental health and well-being:  

1. Government to prioritise prevention and treatment of NCDs for the 
next expenditure
  • Increase the CHE % GDP and total expenditure on heath per person
  • Establish a mandate to identify key stakeholders and experts in policy making, assess the existing status of NCDs, prepare a policy document and provide recommendations in response to NCDs
2. Strengthen knowledge and evidence via surveillance and research 
  •  Enhance the monitoring systems in rural areas, to identify the gaps in health care, reduce unreported cases and obtain reliable epidemiology of diseases
  • Allocate domestic resources towards peer-review literature research on health, nutrition, education and disease progression 
3. Implement awareness and improve understand of NCDs 
  • Train doctors and community health workers to use techniques under the WHO guidelines for diagnosing diseases
  • Rational use of drugs to prevent the overuse of antibiotics and curb microbial resistance
  • Reduced inequality to healthcare delivery between private and public sectors 
4. Government to prioritise education for the next expenditure
  • Full and universal access to health programmes and actions to tackle physical inactivity and promote mental health 
  • Funded education and access to higher learning for healthcare professions to increase the rate of doctor-to-population ratio 
5. Exploit digital healthcare platforms and existing partnerships
  • Efficient service delivery to locating appropriate healthcare information, booking appointment with doctors and ordering the correct medication 
  • Maintain transparent communication and collaboration between government, NGO, manufactures, general public and private sector
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References
 
  1. Department of Economic and Social Affairs, Population Division: Pakistan Population (LIVE) [Internet]. World Population Prospects: 2019 [cited 2019 Mar 5]. Available from: http://www.worldometers.info/world-population/pakistan-population/ 
  2. Schweizerische Eidgenossenschaft. General Meeting of the WHO Global Coordination Mechanism for the prevention and control of noncommunicable diseases (GCM/NCD). Co-chairs Statement. Geneva, Switzerland: Swiss Confederation, 2018. 
  3. Hyder AA, Morrow RH. Lost Healthy Life Years in Pakistan in 1990. Am J Public Health 2000;90(8):1235–40. 
  4. Federal Bureau of Statistics, Statistics Division. Pakistan Demographic Survey 2001. Islamabad, Pakistan: Government of Pakistan, 2003. [cited 2019 Mar 5]. Available from: http://www.pbs.gov.pk/content/pakistan-demographic-survey-2001
  5. World Health Organization. World Health Report 2000 - Health Systems: Improving Performance. Geneva, Switzerland: WHO, 2000.
  6. National Institute of Population Studies (NIPS) [Pakistan] and ICF. 2019. Pakistan Demographic and Health Survey 2017-18. Islamabad, Pakistan, and Rockville, Maryland, USA: NIPS and ICF. 
  7. Nanan DJ. The obesity pandemic – Implications for Pakistan. J Pakistan Med Assoc. 2002 Aug; 58(8). 
  8. World Health Statistics 2018: Monitoring Health for the SDGs, Sustainable Development Goals. Geneva: WHO; 2018. 
  9. Jardoon Z, Shah SP, Bourne R, Dineen B, Khan MA, Gilbert CE, Foster A, Khan MD. Cataract prevalence, cataract surgical coverage and barriers to uptake of cataract surgical services in Pakistan: the Pakistan National Blindness and Visual Impairment Survey. Br J Opthalmol. 2007 Oct 9; 91(10): 1269–73. [Online, cited 2019 Mar 5] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2001008/ 
  10. World Health Organization – Cancer Country Profiles. Pakistan: World Health Organization, 2014. 
  11. WHO Global Health Expenditure Atlas: September 2014. Switzerland: World Health Organization; 2014. 
  12. Janjua H. Afghan clerics in talks with Isis to break polio vaccine myths. The Guardian, Global Health, 2018, Mar 27 
  13. National Action Plan for Prevention and Control of Non-Communicable Diseases and Health Promotion in Pakistan. Islamabad, Pakistan: tripartite collaboration of the Ministry of Health, Government of Pakistan; WHO, Pakistan office, and Heartfile; 2004.