CORE Group Global Health Practitioner Conference Fall 2017

1. Tackling Noncommunicable Diseases:
Resources and Opportunities for
Integration within Global Health Practice
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CORE Group Annual Meeting
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September 28, 2017
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2. • Gain an appreciation of the impact of NCDs on
global health.
• Understand the importance of the 4x4 matrix in
addressing NCD burden and leveraging cost
efficiencies.
• Examine how frontline health workers can be
trained to address NCDs and how NCD efforts have
been integrated into chronic and non-chronic
health programs.
• Know what resources are available to address NCD
integration into existing and future programs.
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3. • Part I: Providing Perspective (15 minutes)
• Part II: Panel Presentations (45 minutes)
• Community Health Workers & NCDs
• NCD Integration into Chronic Care
• NCD Integration into Non-Chronic Care
• Part III: Questions & Answers (12 minutes)
• Part IV: Challenges & Solutions (15 minutes)
• Summary
• Small Group Discussion and Sharing Out
• Part V: Wrap-Up (3 minutes)
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4. PROVIDING PERSPECTIVE
Part I
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5. NCDs in Perspective
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Arti Patel Varanasi, PhD, MPH
President & CEO
Advancing Synergy, LLC
avaranasi@advancingsynergy.com
CORE Group Annual Meeting
Baltimore, MD
September 28, 2017
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6. 6
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7. • Usually begin slowly (asymptomatic) and develop
gradually over time
• Require long-term and systematic approach to
treatment
• Primary prevention and early detection critical
• Key NCDs share common risk factors
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Risk Factors: Primary Prevention Opportunities
MajorNCDs:
Prevention,Treatment,Management
• Other NCDs: Mental health, sickle cell, neurological disorders
(epilepsy), unintentional injuries (accidents).
Source: http://www.who.int/ncdnet/about/4diseases/en/

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STATUS
• NCDs on the rise
• Exposure to unhealthy diets and lack of physical exercise
• Epidemiological transition (increase life expectancy)
NEED
• Stronger health systems and health workers  Integration*
• More resource allocation
• Better preventive knowledge and awareness of danger signs
• Earlier diagnosis and treatment
ACTION
• Policy implementation (WHO, UN, etc)
• Advocacy
• Education / Prevention programs
• Integration efforts

10. • Role of Frontline Health Workers
• Vince Blaser
• Anne Katharine Wales
• Integration: NCD Prevention, Screening, and
Follow-Up into Existing Humanitarian and Non-
Humanitarian
• Christy Gavitt
• Integration: NCDs and Community Linkages
• Rebecca Dirks 10
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11. PANEL PRESENTATIONS
Part II
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12. Optimizing the
Frontline Health
Workforce to
Address NCDs
Vince Blaser
Advocacy & Policy Advisor
Medtronic Foundation
Anne Katharine Wales
Senior Philanthropy Portfolio Lead

13. Frontline Health Workers
Belize
• What they do: Provide services directly to
communities where they are most needed often in
remote and rural areas
• Who they are: Any health worker working at the
point of service in communities, including (but not
exclusively)
• Nurses
• Midwives
• Community health workers
• Emergency responders/paramedics
• Pharmacists/ pharmacy assistants
• Doctors in community-based clinics

14. Optimizing the Healthcare Workforce
to Address NCDs
Major Shortage of
Health Workers
Frontline health
workers often not
Integrated with
Health System
Health Workers
not Sufficiently
Compensated
Need to Expand
Scope of Practice
for NCDs

15. Global Gap in Access to NCD Services from
frontline health workers Frontline Health Workers
• More than 400 million worldwide lack access to essential
health services, and NCDs account for 71% of deaths
globally
• If current trends continue to 2030, world will be short at
least 18 million health workers needed to provide
essential health services, and deaths from NCDs will 5X
more deaths from HIV, TB & malaria combined
• Need an adequate supply in right places of qualified
health workers to make health system stronger
• Global Workforce 2030 Strategy and UN Secretary-
General’s High-Level Commission on Health and
Economic Growth (HEEG) Report provide pathway
forward for country-led health workforce plans.

16. Health Workers Often Not Sufficiently
Compensated
• Impacts pipeline from education, to
recruitment, retention and career
development
• Impacts short- and long-term health
outcomes
• Threatens sustainability of health
interventions and programs
• Need for alignment between benefits,
compensation, and need

17. Frontline Health Workers Often Not Integrated
with Health System
• FHWs often provide vital link to health
services for people who do not have
any other access to the health system
• However, some FHWs have no formal
connection to health system which is
critical to both success of interventions
and stability/sustainability of workforce

18. Need to better integrate NCDs into FHW tasks
• NCDs/NCD tasks not often a part of
many FHWs’ defined tasks
• Need for integration of NCD task
sharing/task shifting proposals with that
of other essential health services

19. How Frontline Health Workers CAN Impact
NCD Prevention, Management, & Screening
Belize
• Raise awareness and promoting healthy
behaviors
• Conduct screening of individuals and
households at risk
• Monitor symptoms
• Administer and manage medication
• Provide referrals to a health facility
• Respond to time critical events, and
supporting follow-up after acute events
• Track health outcomes

20. Better Optimizing the Health Workforce for NCDs
Belize
• Analysis conducted by
IntraHealth International in
partnership with the
Medtronic Foundation
• Recognizes Frontline
Health Workers as a
critical yet underutilized
resource in addressing the
global burden of NCDs
• Published November 2016
https://www.intrahealth.org/resources/ca
se-frontline-health-workers-addressing-
noncommunicable-diseases-globally

21. Recommendations:
Better Optimizing the Health Workforce for NCDs
Belize
• Training: NCD prevention, control, and
management
• Integration: Include NCD prevention, control,
and management into scope of work for
frontline health workers who provide service-
and disease-specific interventions
• Policy (Local): Refine and revisit policies for
frontline health workers and task-shifting
• Policy (National and Global): Provide
resources and implement policies for
strengthening health workforce & integrating
NCD services into scopes of practice

22. Changing the Outcomes for NCDs:
Evidence and Advocacy
Belize
EVIDENCE
Training & Integration
Training frontline health
workers & incorporating
NCDs into work scope
Case Studies
- HealthRise South Africa
- FUNZOKenya
ADVOCACY
Elevating Voices
Empowering frontline
health workers to share
their stories with
policymakers and other
stakeholders at major
conferences, forums
and events

23. Thank You!
Contact:
Vince Blaser
vblaser@intrahealth.org
Anne Katharine Wales
anne.k.wales@medtronic.com
Follow us:
facebook.com/intrahealth
twitter.com/intrahealth
www.intrahealth.org

24. Integrating NCD prevention,
screening & follow-up into
existing humanitarian and
non-humanitarian services
Christy Gavitt
Global Health Consultant

25. “NCDs’ importance in
humanitarian emergencies
has not yet been fully
recognized”.
WHO and UN Interagency Task Force on NCDs

26. Medair/Lebanon Baseline NCD Data
(December 2015)
• Self-reports from Syrian refugee and vulnerable
Lebanese mothers (n=574) in Bekaa Valley
 42% = Diabetes in family
 49% = High blood pressure in
family

27. How emergencies compromise
the health of those with NCDs
• Physical injuries
• Severe stress
• Degraded environment
• Forced displacement
• Shortage of water & regular food supplies
• Interruption of regular medical services
and medications

28. Why international relief agencies are
not addressing NCDs in emergencies
• Refugee health services: Traditionally
shaped around communicable diseases, not
chronic diseases.
• Lack of guidelines/tools: (WHO, Sphere) -
MSF guidelines currently the most
comprehensive
• Not addressed/diagnosed at primary level:
And if diagnosed, often referred to specialist
care or secondary/tertiary level (if it exists).

29. Acute vs. chronic disease treatment
Infectious/acute disease:…
________↗↘
Chronic disease:
__________↗--------------------→

30. Step-wise approach to addressing
NCDs in emergencies
• Immediate / initial response
– Life-threatening conditions/severe symptomatic
– Treatment interruption
• Response between 30-90 days
– Continue treatment of above
– Identify subgroups with critical needs
– Avoid sudden discontinuation of treatment
• Continuing response (protracted emergencies)
– Expand management to sub-acute and chronic
presentations of NCDs
– Case-finding/screening (clinic  camp level via CHWs)
– Expand prevention education at clinic and
camp/community level (for patient & families)

31. NCD Minimum Package goal: To provide care
for acute presentations & continuity of care to
those with existing diagnosis
1. Essential drugs, equipment and
protocols
– WHO’s Package of Essential NCD
Interventions – PEN (protocols, medicines &
equipment)
2. Training and Support to staff
– Diagnostic & treatment guidelines, referral
protocol, counseling, follow-up support, TASK
SHIFTING

32. NCD Minimum package (cont’d)
3. Support to patients
– Self management
– Adherence and psychological support from
family members
– Protracted emergencies: Changing lifestyle
4. Monitoring
– Longitudinal follow-up
– Database development

33. Role of Community Health Workers
• Adherence support
– Taking meds, monitoring need for
replenishment, reminder of appointments, etc.
– Task shifting
• Lifestyle adaptation support
• Initial screening / risk assessment
• NCD prevention education (clinic- and
community-based.
– Can be combined with initial screening &
referral

34. Integration of Services
• HIV and AIDS
• TB
• MCH (gestational diabetes &
high blood pressure)

35. Integration of NCD services with
HIV and AIDS services
• HIV+ individuals on ART are 3 times
more likely to develop diabetes than
HIV+ individuals not on ART
Recommendations:
Check blood glucose levels and assess CVD risk
in HIV+ individuals before beginning ART or if
already taking ART. If levels abnormal, may
need to take other HIV meds or take steps to
prevent diabetes onset.

36. Integration of NCD services with TB services
• About 10% of TB cases globally are linked to
diabetes
• People with diabetes have a 2-3 times higher
risk of TB
Recommendations:
• All people with TB should be screened for
diabetes
• Screening for TB in people with diabetes
should be considered in settings with high TB
prevalence

37. Integration of NCD services with MCH:
NCDs during pregnancy
• Gestational diabetes mellitus (GDM)
– Affects 1 out of 6 pregnancies worldwide (88% in
LMICs)
• High blood pressure
– 6-8% of all pregnancies
– Cause of 13% of maternal mortality in LMICs
Recommendations:
Screen for GDM and HBP during pregnanacy
as part of pre-natal visits

38. Advantages of Integrating NCD services
with other chronic disease health services
• Adherence support
• Frequent co-morbidities (HIVCVD; HIVDiabetes
Diabeteslatent to active TB)
• Patient-centered approach/Importance of
counseling quality
• Med management: contingency planning of both
ARV’s and NCD meds
• More efficiencies of service (“One Stop Shop”
screening in both directions)
• Task-shifting key: nurse- and CHW-led interactions
after initial appointment with doctor

39. Decentralized initial Screening
and NCD Prevention
• In humanitarian settings: Management of
NCDs should be primary focus…
BUT
• ↑ of protracted emergencies = NCD
prevention-related interventions focused on
healthy practices should be an integral part of
NCD services.
BOTH NCD TREATMENT AND
PREVENTION NEED TO BE PART OF
NCD SERVICES

40. Medair/Lebanon baseline survey:
Knowledge of how to reduce risk of
diabetes and high blood pressure
Among Syrian refugees and vulnerable
Lebanese:
42% and 49% stated that a family member
had diabetes and HBP, respectively
And yet….!
74% had no idea or knew only 1 way to
reduce the risk or better manage diabetes or
high blood pressure

41. IFRC Curriculum: “Healthy Lifestyles:
NCD Prevention and Control”
• Consists of 4 key manuals:
– Implementation guide
– Facilitator training manual
– Volunteer manual
– Community toolkit (visual aids, games)
• Manuals are open source (see reference sheet)
• Translated into Arabic, French, Spanish and other
languages
• Targets CHWs (but can also be used with clinic-
based educators)

42. How “Healthy Lifestyles” is organized
I. NCDs: What they are? Threat to
personal health and risk factors (4x4)
II. Self-assessment of personal risk of
NCDs
III. Assisted assessment (by CHW) and if
needed a clinical assessment
IV. Tips for healthy behavior
V. Personal action plan
VI. Follow-up by CHW

43. THANK YOU
cgavitt@cox.net

44. Integrating hypertension services into
a community health system:
Community-based Hypertension Improvement
(ComHIP) Project in Ghana
September
2017
Rebecca Dirks
Technical Advisor, NCD
FHI 360/Washington DC

45. Background: Hypertension (HTN) in Ghana
• National prevalence of overweight and obesity are 25.4% and
17.1%
• HTN prevalence among adults (≥ 25 years) is 32.7% among
males and 31.6% among females
– Only 4.1% of HTN patients have their blood pressure controlled
• Stroke is 2nd leading cause of death (8.7%) and Ischaemic
heart disease is 4th (5.8%)
• Primary care system not oriented to routinely screen, counsel
and manage hypertension
Ref: WHO. January 2015. Ghana WHO Statistical Profile; Peter Lloyd-Sherlock, John Beard, Nadia Minicuci, Shah Ebrahim, Somnath
Chatterji; Hypertension among older adults in low- and middle-income countries: prevalence, awareness and control. Int J Epidemiol
2014; 43 (1): 116-128; Ofori-Asenso, R., Agyeman, A. A., Laar, A., & Boateng, D. (2016). Overweight and obesity epidemic in Ghana—
a systematic review and meta-analysis. BMC Public Health, 16(1), 1239. doi: 10.1186/s12889-016-3901-4

46. The ComHIP model: public-private partners and
innovation
To extend the
ability of the
private sector
to support
the mgmt. of
HPT
To extend the
ability of
Ghana Health
Service in
HTN
management
To improve
HTN self
management
among
individuals
To improve
screening for
hypertension
in the
community
Objectives

47. Location and Partners
Target population: Lower Manya Krobo District, Eastern Region
Funder/Technical
Advisor
Novartis
Foundation
Technical
Assistance
Provider
FHI 360
Implementers
Ministry of
Health
Ghana
Health
Service
Licensed Chemical
Sellers
/Community
Pharmacies
Local private
technology
partner
VOTO Mobile
Evaluation
Partners
LSHTM
University of
Ghana

48. Project Coverage
3 hospitals
5 health centers
32 Community Health Planning
Service (CHPS) zones
44 Licensed Chemical Shops
The Ghana Health Services implements ComHIP in the six sub-districts of
Lower Manya Krobo

49. 49

50. Patient Flow:
HYPERTENSION SCREENING AND COUNSELING
Community Pharmacy Licensed Chemical Seller
Community Clinics
(CHPS)

51. Patient Flow:
CONFIRMATION, DIAGNOSIS, & ENROLLMENT
Community CVD Nurses
*Referral to physician if indicated

52. Patient Flow:
ONGOING MANAGEMENT AND SUPPORT
Treatment managed by
CVD nurse/physician
BP monitoring at LCS Prescription refill (NHIA)
SMS Adult Health Card Routine labs at hospital
*Referral to physician if indicated

53. Role of Technology
• SMS for education and communication
• Tele-medicine referral management by CVD Nurse and doctors at
district hospitals via Commcare
• Electronic data collection and management

54. Service Statistics: Snapshot
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• Total of 19,785 screened
– 23% (4,483) had elevated BP
• Total enrolment is 1,381 (69% women)

55. Screenings by Service Provider
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56. What’s Next?
 Complete evaluation and use results to guide future
programming and provide evidence to policy makers
 Reduce role of FHI 360 in Lower Manya Krobo and
increase local ownership
 Expand to two additional districts
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57. Acknowledgments
National Partners
• Ghana Health Service
• School of Public Health-University of
Ghana
• Ministry of Health
• Ghana National Health Insurance
Scheme
• Ghana College of Physicians &
Surgeons
• Ghana Medical and Dental Council
• Pharmacy Council
• Licensed Chemical Sellers Association
• Ghana Nursing Board
International Partners
• FHI 360
• LSHTM
• VOTA
• Novartis Foundation
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The Novartis Foundation is the primary funder and key collaborator with FHI 360 in designing and
developing the program. The Novartis Foundation also provides technical input into the
implementation plan.

58. QUESTIONS & ANSWERS
Part III
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59. CHALLENGES & OPPORTUNITIES
Part IV
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CHALLENGES OPPORTUNITIES
Lack of focus on NCD
prevention
Highlight benefits of prevention and its relatively
low cost
Access to affordable drugs Negotiate pricing; Leverage health insurance
schemes or advocate for health insurance
Need for nutritional
diversity in emergencies
Advocate for locally- or regionally-sourced
supplementary food procurement mechanism
Limited funding for NCD
screening, treatment and
prevention
Explore non-traditional partnerships; Advocate
for local resource allocation; Include evidence-
based & low-cost NCD interventions into MCH,
HIV, TB proposals; Recent funding of $225M for
NCDs (Gates, Bloomberg, Zuckerberg)
Optimizing NCD workforce Use of team-based care models; SDGs, new global
HRH strategy, 2018 NCD High-Level Meeting
Sustainability and
scalability (pilotitis)
Design local stakeholder-led interventions;
Prioritize publishing & results (lessons learned)
dissemination; Strengthen local capacity

61. 1. Identify a group note taker and group reporter.
2. Identify 3 challenges to NCD integration and the
proposed solution in context of your projects.
3. Group note taker lists the 3 challenges and 3
solutions on a flip chart.
4. Select the top challenge and associated solution
based on group discussion to present during the
sharing out by the group reporter. 61
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62. • Top challenge and solution identified by group
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63. WRAP-UP
Part V
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64. Tackling Noncommunicable Diseases:
Resources and Opportunities for
Integration within Global Health Practice
64
innovate.empower.impact
CORE Group Annual Meeting
Baltimore, MD
September 28, 2017
2017COREGroupAnnualMeeting