Presentation by Dr Albert Francis Domingo, Consultant of the Division of NCDs and Health through the Life-Course, WHO Regional Office for the Western Pacific delivered at the Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region (6-7 Dec 2016, Beijing, China).

1. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
Addressing hearing loss through
a health care systems approach
Albert Francis Domingo, MD MSc
Division of NCDs and Health through the Life-Course
WHO Regional Office for the Western Pacific
Email: domingoa@who.int

2. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
Presentation Outline
1. Goals for an ear and hearing care programme
2. Essential attributes of a system for ear and
hearing care
3. Building blocks for an ideal ear and hearing care
programme
4. The WPR UHC Action Framework
5. Designing a holistic model of care
6. Integrating with other health programmes

3. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
What do we want from an
ear and hearing care programme?
• Reduce/prevent risk factors leading to hearing loss
• In those already with hearing impairment
– Prevent complications and further deterioration
– Improve outcomes and functional level
• Avoid financial risk due to costs of care
• Ensure equitable spread of improved outcomes
(i.e., leave no one behind)

4. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
To get what we want, how should we implement
an ear and hearing care programme?
Essential attributes
(1-3/5)
Some domains for action
Quality Regulations and regulatory environment
Effective, responsive individual and population-based services
Individual, family and community engagement
Efficiency Health system architecture to meet population needs
Incentives for appropriate provision and use of services
Managerial efficiency and effectiveness
Equity Financial protection
Service coverage and access
Non-discrimination

5. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
To get what we want, how should we implement
an ear and hearing care programme?
Essential attributes
(4-5/5)
Some domains for action
Accountability Government leadership and rule of law for health
Partnerships for public policy
Transparent monitoring and evaluation (M&E)
Sustainability and
resilience
Public health preparedness
Community capacity
Health system adaptability and sustainability

6. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
What are the building blocks for an ideal
ear and hearing care programme?
People-Centred Ear and Hearing Care Services
Health
workforce
Resource
generation and
health
financing
Essential
medicines,
commodities
and
technologies
Health
information
system
Good Governance

7. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
In summary: The WPR UHC Action Framework

8. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
The Continuum of Care
Health
Risk
exposure
Risk contact
Latent
disease/injury
Early
disease/
injury
Disease
progression
Advanced
disease/injury
Chronic
disease
Impairment
or Death
Primary Prevention:
Reduce risk exposure
Secondary
Prevention:
Detect and intervene
early
Tertiary Prevention:
Reduce progress or
complications of
established disease
ResourceGeneration,
Financing,Stewardship
Interventions

9. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
Healthy population
Population at risk
Population with sickness
Sick that need
hospitalization
but have no
access to
hospital care
Sick
and
Hospitalized

10. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
The Supply Side of the Health System

11. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
Designing a Holistic Model of Ear and Hearing Care
Continuum
of Care
Level of Care
Self-care Family and
household
level
Community
level
General
primary care
District
hospitals
Referral
hospitals
A B C D E F
Health
Promotion
1
Disease
Prevention
2
Screening, Risk
Assessment, and
Diagnosis
3
Treatment and
Rehabilitation
4

12. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
A Sample Holistic Model of Care for Diabetes
Continuum
of Care
Level of Care
Self-care Family and
household
level
Community
level
General
primary care
District
hospitals
Referral
hospitals
A B C D E F
Health
Promotion
1 Healthy
lifestyle
Healthy
lifestyle
Regulation of the
sale and
marketing of
sugar-sweetened
beverages
Disease
Prevention
2 Risk factor
screening
through medical
history
Outpatient
nutrition
counselling
Screening, Risk
Assessment, and
Diagnosis
3 Careful
assessment of
family history
Early detection
Fasting plasma
glucose
screening
HbA1C
screening
Treatment and
Rehabilitation
4 Adherence to
medication
Foot care
Patient
support
groups
Periodic eye
examination
Diabetic registry
Surgery and/or
hemodialysis as
indicated
Specialist
management of
co-morbid
diseases (TB)

13. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
What are the main causes
of hearing loss?
High Proportion Moderate Proportion Low Proportion
Inherited causes Excessive noise Nutritionally-related
Otitis media Ototoxic drugs & chemicals Trauma-related
Presbyacusis Ante- & peri-natal
problems
Meniere’s disease
Infectious causes Tumours
Wax and foreign bodies Cerebrovascular disease

14. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
What are the interventions to address
hearing loss? (Pre-Natal)
Disorder Primary Prev’n Secondary Prev’n Tertiary Prev’n
Rubella Immunization
Early detection by
screening all or high-
risk groups and
treatment, if available
Hearing aids
Special education
Rehabilitation
Toxoplasmosis Health education,
treatment of the
mother
Iodine deficiency Nutrition,
supplementation
Ototoxicity Avoidance, rational
use
Genetic causes Health education,
counselling,
identification of
carriers
Congenital
malformations
None Surgery, when
appropriate

15. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
What are the interventions to address
hearing loss? (Peri-Natal/Neonatal)
Disorder Primary Prev’n Secondary Prev’n Tertiary Prev’n
Low birth weight Nutrition, ante-natal
care
Early detection by
screening all or high-
risk groups and
treatment, if available
Hearing aids
Special education
Rehabilitation
Birth trauma, hypoxia Improved birthing
practices
Herpes simplex Caesarian section
Cytomegalovirus Personal hygiene,
health education
Jaundice Detection of at-risk
groups
Ototoxicity Avoidance, rational
use
Noise-induced hearing
loss from noisy
incubators
Reduction in noise

16. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
What are the interventions to address
hearing loss? (Childhood)
Disorder Primary Prev’n Secondary Prev’n Tertiary Prev’n
Impacted ear wax
Otitis externa
Foreign bodies
Personal hygiene
Health education (e.g.
avoid use of ear buds)
Health education &
screening for early
recognition of disease
and hearing loss, prompt
treatment of disease
and/or complications
Case follow-up
Surgery
Hearing aids
Special education
Rehabilitation
Social integration as
appropriate
Acute & Chronic otitis
media
Personal hygiene, better
living conditions
Proper management of
upper respiratory tract
infections, better
nutrition, breastfeeding
Measles, mumps Immunization
Cerebral Malaria Vector reduction and
prophylaxis
Meningitis Prophylaxis,
immunization
Ototoxicity Avoidance, rational use

17. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
What are the interventions to address
hearing loss? (Adults)
Disorder Primary Prev’n Secondary Prev’n Tertiary Prev’n
Ototoxicity Avoidance, rational
use
Early detection
Rehabilitation
(hearing aids, cochlear
implants)
Special education
Social integration/
accessibility
Noise-induced hearing
loss
Education
Hearing conservation
Presbyacusis None Avoid ototoxic agents
& noises
Trauma Helmets
Seat belts Surgery
Otosclerosis None

18. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
Designing a Holistic Model of Ear and Hearing Care
Continuum
of Care
Level of Care
Self-care Family and
household
level
Community
level
General
primary care
District
hospitals
Referral
hospitals
A B C D E F
Health
Promotion
1
Disease
Prevention
2
Screening, Risk
Assessment, and
Diagnosis
3
Treatment and
Rehabilitation
4
• Neonatal hearing screening
• Immunization
• Regulations for noise reduction
• Rational use of ototoxic drugs
• Prompt treatment of ear
infections
• Early detection by screening
• Surgery
• Hearing aids
• Special education
• Accessibility policies
• Social integration
• Water and sanitation

19. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
Who is/are the patient(s)?
What are the diagnostics and therapeutics?
Figure from: GBD 2013 Risk Factors Collaborators (2015)

20. Self-harm and
interpersonal violence;
unintentional injuries;
transport injuries
Major NCDs: Diabetes,
urogenital, blood, and
endocrine diseases;
cardiovascular diseases;
chronic respiratory
diseases; neoplasms
Mental and
substance use disorders
Other NCDs
Maternal and
neonatal disorders
HIV/AIDS and TB
Diarrhea, lower respiratory,
and other common
infectious diseases
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-6 7-27 28-364 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+
Causes of Death over the Life-Course in the Western Pacific Region (2013, both sexes)
Forces of nature, war, and legal intervention Nutritional deficiencies
Other communicable, maternal, neonatal, and nutritional diseases Neglected tropical diseases and malaria
days years
Data from the Global Burden of Disease (2013) as published in The Lancet

21. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
How can we integrate ear and hearing care
with other health programmes?
Consider linkages with
• Immunization
• Infectious disease
control
• Rational drug use
• Maternal, antenatal and
perinatal care
• Occupational health
• Environmental health
• Urban health
• Habilitation and
rehabilitation
• Healthy ageing

22. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China

23. SDG3: Ensure healthy lives and
promote well-being for all at all ages
• Reduce maternal mortality
• End preventable deaths of newborns
and children under 5 years of age
• End epidemics of AIDS, TB, malaria and
NTDs and combat hepatitis, water-
borne diseases and other
communicable diseases
• Reduce by one third premature
mortality from NCDs and promote
mental health
• Strengthen prevention and treatment
of substance abuse
• Halve deaths and injuries from road
traffic accidents; ensure universal
access to sexual and reproductive
health
• Achieve universal health coverage,
access to quality essential health-care
services and access to medicines and
vaccines
• Substantially reduce deaths and
illnesses from hazardous chemicals,
pollutants and contaminants
• Strengthen implementation of the
WHO FCTC, as appropriate
• Support R&D of vaccines and medicines
in accordance with the Doha
Declaration on the TRIPS Agreement
and Public Health
• Substantially increase health financing
and development of the health
workforce in developing countries
• Strengthen country capacities for early
warning, risk reduction and
management of national and global
health risks

24. Multi-country Workshop on Ear and Hearing Care in the Western Pacific Region
6-7 December 2016 | Beijing, China
HEALTH AND THE ENVIRONMENT
Division of Noncommunicable Diseases and Health through the Lifecourse
Albert Francis Domingo, MD MSc
Email: domingoa@who.int