Paper presented at the Payor Network Initiatives 2014 Meeting in KL, 11 September

1. Ministry of Health
Malaysia
Increasing Burden of Non-
Communicable Diseases in
Malaysia:
Challenges in Resource Allocation
Feisul Idzwan Mustapha MBBS, MPH, AM(M)
Public Health Physician, NCD Section, Disease Control Division
Ministry of Health, Malaysia
Payor Network Initiatives 2014
11 September 2014
Kuala Lumpur
dr.feisul@moh.gov.my

2. There are FourMajor Groups of Non-
Communicable Diseases;
Fourmajor lifestyles related risk factors
Modifiable causative risk factors
Tobacco use
Unhealthy
diets
Physical
inactivity
Harmful
use of
alcohol
Noncommunicable diseases
Heart disease
and stroke
   
Diabetes    
Cancers    
Chronic lung
disease
 2

3. 3

4. Proportional mortality, Malaysia
(% of total deaths, all ages, both sexes)
4

5. Premature mortality due to NCDs,
Malaysia
5
The probability of dying between ages 30 and 70 years
from the 4 main NCDs is 20%

6. DALYs attributable to risk factors
6
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, slide courtesy of Dr Mohd. Azahadi Omar, Institute for Public Health

7. 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, slide courtesy of Dr Mohd. Azahadi Omar, Institute for Public Health
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8. Sub-analysis of NHMS 2011 data
• At least 15% (18 years and above) already with known NCD
risk factors (diabetes, hypertension or hypercholesterolemia).
• Undiagnosed high blood sugar, high blood pressure or high
cholesterol: 42.1% (18 years and above).
• Or, if include obesity: 48.3% (18 years and above).
• Therefore our high risk and at risk population: 63.3% (18
years and above)
8

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

10. 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.
10

11. 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
11

12. UN Secretary-General:
NCDs in developing countries are hidden,
misunderstood and under-recorded
A rapidly rising epidemic in developed and
developing countries…
… with serious socio-economic impacts,
particularly in developing countries.
Workable solutions exist to prevent most
premature deaths from NCDs and mitigate the
negative impact on development.
The way forward: These solutions need to be
mainstreamed into socio-economic development
programmes and poverty alleviation strategies.
12

13. Non-Communicable Diseases:
Socio-economic Impact
• Macro-economic impact:
• World Economic Forum estimates high risk and likelihood of
negative economic impact from NCDs.
• Heart diseases, stroke and diabetes alone estimated to reduce
GDP between 1-5% in developing countries.
13
REDUCED ECONOMIC GROWTH
Then how to initiate or sustain UHC?

14. Non-Communicable Diseases:
Socio-economic Impact
• Impact at household level:
• World Bank estimates that one-third of people living on US$1-2 a
day die prematurely of NCDs.
• People in developing countries die younger from NCDs, often in
their most productive years.
• Low-income households suffer from the cost of long term
treatment and the cost of unhealthy behaviours:
• Cost of caring for a family member with diabetes: 20% of low-income
household income
• Poorest households spend more than 10% of their income on
tobacco
• Cost of essential drugs to treat and cure cancer makes them
unaffordable for the poor
14

15. Economic Burden of Diabetes
• Chronic diseases place a substantial economic burden on
society. Estimates for the United States place the costs of
chronic illness at around three-quarters of the total national
health expenditure (Hoffman et al. 1996).
• Some individual chronic diseases, such as diabetes, account
for between 2% and 15% of national health expenditure in
some European countries (Suhrcke et al. 2005).
15
WHERE IS OUR DATA?
We need Malaysian data

16. Cost of Diabetes in Malaysia
• People diagnosed with diabetes have access to diabetes care
and treatment in Malaysia.
• Diabetes costs are estimated to account for 16% of the
national Malaysian healthcare budget.
• placing Malaysia among the top 10 countries in the world in
terms of percentage of healthcare budget spent on diabetes.
• In 2010, an estimated RM 2.4 billion was spent on diabetes-related
healthcare.
16
Zhang P. et al. Global healthcare expenditure on
diabetes for 2010 and 2030. Diabetes research
and clinical practice. 2010; 87: 293– 301.

17. Cost of Diabetes in Malaysia
• Cost of managing diabetes in Malaysia: ~RM19,000.00 per
patient per year
• Conservative estimate from a study we did in 2007
• Not ideal treatment
• Data from NHMS 2011 estimates about 1.1 million patients
are on follow up at MOH hospitals and clinics
• 1.1 M x RM 19k = RM 20.9 billion!!
17
QUALITY OF CARE?
Dichotomy between public – private
Increasing number of patients in public
health facilities

18. Complications drive costs!
• While there are no studies in Malaysia that outline the breakdown
of diabetes costs, a study (CODE II) shows that up to 73% of
diabetes-related healthcare costs result from hospitalisation and
ambulatory care, as a result of complications due to poor blood
sugar control.
• Only 7% of the total
diabetes-related
healthcare cost is spent
on anti-diabetic drugs.
18 Jonsson B. Revealing the costs of type 2 diabetes
in the EU and findings from 8 EU countries.
Diabetologia 2002;45:S5–S12.

19. Financing NCD prevention
and control programmes
• Policy & regulatory interventions do not require a huge
budget.
• What is more crucial is the political leadership and commitment.
• Support from civil society is also essential.
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20. Summary
• The issue is not should we spend more money (GDP) for
health
• We already have universal health coverage
• We subscribe to cost-effective treatment
• The question remains that if we were to spend more money
(GDP) on health NOW, how are we assured that especially for
NCDs, we will get our money’s worth.
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21. 21

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