From deep inside of me, I thank to Irene Buonafina, Juliette Li, Albine Moser, ...... The Chilean Society of Cardiology, or 'Sociedad Chilena de Cardiologia' may be ...... gauge. Available from: http://www.paho.org/English/HDP/Equity-Chile.pdf.
Maastricht University Master of Public Health Program
Health Policy for Cardiovascular Disease Prevention and Control in Chile
Master Thesis
Jossiana Robinovich Benadof ID Number 201839
Supervisor: Jan van der Made December 2004
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Table of Contents Acknowledgments ………………………………………………………….......... 1 Summary ………………………………………………………………………… 3 Introduction ……………………………………………………………………… 5 Chapter 1: Cardiovascular disease as a Public Health Problem 1.1
Preface …………………………………………………………………… 9
1.2
The extent of the problem ……………………………………………….. 10
1.3
Cardiovascular disease risk factors ……………………………………… 10 1.3.1 Biological risk factors …………………………………………… 11 1.3.2 Behavioral risk factors …………………………………………... 12 1.3.3 Associations between risk factors and disease …………………... 14
1.4
Life course perspective for cardiovascular disease versus lifestyle model..16 1.4.1 The Barker hypothesis ..…………………………………………. 17 1.4.2 Life course socio-economic status’ influence on risk factors……. 18 1.4.3 The social context and the environment …………………………. 19
1.5
The epidemiological transition …………………………………………... 19 1.5.1 Nutrition transition and lifestyle changes ………………………... 20 1.5.2 Variation in the epidemiological transition ……………………… 21
1.6
Association between cardiovascular morbidity and mortality and socioeconomic status …………………………………………………….. 23
1.7
Determinants of CVD risk factors ……………………………………….. 24 1.7.1 Urbanization and changes in diet and lifestyle …………………... 24 1.7.2 Effects of globalization and macroeconomic forces on CVD risk factors ………………………………………………………. 25 1.7.2.1 Indirect effects of globalization: Macroeconomic factors and health behavior ………………………………………. 26 1.7.2.2 Direct effects of globalization: Global marketing ……….. 26 1.7.3 Differences between developed and developing countries’ determinants …………………………………………………….. 27
1.8
Conclusions ……………………………………………………………… 28
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Chapter 2: CVD policy and CVD-risk preventive policies 2.1
Preface …………………………………………………………………… 29
2.2
Strategies to reduce CVD risk factors …………………………………… 30 2.2.1 Individual and population-based approach ……………………… 31 2.2.2 Cost-effectiveness of different interventions ……………………. 33 2.2.3 Risk reduction and behavior change ……………………………... 36
2.3
Selecting strategies ………………………………………………………. 37
2.4
Population-based approach to primary prevention: How to change population’s behavior ……………………………………………………. 39 2.4.1 Multiple risk factor interventions ………………………………... 39 2.4.2 Environmental change …………………………………………….42
2.5
Individual-based approach to primary prevention and secondary prevention: targeting people at high risk ………………………………… 44 2.5.1 Health system – related factors …………………………………. 47 2.5.2 Patient-related factors …………………………………………… 49
2.6
Parameters for the selection of strategies ………………………………... 50 2.6.1 Selection of strategies for CVD prevention and control in developing countries …………………………………………. 51 2.6.2 Research on CVD prevention strategies ………………………… 53
2.7
Impediments to prevention and control of CVD ……………………….. 55
2.8
Conclusions ……………………………………………………………... 59
Chapter 3: The World Health Organization initiatives for CVD prevention and control 3.1
Preface …………………………………………………………………… 61
3.2
Evolution of WHO’s strategies for prevention and control of NCDs …… 62
3.3
WHO Global Strategy for NCD Prevention and Control ……………….. 63 3.3.1 The Inter Health, CINDI and CARMEN programs ……………… 64 3.3.2 WHO Department of Chronic Diseases and Health Promotion …. 66
3.4
Cardiovascular disease management package …………………………… 67 3.4.1 Barriers for the implementation of the package …………………. 73 3.4.2 Assessment of the package’s feasibility ………………………… 74
3.5
Conclusions ……………………………………………………………… 76
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Chapter 4: Cardiovascular disease in Chile 4.1
Preface ………………………………………………………………….. 78
4.2
Cardiovascular disease indicators and CVD risk factors in Chile ……… 78 4.2.1 Cardiovascular disease risk factors in Chile ……………………. 80 4.2.1.1 Behavioral risk factors ………………………………….. 80 4.2.1.2 Biological risk factors …………………………………... 84
4.3
Determinants of CVD risk factors in Chile …………………………….. 90 4.3.1 Income inequality, psychosocial stress and the economic and political processes in Chile …………………………………. 93 4.3.2 Psychosocial stress, depression and its relationship with CVD risk factors in Chile ……………………………………….. 94
4.4
Conclusions ……………………………………………………………… 95
Chapter 5: Strategies for CVD prevention and control in Chile 5.1
Preface ……………………………………………………………………. 98
5.2
Population-based approach to primary prevention: The National Health Promotion Plan ……………………………………………….………… 99
5.3
Individual-based approach to primary prevention and secondary prevention: ESPA and Cardiovascular Health Programs ……………….. 103
5.4
The WHO/PAHO CARMEN and Inter Health programs in Chile ………. 106
5.5
Assessment of the strategies utilized in Chile for prevention and control of CVD risk factors ……………………………………………………… 107 5.5.1 Risk reduction and behavior change with the National Health Promotion Plan ………………………………………………….. 108 5.5.2 Treatment provision to control prevalence of CVD risk factors and reduce recurrences of cardiovascular events in Chile ……….. 110
5.6
Conclusions ……………………………………………………………… 113
Conclusions & discussion ……………………………………………………...... 116 Appendix A: Chilean demographic and economic indicators A.1
Chile: Country profile ……………………………………………………. 125
A.2
Economic and social context……………………………………………... 125
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A.3
Health Status …………………………………………………………….. 126
A.4
Demographic and epidemiologic transition in Chile ……………………. 127
Appendix B: The Chilean health system B.1
Health system organization ………………………………………………. 129
B.2
Health care financing …………………………………………………….. 131
B.3
Chilean health reforms …………………………………………………… 132
References ……………………………………………………………………….. 135
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Acknowledgments In every stage of life, each goal is not achieved in isolation but thanks to many people that contributes either directly or indirectly to transform an intention into reality. This thesis and the consequent degree to obtain are not the exception. It would not be possible for me to carry out post-graduate studies at the University of Maastricht without the academic and personal support I received from people at Universidad de La Frontera and at the University of Maastricht, as well as from those whom with their love and friendship gave me the strength to complete this endeavor. I have been fortunate to count with the collaboration of many people at my sponsoring institution, Universidad de La Frontera, whom made possible my pursuing post-graduate studies and the completion of this thesis. I want to express my gratitude to Pedro Montecinos, for introducing me in the field of cardiovascular disease prevention; to Dolly Standen, for providing me the necessary guidance and support for the application and departure processes; and to Mirtha Cabezas, for trusting me when granting financial support. My deepest thanks to my colleagues from the Physical Therapy Career at the Faculty of Medicine of Universidad de La Frontera, whom with great solidarity assumed my duties as a team during my absence to study in Maastricht, and to every person I daily work with, for their constant support to the development of this thesis. I am sincerely grateful to all and each one of them. I am thankful to many people from both the academic and the administrative staff that contributed to the learning process I experienced at the University of Maastricht. My especial thanks to Anja Krumeich, for showing me a new perspective toward human health; to Jan van der Made, for his valuable advice, careful supervision and stimuli to the development of this thesis; and to Ria Westenberg, for her warm attitude and constant care for the MPH students’ well being. Would like to express as well my gratitude to the Randwyck’s Library personnel, whom always provided me a helping hand to find the necessary literature for the different units as well as for this thesis. From deep inside of me, I thank to Irene Buonafina, Juliette Li, Albine Moser, Assaf Givati and Joachim Thyssen, for being as a family to me while I lived in The Netherlands, for the privilege of their friendship and love, and for all the good moments
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spent together. I want also to express my gratefulness to the MPH classmates, for turning our daily activities into an unforgettable experience to me I must thank to Rodolfo Figueroa for permanently encouraging my academic development, and for showing me that with perseverance and self-determination it is possible to overcome every encountered obstacle in life. Finally, I wish to thank to my small but great family for their enthusiastic and patient support to my professional growth, and for always being there for me. I am deeply grateful to my mother, Dona Benadof, for her unique way to make me feel loved and cared, and for her respect and attention while I developed this thesis. To my sister, Pamela Robinovich, whom is also my dearest source of emotional support, I am endlessly thankful for helping me to reunite the necessary strength to go on every time I felt hopeless, tired, and even incapable to finish this master thesis.
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Summary Cardiovascular disease (CVD) is the leading cause of death in developed countries and is becoming an important cause of death and disability in the developing world. The main determinants of the problem are adverse environmental conditions brought by the globalization phenomena and the associated urbanization and industrialization processes that have changed the nutrition and physical activity patterns of populations and increased the consumption of tobacco, especially among developing nations. The differences between nations with regard to the burden of disease that CVD represents is determined by the stage of the epidemiologic transition that the country is traversing, which partially depends on economic development. The level of exposure to adverse environmental conditions within population groups depend as well on economic and social factors. The epidemic of CVD usually commences in members of higher socioeconomic status, but evolves in such a way that a pattern of inverse association between socioeconomic status and risk of cardiovascular death is progressively established. Research has shown that it is possible to reduce CVD incidence and control its prevalence by targeting CVD behavioral and biologic risk factors. The strategies available broadly include personal interventions aiming to modify unhealthy behavior and treat biologic risk factors, and non-personal interventions to modify environmental conditions that difficult healthy choices. The recent decline in mortality rates observed in developed countries was mostly attributed to personal interventions; however, when this type of strategy accounts for most of the reduction in CVD death rates in a given setting, there is a tend to favor inequalities in the distribution of CVD risk factors among the population. Policy interventions to modify environmental conditions that hold back healthy lifestyles are effective ways to reduce the risk in a more equitable manner, but intersectoral work, a strong political commitment, and the support of the international community is reacquired, especially for developing countries’ policy development. The epidemiologic profile of the Chilean population has experienced significant changes in the last decades; a marked decrease in prevalence rates of diseases characteristic of underdevelopment and an increase in the prevalence of the so called “diseases of affluence” evidence that the country is in a late stage of the epidemiologic
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transition. CVD is the main cause of death and disability, accounting for about one third of deaths. The distribution of CVD risk factors among the population is not randomized, as it occurs in developed and some developing nations; CVD are progressively clustering among the less educated and less affluent segments of the Chilean population. The strategies currently utilized in Chile for CVD prevention and control are mainly based on personal interventions, despite the efforts made by some groups to develop policy interventions for environmental change. The possible consequences of this approach and important aspects that should be considered for the formulation of CVD policy, as well as the main constraints that impede the development of CVDpreventive policies in Chile will be detailed and further analyzed in the following pages.
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Introduction Cardiovascular disease (CVD) constitutes a major public health problem worldwide. According to The World Health Report (2002), CVD is the world’s leading cause of mortality, being responsible for one-third of all global deaths, with nearly 85% of the global mortality and disease burden being borne by low and middle-income countries (WHO,2002). Stroke and coronary heart disease are the major cause of death and disability due to CVD, however, most of these events are preventable if action is taken against CVD risk factors. The Framingham study (quoted by McArdle et al.,1996) identified the main risk factors for cardiovascular disease and classified them in modifiable and non modifiable. Since then, research have proven that identification and management of modifiable risk factors for CVD can substantially decrease death and disability due to this cause (Levenson et al., 2002). However, CVD risk factors represent only the top of the iceberg of a more complicated scenario. Research has shown that CVD have their roots in unhealthy lifestyles or adverse physical and social environments (Nissinen et al., 2001). They are the product of an industrialized lifestyle where smoking, unhealthy diet and physical inactivity are expressed as hypertension, obesity and high blood lipid levels, all these closely intertwined and together contributing to the total cardiovascular risk, being the root causes of the global CVD epidemic. Therefore, a combination of high–risk and population-based preventive strategies are essential to control this major public health problem, providing treatment for hypertension and high blood lipids level as well as promoting a tobacco-free environment, healthy diet and physical activity. This poses a big challenge in low and middle income countries where several factors like limited financial resources, poor access to health care and health care providers and low responsiveness of the health care system influence the outcomes (WHO, 2002). WHO (2002) developed a basic package for CVD risk management in under resourced-settings based on targeting individuals and populations at high risk with interventions proven to be cost-effective. The package proposed by WHO is designed to select and target high-risk patients because of resource considerations, although points that “is imperative that adequate measures are taken to address low risk individuals through population strategies” because these benefit the whole population and help to
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shift the distribution of the risk. In low resource settings the population approach has obvious benefits and should be given priority according to WHO. Remarkable savings would occur in nations if cigarette use or nutritional patterns could be altered through policy, as opposed to one-on-one treatment programs. Unfortunately, the countries in need of such policies have often weak regulatory structure and depend on market forces outside the scope of the health sector. WHO (2002) states that for the basic package to be implemented, big changes must occur in health systems at policy, organization and training and facilities level. At policy level, this includes a clear and up-to-date evidence-based CVD policy formulation. The aim of this thesis is to analyze the formulation of CVD policy, as well as CVD-risk preventive policies in Chile, a middle income country where CVD is the main cause of mortality for both sexes, being responsible for approximately one-third of deaths, and therefore constituting a major public health problem.
0.1
Problem Statement Since a balanced combination of high-risk and population-based preventive
strategies are necessary for the effective control of the CVD epidemic, it is important to analyze the formulation of policies for the strategies to be implemented. Therefore a first step in the analysis of preventive efforts to manage CVD problem in Chile must address the following: How CVD policy and CVD-risk preventive policies are formulated in Chile?
0.2
Research Questions In order to answer the question posed in the problem statement it is necessary to
address the following specific research questions: 1.
What is the scope of CVD problem in Chile?
2.
How is the problem of CVD addressed in Chile?
3.
What is the status of CVD-risk preventive policies in Chile?
4.
Is the problem of CVD in Chile being managed according to WHO’s advice? 11
0.3
Methodology A review of relevant literature on the field will establish an adequate frame for a
posterior analysis of the existing documents with regard to CVD policies and CVD-risk preventive policies in Chile and therefore answer the main research question and the four specific research questions of this thesis.
0.4
Thesis Structure This thesis will consist of five chapters.
Chapter 1: CVD as a Public Health Problem. This Chapter will explain why and how cardiovascular disease has become a major public health problem as the world experiments the so called “epidemiological transition” and will describe how the problem is distributed among the population.
Chapter 2: CVD policy and CVD-risk preventive policies. This chapter will address the strategies for the management of the problem, describing policy formulation for the high-risk and population-based approach in order to perform personal and non-personal interventions.
Chapter 3: The World Health Organization initiatives for CVD prevention and control. This chapter will describe the strategies for the management of the problem proposed by WHO and assess its feasibility and adequacy based on the findings of chapter 2.
Chapter 4: CVD in Chile. This chapter will describe the scope of the problem in Chile, the distribution of risk factors among the population as well as the determinants of the situation.
Chapter 5: Strategies for CVD prevention and control in Chile. This chapter will describe the strategies used for the management of the problem (CVD policy) and the status of CVD-risk preventive policies in Chile. The adequacy of the strategies and potential impact on CVD indicators will be assessed based on the findings of previous chapters.
Conclusions and discussion: Conclusions will be drawn with regard to the formulation of CVD policy and CVD-risk preventive policies in Chile based on the findings of the previous chapters. Afterwards the discussion will focus on an 12
adequate model to place health issues higher into the political agenda, possible constraints and the selection of policy instruments.
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Chapter 1
Cardiovascular disease as a Public Health Problem
1.1
Preface During the last century, cardiovascular disease (CVD) has shifted from a
relatively minor disease worldwide to a leading cause of morbidity and mortality. While developed countries exhibited a rise and recently a decline of the CVD epidemic, the developing world shows and alarming rising trend in CVD mortality rates. Because the majority of the world's population lives in the developing world, the increasing rate of CVD in these countries is the driving force behind the continuing dramatic worldwide increase in CVD (Reddy & Yusuf, 1998). Some factors that might explain this increase are positive, like the increasing average life expectancy resulting from improvements in public health and medical care that are reducing rates of communicable disease, malnutrition, and maternal and infant deaths. Other factors are not so positive. Economic, social and cultural changes have modified lifestyles toward the adoption of western diet and physical activity patterns, and strong market forces impeding the control of tobacco consumption in low- and middle-income countries result in greater exposure to CVD risk factors (Lenfant, 2001; WHO, 2002). As the majority of threats to health, socioeconomic factors are closely involved with the genesis, progression and outcome of cardiovascular diseases, exhibiting an inverse association pattern between socioeconomic status and risk of cardiovascular death (Kaplan & Lynch, 1999; Yu et al., 2000). This chapter will deeply analyze the problem of CVD, its extent and risk factors, as well as biological, societal and environmental forces that might influence the progression of the CVD epidemic. The impact of urbanization and globalization on CVD indicators and its repercussions on the distribution of risk factors among countries and populations will also be explored. Finally, the conclusions drowned might shed some light with regard to the relative weight of the different factors that determines the current status of the problem.
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1.2
The extent of the problem Cardiovascular diseases (CVD) are and will remain the first cause of death and
disability in developed countries despite the gradual decline in disease rates recently experienced in most of them. In 2000, 48.6% of deaths were caused by CVD. By 2020 still 46.4% of all deaths are expected to be attributable to this cause. In the developing world CVD threats to become the main cause of death and disability: by 2020, 33.8% of all deaths are expected to be due to CVD (Murray & Lopez in Aboderin et al, 2001). Cardiovascular disease is a major contributor to the global burden of disease, accounting for 20.3% of disability adjusted life years (DALYs) lost in developed countries and for already 8.1% of those lost in the developing world (Murray et al., 2003). Coronary heart disease (CHD) and cerebrovascular disease (stroke), the main causes of death due to CVD, kill about 12 million people every year. It is projected that by 2020, 71% of CHD deaths and 75% of stroke deaths will occur in developing countries (The World Health Report, 2002). The World Health Report (2002) quantified the major contributions of tobacco use, alcohol consumption, high blood pressure, high cholesterol concentrations, low intake of fruit and vegetables, physical inactivity, and high body mass index to the global burden of disease and of cardiovascular disease in particular. These risk factors, independently and often in combination, are the major causes of the CVD epidemic worldwide.
1.3
Cardiovascular disease risk factors.
There is a strong body of scientific evidence that proves that a change in the risk behaviors of unhealthy diet, lack of physical activity and tobacco use can positively influence the associated biological risk factors of obesity, high blood pressure and high cholesterol levels, which are the most firmly established risk factors for CHD and stroke (Aboderin et al., 2001).
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1.3.1 Biological Risk factors.
•
Obesity.
Overweight and obesity are commonly assessed using body mass index (BMI), a weight / height formula with a strong correlation to body fat content. WHO criteria define overweight as a BMI ≥ 25 kg/m2 and obesity as a BMI ≥ 30 kg/m2, but the risks of disease increase progressively from BMI levels of 20-22 kg/m2. Overweight and obesity lead to adverse metabolic effects on blood pressure, cholesterol, triglycerides and insulin resistance. The risk of coronary heart disease and stroke increase steadily with increasing BMI. Modest weight reduction reduces blood pressure and abnormal blood cholesterol. Increases in free sugar and saturated fats, combined with reduced physical activity, have led to obesity rates that have raised three-fold or more since 1980 in some areas of North America, the United Kingdom, Eastern Europe, the Middle East, the Pacific Islands, Australia and China. The affected population has increased to epidemic proportions, with more than one billion adults worldwide overweight and at least 300 million clinically obese. Approximately, 21% of CHD are attributable to BMI above 21 Kg/m2. About 10% of deaths in developed countries and 8-15% of DALYs lost are due to this cause.
•
High blood pressure. Blood pressure is a measure of the force that the circulating blood exerts on the
walls of the arteries. Elevated blood pressure produces several changes in the arteries that irrigate brain, heart, kidneys and elsewhere. The main modifiable causes of high blood pressure are diet, especially salt intake, levels of physical activity, obesity and excessive alcohol intake. As a result of the cumulative effects of these factors blood pressure usually raises steadily with age, except in societies where comparatively salt intake is low, physical activity high and obesity almost absent. It has become clear in recent decades that the risk of stroke and CHD are not confined to a subset of population with particularly high blood pressure levels (hypertension) but rather continue among those with average levels. Globally, about 62% of stroke and 49% of CHD are attributable to suboptimal blood pressure (systolic>115 mm Hg), with little variation by sex. The number of deaths due to this
16
cause is estimated in 7.1 million, 13% of the total worldwide, which accounts with 64.3 million DALYs, or 4.4% of the total. This small proportion of the total, but nevertheless substantial, is because most blood pressure related deaths or nonfatal events occur in middle age or the elderly.
•
High cholesterol Cholesterol is a fat-like substance, found in the bloodstream as well as in bodily
organs and nerve fibers. Most cholesterol in the body is produced by the liver from a wide variety of food products, especially from saturated fats. Therefore a diet high in saturated fat content influences an individual’s level of cholesterol, as well as various metabolic conditions and heredity. High cholesterol levels (more than 2.0 mmol/l in any age group) increase the risk of coronary heart disease and stroke. As with high blood pressure, the risks of high cholesterol are continuous and extend across almost all levels seen in different populations, even those with levels much lower than those observed in North American and European populations. This disorder is estimated to cause 18% of global stroke (mostly nonfatal events) and 56% of global CHD. Overall this amounts to about 4.4 million deaths (7.9% of the total) and 40.4 million DALYs (2.8% of the total) (The World Health Report, 2002). Regional analyses have shown that high blood pressure and high cholesterol concentrations are major risks to health in all regions of the world, not just high-income countries. Due to the multi-causality of cardiovascular disease and the joint action of these two risk factors, the joint effects of blood pressure and cholesterol concentrations would be less than additive (Murray et al, 2003).
1.3.2 Behavioral risk factors.
•
Physical inactivity There is no international agreed definition or measure of physical activity,
therefore, The World health Report (2002) used a number of indirect and direct data sources for the estimation of activity levels in four domains: at work, for transport, in domestic duties and in leisure time. 17
Physical activity reduces the risk of CVD through a number of mechanisms like reducing body fat and lowering blood pressure. Physical inactivity it is estimated to cause globally about 22% of CHD. The global estimate for prevalence of physical inactivity among adults is 17%, ranging from 11% to 24% across sub-regions of the world. Estimates for some, but insufficient activity (less than 2.5 hours per week of moderate activity) ranged from 31% to 51%, with a global average of 41%. Overall physical inactivity was estimated to cause 1.9 million deaths and 19 million DALYs worldwide.
•
Unhealthy diet and alcohol consumption. Fruit and vegetable intake could help to prevent CVD, mostly by protective
mechanisms offered by antioxidants and other micronutrients. Its consumption varies among countries, reflecting the prevailing economic, cultural and agricultural environments. Low intake of fruit and vegetables is estimated to cause about 31% of CHD and 11% of stroke worldwide. Overall, 2.7 million deaths (4.9%) and 26.7 million DALYs (1.8%) are attributable to this cause. Of the burden of disease attributable to the latter, about 85% were from CVD. The burden of disease attributable to excessive consumption of salt and saturated fat it is not quantified in the report from where this data were taken, however, is noticeable the direct cause-effect relationship with all the biological risk factors mentioned above. With regard to alcohol consumption, the patterns of drinking as well as the volume of alcohol consumed are relevant to health, binge drinking being hazardous. Provided low-to-moderate consumption, there are beneficial effects over CHD and stroke. It is estimated that CHD and stroke would be about 17% higher in developed countries if no one consumed alcohol.
•
Tobacco use. Smoking causes the majority of adverse effects of tobacco. Prevalence of
smoking does not completely reflects the cumulative hazards that this addiction produces, which depends on several factors such as age at which smoking began, duration of smoking, number of cigarettes smoked per day, degree of inhalation, and cigarette characteristics like tar and nicotine content or the type of filter. Health risks come also from passive smoking. While prevalence of smoking has declined in some 18
developed countries, mostly among men, it is increasing in the developing ones, especially among youth and women. It is estimated that tobacco causes about 8.8% of deaths (4.9 million) and 4.1% of DALYs (59.1 million). The evolution of this epidemic can be illustrated when comparing these estimates for 2000 with those for 1990: there are at least a million more deaths attributable to this cause, with the increase marked by the developing countries. The attributable fraction of smoking for CVD was about 12% worldwide (The World Health Report, 2002).
1.3.3 Associations between risk factors and disease Although the already mentioned risk factors for CVD might account for a great proportion of the burden of disease attributed to this cause, they can not fully explain why some people develop myocardial infarction and stroke while others do not. Other potential or “emerging” risk factors might play a role in the development of clinical disease. These include the use of antioxidants, the use of angiotensin converting enzyme inhibitors and homocysteine levels lowering (their effects over disease will not be further described because are out of the scope of this thesis). Although this areas are promising with regard to CVD prevention, “definite conclusions must await the results of randomized clinical trials” (Lonn & Yusuf, 1999). Epidemiological studies make a distinction regarding risk factors, classifying them in two categories: those that have proven to be causal (risk factors) and those that show associations with CVD but for whom a cause-effect association has not been proven (risk markers). Tobacco consumption, high cholesterol, high blood pressure and elevated glucose levels are causally linked risk factors for CVD. In addition to being associated with an increased prevalence of hypertension and dyslipidemia, the elevated blood glucose levels characteristic of diabetes is itself associated with a large increase in risk for CVD (WHO; 2002). Physical inactivity, obesity, inadequate diet, low socioeconomic status, psychological factors (depression, hostility, stress) and breakdown in social structures (loss of social support and cohesion) are considered predisposing risk factors, meaning that they have an impact on other risk factors that act directly.
Risk markers that show associations with CVD are elevated levels of
19
homocysteine, elevated prothrombotic factors (related with angiotensin converting enzyme levels), and markers of infection or inflammation (Yusuf et al., 2001, Part I). Figure 1 shows continuous dose-response associations for a number of risk factor-outcome combinations. The associations reveal that the relative risk of ischemic heart disease increases markedly with higher diastolic blood pressure values and decreases as fruit and vegetable intake per day augments. Its incidence rises notoriously with BMI ≥ 20 kg/m2. Mortality due to this cause increases with serum cholesterol levels over 4 mmol/l. Systolic blood pressure over 115 mm Hg reveals continuous increases in the relative risk for both hemorrhagic and ischemic stroke, although this association is stronger for hemorrhagic stroke.
Figure 1: Six examples of continuous associations between risk and disease
1
Law, M.R., Wald N.J. (2002). Risk factor thresholds: their existence under scrutiny. British Medical Journal. 324: 1570-76 2 Eastern Stroke and Coronary Heart Disease Collaborative Group (1998). Blood pressure, cholesterol and stroke in eastern Asia. Lancet. 352:1801-07
Extracted from The World Health Report 2002
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1.4
Life course perspective for cardiovascular disease versus lifestyle model. In the first half of this century there was considerable interest in the notion that
early life experiences influenced adult health status and longevity, being the relative importance of nature and nurture vigorously debated. After the Second World War, when cardiovascular disease mortality rose sharply in developed countries whose birth weight distributions have for some time been among the highest in the world, that the focus switched to adult diet and life-style as an explanation for this rise. As a result of the success of cohort studies that confirmed the cause-effect relationship between risk factors and disease, the individual risk for CVD has been explained focusing mostly on adulthood risk factors. This trend, also called the “lifestyle model”, is mainly based in the belief that health decisions are fully under the control of individual decisions. This approach, however, can not fully explain many of the geographical and social differentials observed in chronic disease risk, especially for diseases with clear social class gradients, such as cardiovascular disease and type 2 diabetes. The life-course perspective provides a framework that might help to explain the socio-economic differences observed in chronic conditions in all industrialized societies, suggesting that chronic diseases are not only the product of adult risk behaviors but arise as a result of an accumulation of risk throughout life. This perspective takes into account the social and physical hazards, and the resulting behavioral, biological and psychosocial processes that act across all stages of the life span to affect risk of disease later on. Its main focus is on early life factors or exposures, emphasizing that the risk of non-communicable diseases, in particular CVD, non-insulin dependent diabetes and chronic bronchitis, it is not just determined by risk factors in mild-adult life but already begins in childhood or adolescence, and potentially even during fetal development. Risk factors emerge and act in early life thus influencing risk of later disease. Obesity, high blood pressure and high cholesterol levels track from childhood through to adolescence and young adulthood. Parent’s lifestyles have an important impact on children’s dietary habits, level of physical activity and uptake of tobacco use (Kuh & Ben Schlomo, 2002; Aboderin et al., 2001).
Whitaker et al. (1997) suggests that
parental obesity increase the risk of obesity, and consequently the risk of disease in their offspring. 21
1.4.1 The Barker hypothesis. The work of David Barker and colleagues, also called the “Barker Hypothesis”, suggests that a number of chronic diseases had their origins in fetal life. When it was first published in the mid-1980s, many leading scientists treated this work with some skepticism. The concept of “programming” of the development and function of organ systems during sensitive periods in early life has gained some credibility as the results have been reproduced in the study of historical cohorts, and linkages have been made with research in fetal physiology using animal models. This revealed that poor nutrition in utero can have many long-lasting consequences in the offspring related to impact in organ development. Although in many cases animal models do not accurately reproduce the observations in humans, they illustrate the biological plausibility of the concept of “programming”. This view has provoked great controversy and more research is necessary to clarify this hypothesis. Based on the findings of Baker, Stein et al. (1996) suggested that coronary heart disease in a population in South India was associated with small size at birth, consistent with similar findings reported in UK and US by Baker and colleagues. Kramer & Joseph (1996) criticized methodologically the findings of this work, stating that studies of associations between fetal growth and subsequent chronic disease must control for socioeconomic status at birth and during early childhood in order to avoid confounding of those associations. Singhal & Lucas (2001) suggested, after testing the hypothesis that diet in infancy influences or “programs” blood pressure in later life, that “much of what was claimed to be fetal in origin may in fact relate to post-natal nutrition and growth” and remarked the potential benefits of breastfeeding in the prevalence of hypertension. The most recent studies are still controversial in this regard, reinforcing on one hand the association between birth weight and risk of CHD, and on the other hand suggesting that this association may be genetic and therefore not susceptible to modifications by interventions that influence intra-uterine development (Alvarez-Dardet & Ashton, 2004). Although more research is necessary, it is reasonable to infer that socioeconomic factors might influence blood pressure and consequently CHD later in life since both are related to individual’s nutritional status whether in utero or in the post-natal period.
22
The life course approach to chronic disease epidemiology does not diminish the importance of adult risk factors and behaviors, but provides an explanation for the unequal distribution of CVD risk factors among different sectors of the population.
1.4.2 Life course socio-economic status’ influence on risk factors. The prevalence of behavioral or biological risk factors is influenced by socioeconomic status (SES) over the life course. In adults the prevalence of risk factors is not just determined by adult SES but also by their socioeconomic position in childhood and the different social trajectories that individuals traverse as they become educated, enters the labor market and generates income. In developed countries, the prevalence of risk behaviors among adults is generally higher among those from low socioeconomic strata. Similarly, poorer childhood SES is associated with more risk behavior, suggesting that early economic disadvantage may increase later disease risk since children adopt particular detrimental behaviors and attitudes. The general developed country pattern of low SES = high risk however does not hold in all cases. The effect detrimental or protective of SES on risk behaviors can differ considerably between populations, ethnic groups, cohorts and genders. For example among older women cohorts, low early SES was shown to protect against smoking, whereas among younger cohorts at present is associated with an increased risk Life course impacts on disease cannot be generalized from one population to another or from one cohort to the next since important differences appear reflecting the existing diversity in social, economic, cultural and nutritional contexts. What determines population or cohort differences, particularly what is the relative role of different social contexts, is not well understood, but is a key area for future research. Regrettably, in developing countries, where CVD are emerging as a serious public health problem, the efforts to disentangle the life course effects of the behavioral and biological risk factors are seriously hampered by methodological limitations in the existing studies and their prevalence, social patterning and trends (Aboderin et al, 2001).
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1.4.3 The social context and the environment. Since the major challenge of the life course perspective for public health is to fully elucidate the pathways and mechanisms by which, in different populations and at different historical periods, factors or exposures in earlier and later life act to determine subsequent risk of disease, an obviously complex and difficult task since the interaction of risk factors in each stage of life vary from one population to another, risk factors should be addressed taking into consideration underlying economic, social, political, behavioral and environmental factors that foster disease risk. Unhealthy lifestyles are taken up by children or adolescents (leading to the early development of obesity, high blood pressure and high cholesterol levels) as a result of parent’s own health behaviors but largely influenced by massive marketing and media pressure as well. The prevailing social, economic, political and cultural context determine the exposure to risk inducing environments, the resources necessary and available to opt for healthy lifestyles and the social meaning that risk behaviors have for different population groups. For the developing world in particular, this means that the processes by which urbanization and development lead to increased risk cannot be assumed to be the same across different societies (Kuh & Ben Schlomo, 2002). The differences observed between populations are probably reflecting genetic differences, but certainly they are the product of their particular process of social and economic change, which determines environmental conditions. This process experienced by societies is known as the epidemiologic transition.
1.5
The epidemiological transition Pre-industrial societies are characterized by high rates of infant mortality
primarily due to infection and malnutrition, and relatively short average life expectancy. As societies develop infant mortality generally declines and the causes of death shift from infectious to chronic diseases (e.g. CVD, cancer), increasing average life expectancy. This evolution was denominated by Omran (in Levenson et al., 2002) as the epidemiological transition. This phenomenon includes economic, demographic and social changes that provoke major changes in population’s health. Increasing per-capita income marks the economic transition. Industrialization and the resulting urbanization, 24
development of public health infrastructure, wider access to health care and health care technologies characterize the social transition, and the demographic transition exhibits declines in fertility and age-adjusted mortality rates that leads into an increased life expectancy and therefore an aging population. Improvements in economic circumstances, combined with industrialization and urbanization lead to dramatic changes in diet, activity levels and behaviors such as smoking. Cheaper and higher-fat food increases the total caloric intake, while mechanization results in lower daily caloric expenditure. The increasing longevity provides longer periods of exposure to CVD risk factors, resulting in a greater probability of CVD events (Levenson et al., 2002).
1.5.1 Nutrition transition and lifestyle changes. Rapid changes in diets and lifestyles resulting from industrialization, urbanization, economic development and market globalization are having a significant impact on the nutritional status of populations. Food products have become commodities produced and traded in a market that has expanded from an essentially local based to an increasingly global one. This globalization of food production and marketing is contributing to shift dietary patterns, increasing consumption of energydense food poor in dietary fiber and several micronutrients and high in sugar and saturated fats or excessively salty. The latter is associated with a decline in energy expenditure related with a sedentary lifestyle, where motorized transport and laborsaving devices at home and at work have replaced physically demanding manual tasks, and leisure time is often dominated by physically undemanding activities. Together with a sedentary lifestyle and inadequate nutrition patterns, the threat of the increasing rate of tobacco consumption in developing countries, especially among young people and women, has a significant impact in CVD and total morbidity and mortality, contrasting sharply with the overall decline in the industrial nations. Because of these changes in dietary and lifestyle patterns, diet-related diseases are increasingly becoming significant causes of premature death and disability in developing countries. They are taking over from more traditional public health concerns like under nutrition and infectious disease, and placing additional burdens on already insufficient national health budgets (WHO, 2003). 25
1.5.2 Variation in the epidemiological transition. Because of its link with economic, social and demographic forces, the epidemiological transition affects different regions and countries at different rates. The ratio of deaths due to pre-transitional diseases (related to infections and malnutrition) to those caused by post-transitional diseases (CVD, cancer) varies between countries and among regions of the world, depending on factors such as the level of economic development and literacy as well as availability and access to heath care (Reddy & Yusuf, 1998). In 1990 the established market economies of Western Europe, North America, Australia, New Zealand and Japan exhibited a pattern where CVD accounted for 45% of all deaths and communicable diseases for 10%, while in the emerging market economies which include the former socialist states of Eastern Europe, 54% of all deaths where due to CVD. In the developing economies that include China, India, other Asian countries and islands, Sub-Saharan Africa, Middle East, and Latin America and the Caribbean, CVD was responsible for 23% of all deaths while communicable diseases accounted for 42% of deaths. Across the groups of developing economies, however, there remains a high degree of heterogeneity. In Sub-Saharan Africa communicable disease rates still far exceed those of chronic diseases; however, Van der Sande et al. (2001) reported that non-communicable diseases and injuries are emerging as important contributors to mortality in this part of the world. Although the relative contribution of CVD deaths to total mortality was higher in the developed countries than that in the developing ones, global rates of CVD are by far driven by rates in the latter since they account for more than 80% of the world’s population. It has been estimated that 5.3 million deaths attributable to CVD occurred in the developed countries in 1990, whereas the corresponding figure for the developing countries ranged between 8 to 9 million (Levenson et al., 2002). The direction of change toward a rising in the relative contribution of posttransitional diseases to mortality is consistent and common among developing countries. Illustrative of this phenomenon is the proportion of CVD deaths in urban China, which rose from 12.1% in 1957 to 35.8% in 1990. Another factor to take into account in the contribution of developing countries to the global burden of CVD mortality is the early age of occurrence of CVD deaths when compared with the developed ones. In 1990 the proportion of CVD deaths occurred below the age of 70 was 26.5% in the developed 26
world, while in the developing one reached 46.7%. Therefore, the contribution of developing countries to the global burden of CVD in terms of DALYs lost is 2.8 times higher than that of developed countries (Reddy & Yusuf, 1998). The profile of CVD, however, varies among developing countries according to the stage of the economic transition they are traversing. In the earliest phases of epidemiological transition countries have a large burden of rheumatic heart disease, as well as infectious and nutritional cardiopathies. In the next phase hypertension emerges as salt consumption rises, adding hemorrhagic stroke and hypertensive heart disease to the burdens of rheumatic heart disease. As countries advance further in their demographic and socio-economic transitions, increased fat intake and rises in blood lipids contribute to atherothrombotic vascular disease thus replacing hemorrhagic stroke, hypertensive heart disease and rheumatic heart disease by thrombotic stroke and coronary heart disease. The transition to the atherothrombotic phase of the epidemic might be preceded by a fall in hemorrhagic strokes’ burden. The recent decline in CVD mortality occurred in South Korea reflects such a fall in the contribution from hemorrhagic strokes, while thrombotic stroke and coronary heart disease burdens have just begun to rise. Large developing countries might experience different phases of health transition in different regions, which is becoming evident in Latin America, China, India and parts of Africa. Most of the developed countries have entered the phase of delayed degenerative disease, with CVD remaining the leading cause of death and disability, but mainly manifested at a late age mainly due to improvements in health care, and with an overall decline in mortality (Reddy, 2002). The epidemiological transition occurs at different rates also across economic groups. The decline in malnutrition and communicable diseases, as well as the adoption of the modern lifestyle and nutrition pattern responsible for the high rates of CVD generally begins among individuals with higher socioeconomic status and eventually spreads to those with lower socioeconomic status as society and economy develops. However, those in the lowest stratum are less likely to have access to advanced medical care and health education, and therefore exhibit higher CVD mortality rates (Levenson et al., 2002).
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1.6
Association between cardiovascular morbidity and mortality and socioeconomic status Research has proven a consistent inverse association between cardiovascular
morbidity and mortality and socioeconomic status.
The experience of developed
countries reveals that the CVD epidemic usually commences in members of higher socioeconomic status, whom change first their nutrition and lifestyle patterns from a low-risk of CVD to a high-risk one. Later the risk permeates across the socioeconomic spectrum affecting all classes, but again the better-off group is the first in changing their habits, responding to the message of prevention. CVD rates begin to decline in the latter, with a pattern of higher CVD rates among the lower socioeconomic status group becoming increasingly established (Reddy & Yusuf, 1998). The declining trend in CVD exhibited in developed countries has been more pronounced among individuals in higher socioeconomic groups and the differences in CVD rates between the higher and the lower socioeconomic groups are widening. According to Yu et al. (2000), preventive efforts that contribute to the decline in CVD rates might have had a greater impact on higher socioeconomic status individuals’ health, increasing disparities in CVD morbidity and mortality. This pattern exhibited by developed countries, where the burden of disease progressively shifts from the higher to the lower socioeconomic groups, is likely to be replicated among the developing world as the epidemic advances. The findings of studies based on community surveys carried out in India and China suggest that the distribution of CVD risk factors across the social gradient does not differ from those observed in the developed world (Gupta et al, (1994); Yu et al, (2000)). The CVD epidemic threats to continue in developing countries with the current trend of distribution among the population as nations goes through the epidemiological transition at different speed according to their particular political, cultural, social and economic development. Progressively larger numbers of poor people will suffer its consequences over health, unable to get adequate treatment from overburden health care systems with limited financial resources. Due to the early age of CVD death in developing countries, this also might have an impact in terms of social development and economic growth. According to Aboderin et al. (2001), CVD “poses substantial threat to the economies of individual countries and are important in the increasing health inequalities between countries and within populations worldwide”. 28
1.7
Determinants of CVD risk factors. There is now a large body of evidence concerning the determinants of unhealthy
behavior at the individual and societal level, although surveillance is needed to clarify trends in different cultures and settings. The accumulated knowledge about risk factors and its distribution among the population reveals the wide spectrum of its determinants. Genetic, social, economic, cultural and political determinants are closely intertwined in the genesis and progression of CVD, however, there are enough evidence to conclude that most of the risk is environmentally determined (Reddy, 2004). The adverse environmental conditions that hold back healthy lifestyles are diverse, ranging from the lack of safe streets and paths for cycling and walking that encourages physical activity to the high availability of cheap fast food with a high content of saturated fat ( WHO, 2003 (STEPS)). Although there might be some variations in genetic susceptibility among ethnic groups and the interactions between genes and environment, the main risk factors for CVD are relevant to all populations, playing a dominant role in the development of clinical disease in all ethnic groups The rapidity with which CVD rise in some populations (as in Russia) or fall in others (as in Poland) indicates that societal factors might have a substantial impact on disease rates (Yusuf et al., 2001; Part II).
1.7.1 Urbanization and changes in diet and lifestyle. One of the most marked societal and environmental changes has been associated with urbanization (or migration to western environment). With urbanization there is an increase in energy rich food consumption, a decrease in energy expenditure through less physical activity mostly due to the change in the type of work (industrialization of production processes) and leisure time activities when moving from rural to urban areas, and a loss of the traditional social support, which leads to decreases in social cohesion and increases in social stress. Together with the migration of individuals from rural to urban areas, rural areas themselves are also being transformed, with mechanization in agriculture and increased use of automobile and bus transportation (Yusuf et al., 2001; Part I). With better mobility, and therefore better access to urban areas, feeding patterns
29
are progressively changing to an urban diet based mostly on processed food, and regrettably the purchase of tobacco becomes easier. Currently, in most developing countries, urban populations have higher levels of diet and physical activity related cardiovascular risk factors (overweight, hypertension, high blood lipids and diabetes), while tobacco consumption is more widely prevalent in rural populations. Examples of this are recent surveys carried out in China and India, which showed higher urban prevalence of hypertension compared with rural populations. Indian studies estimate a prevalence of adult hypertension of 27.3% in urban settings and 12.2% in rural settings, and urban diabetes prevalence rates are threeto fourfold higher than rural prevalence rates in most parts of the country. The higher rates of tobacco consumption in rural areas might suggest that this is more influenced by educational status (Reddy, 2002). The rates of urbanization are increasing globally: in 1970, 36.6% of the world’s population lived in urban areas while in 1994 this proportion rose to 44.8%. This proportion is projected to increase to 61.1% by 2025 (Yusuf et al., 2001; Part II). Urbanization and globalization, which shifts production from the small farmer to the large corporation, distribution from the shopkeeper to the supermarket, consumption from fresh to processed foods and supply from local to export markets, are the driving force behind the changes in dietary patterns. The falling price of vegetable fat in the international market and the rising price of dietary fiber (fruit and vegetables) in the domestic markets are economic factors fostering this change. The proportion of Chinese citizens consuming more than 30% of fat as an energy source in their daily diet rose steeply across all income classes between 1989 and 1993. Worldwide food trends are reflecting the dominant forces in globalization (Reddy, 2002).
1.7.2 Effects of globalization and macroeconomic forces on CVD risk factors. Globalization affects directly and indirectly the development of noncommunicable diseases epidemics and therefore CVD. The indirect effects are mediated by national economic performance, acting through changes in household income, government expenditure and prices. The direct negative health effects are illustrated by the increasing globalized production and marketing of tobacco and alcohol. Household
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income is especially important because of its influence on health-related behaviors, in particular in low-income households (Beaglehole & Yach, 2003).
1.7.2.1 Indirect effects of globalization: Macroeconomic factors and health behavior. How macroeconomic changes affect health behaviors and risk factors has not been well studied, although they have important influences on individual’s daily lives. Nowadays in order to meet expenses, both adults in a household progressively work longer hours and sometimes take more than one job, having scarce time available for other activities such cooking or leisure time physical activity, with the consequent social stress that this convey. The latter may be even more important to low-income groups, where the premium on skill returns has not increased over time as it has for certain sectors of the economy such as those trained in high technology fields. Therefore, the increased demands of work might influence eating habits and physical activity levels. In United States more than 40% of the population eats out at least once per day and fast food restaurants account for more than one third of all meals eaten out. The impact of this on the development of atherogenic disease could be significant, given the high fat content of most of these meals. According to Kaplan & Lynch (1999), “changes in the nature of work brought on by macroeconomic forces could be partly responsible for increased fast food consumption”. That pattern in eating habits may respond to the current status of the global economy. Thus, macroeconomic factors might be considered an important part of the driving force that moves populations through the epidemiological transition to high rates of CVD (Kaplan & Lynch, 1999).
1.7.2.2 Direct effects of globalization: Global marketing. Developed countries and their organizations for protection of domestic producers have a direct impact on non-communicable disease epidemics. For example the U.S. and European Union agricultural subsidies limit competition from developing countries’ primary producers of fresh products, thus considerably reducing these countries’ national incomes. The subsidization of tobacco production by U.S. is only 31
one more example of the power of tobacco interest, which hinders progress on tobacco control. About €1 billion is spent by U.S. on tobacco production subsidies and only €1020 million on agricultural diversification and tobacco control programs. Global marketing of tobacco and alcohol, and salty, sugary and fatty foods now reaches most parts of the world, with a significant proportion of their target population being constituted by children between 5-14 years old. Worldwide, about US$ 200 billion is spent on fast food, soft drinks, cigarettes and alcohol (Beaglehole & Yach, 2003). Global marketing affects developing countries to a greater extent. They are the target of tobacco industry international operations, which after the saturation of their original market and the development of health concerns and consequent regulation in developed countries looked for new markets.
This is illustrated by the fact that
increased tobacco consumption in the developing world accounted for all the worldwide increase between 1975 and 1995. The main targets of their campaigns are women and young people, using in many countries marketing strategies that have long been banned in developed countries. Tobacco provides a major source of revenue for developing countries. An example of this is the estimation that about 10% of the total tax revenues in China come from tobacco products (Kaplan & Lynch, 1999).
1.7.3 Differences between developed and developing countries’ determinants. The determinants of the epidemiological transition, and therefore of the CVD epidemic in developing countries are similar to those that marked the course of the epidemics in the developed world, however, their dynamics are different. While in developed countries urbanization occurred in prospering economies, in developing countries it occurs in settings characterized by high poverty levels and considerable international debt, with restricted resources for public health responses (Reddy, 2002). Organized efforts for prevention started in developed countries when the epidemic was close to its peak and the community became then aware, thus accelerating a secular down trend since at high levels of economic development counseling for lifestyle modification to reduce the risk of disease is more easily accepted. On the other hand, in developing countries the efforts are starting when the epidemic is on a growing trend, facing the double burden of communicable and non-communicable diseases, and community awareness of the potential harm of CVD is low. Messages of moderation 32
might not be welcomed during that period of change (Reddy & Yusuf, 1998). The latter is especially important because these similarities and differences should be recognized in developing countries when planning and selecting strategies for prevention and control of CVD.
1.8
Conclusions The need to reduce the impact of CVD in terms of morbidity and mortality as
well as to control the growing trend of the CVD epidemic in developing countries is undeniable. Despite the vast body of knowledge available in this regard this is a difficult task since CVD rates in each population reflects particular interactions between genetic predisposition and environmental conditions that depends on urbanization, economic development and globalization and the extent to which the latter influences individual’s stages of life, from early childhood and perhaps fetal life to adulthood. Context-specific research in developing countries is essential to implement strategies for prevention and control. This might be based on the evidence gathered in developed countries; however interventions must be tailored according to developing countries’ reality within a global economy, affordability and local culture. It is crucial to increase awareness among key decision-makers (namely international donors, NGO’s, the World Bank, heads of state and health ministries) that CVD are no longer diseases of affluence that arise as a result of the irresponsibility of individuals but are largely determined by environmental conditions that holds back healthy lifestyles especially among the poor.
Of great importance as well is to
recognize the potential impact that CVD might have in terms of productivity and development in low and middle-income countries in the long term. Regrettably, not much can be done in developing countries regarding environmental conditions without the support of the developed world, especially for tobacco control.
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Chapter 2
CVD policy and CVD-risk preventive policies
2.1
Preface Of the estimated 32 million heart attacks and strokes that occur globally each
year, about 12.5 million are fatal. Stroke is a major cause of death among the elderly and coronary heart disease (CHD) is becoming an important public health problem in urbanized populations. In most countries coronary heart disease is the predominant cause of cardiovascular mortality while in others stroke mortality predominates. Due to the disability associated with non-fatal strokes, in some countries stroke prevention might have a greater impact than CHD prevention. In developing countries the case fatality rates from stroke are two to three-folds higher than in the developed ones, which have been attributed to limited health care facilities and untreated risk factors. In both developed and developing countries 40% - 75% of all victims of a coronary event (heart-attack) die before reaching hospital. Given the high costs of treating acute events, which in the case of stroke have a poor prognosis, priority should be given to prevent them rather than provide treatment, especially in developing countries, where resourceintensive care is not an option. Conventional risk factors (whether biological or behavioral) account for 75% of the CVD epidemic worldwide, and although its relative importance may vary from one population to another, they have a major role in the development of clinical disease in all ethnic groups. Therefore, strategies aiming to reduce risk factor’s prevalence can substantially reduce the burden of disease attributable to this cause (WHO, 2002). The strategies to reduce risk factors considered as modifiable can be broadly categorized as interventions that seek to reduce risks in the population as a whole, the non-personal interventions, and those which target individuals within a population, or personal interventions. The World Health Report (2002) as well as several other authors (Murray et al., 2003; Nilsson & Berglund, 2000; and Reddy & Yusuf, 1998, among others) suggests that an adequate combination of both strategies is the optimum. These have been well studied and documented in developed countries, however their
34
transferability to developing countries is subject of different opinions (Nissinen et al., 2001; Ebrahim, 2001) and definitely reacquires a careful analysis of local conditions before its implementation in order to avoid failure and waist scarce developing countries’ resources. Therefore, a careful assessment of the costs and effects of the available intervention strategies to reduce these risks is extremely important (Murray et al., 2003). Developed countries are experiencing a decline in CVD mortality rates (Hunink et al., 1997; Unal et al., 2004; Bots & Grobbee, 1996; Capewell et al., 2000); however the fact that only about 50% to 60% reductions can be attributed to risk factors reduction reinforces the need of further research within each population. Nevertheless, the imperatives of tobacco control are universal and non-personal interventions, such as taxation and smoking bans and restrictions, have proven to be an effective strategy (Yusuf et al., 2001, Part II; Mensah et al., 2004) that should be implemented without delay. Regrettably, other forces outside the immediate scope of the health sector influence the implementation of this strategy. The parameters for and adequate selection of the strategies to use in each setting given the resources available reacquires the development of up-to-date evidence-based health policy as well as policy-relevant research that can support and evaluate CVD control programs in developing countries. This chapter will describe the different strategies for CVD risk prevention and management utilized in developed countries and analyzes its suitability for developing nations given the burden of disease that they are experiencing; the main aspects to consider for the population and the high risk approach to be implemented successfully, and parameters to take into account for the selection of the strategies. Finally, the main impediments to prevention and control of the CVD epidemic, especially in developing countries, will be addressed and conclusions will be drawn.
2.2
Strategies to reduce CVD risk factors There is no doubt that strategies aiming to improve living conditions, education
and therefore poverty will certainly reduce indirectly CVD risk factors due to the close relationship between socio economic status and health behavior, however the strategies that will be described here only include actions whose main goal is to improve health. 35
The strategies to deal with CVD risk factors might include interventions directed toward individuals (personal interventions) or populations (non-personal interventions). The latter include interventions by governments though legislation, tax or financial incentives/disincentives and health promotion campaigns targeting the general public, and the former include interventions aiming to change health behavior of individuals, being intervention “any promotive, preventive, curative or rehabilitative activity where the primary intent is to improve health” (The World Health Report, 2002). Preventive strategies might be classified as well in primary and secondary prevention. Primary prevention aims to postpone the disease, event or symptom through behavior modification or early detection of risk factors, and secondary prevention seeks to prevent recurrences or progression to disease (Nilsson & Berglund, 2000). Primordial prevention includes health-supportive actions to prevent acquisition of CVD risks factors within a community assuring environmental conditions that make healthy choices possible (Kaplan & Lynch, 1999; Reddy & Yusuf, 1998). While primordial prevention interventions are directed to the societal determinants of risk behavior in a population, primary prevention can be directed toward individuals at risk (high risk approach) or communities (population-based approach), being its main focus on risk factors’ reduction. Secondary prevention is always directed toward individuals, including interventions with a clinical focus (Yusuf et al., 2001; Part II). The terms personal and non-personal interventions, individual and populationbased approach, as well as the classification according to the levels of prevention are used indistinctly by the literature available in the field and will be utilized in the same manner in this thesis.
2.2.1 Individual and population-based approach The individual-based approach focuses interventions on a few people that are vulnerable and therefore will be largely benefited from the intervention. Population approach on the other hand seeks to reduce risks in the entire population regardless of each individual’s level of risk. To focus on high-risk individuals might reduce costs at the population level because an intervention is provided to fewer people; however it could also add the costs of identifying the group of people at risk to the costs of the 36
intervention itself. Focusing on people who are at risk has a significant impact on the health of a nation, but only when there are large numbers of them. In some cases only a small percentage of the population is at high risk of death from CHD at any given time, and only some of them can be identified based purely on their cholesterol or blood pressure levels. Interventions for people with a combination of risk factors such as being obese, with ischemic changes, smoker, physically inactive and with high levels of blood pressure and cholesterol, might well prove to be more effective in this situations than treating people only on the basis of their cholesterol or blood pressure levels. This form of targeted approach is called the “absolute risk approach”. While the high-risk approach can be viewed as targeting the intervention to the right-hand tail of the risk factor curves in figure 2, the population-based approach aims to shift the entire population’s distribution of risk factors to the left, like shifting the distribution of blood pressure for population 2 in the direction of that of population 1. Figure 2: Distribution of systolic blood pressure in two populations
Population 1
Population 2
Source: Rose, G. (1985). Sick individuals and sick populations. International Journal of Epidemiology. 14: 32-8
Extracted from The World health Report 2002
The population approach has the potential to improve population’s health to a greater extent than the individual-based approach, reducing as well the costs of identifying high-risk people. On the other hand, the costs of providing an intervention to the entire population would be higher than providing it only to people at risk. Which approach is the most cost-effective in a given setting will depend on the prevalence of high-risk people in the population and the costs of identifying them compared with the costs of the available blood pressure and cholesterol reduction strategies. Certain 37
population-wide interventions that have not yet been widely implemented might potentially be very cost-effective ways of improving population’s health and results in substantial health benefits, suggesting as well that the adequate combination of selected individual-based with population-wide interventions would also be cost-effective in most settings (The World Health Report, 2002).
2.2.2 Cost-effectiveness of different interventions The effectiveness and cost of selected interventions with focus on blood pressure and cholesterol are described in detail in The World Health Report (2002). Published population-wide and individual-based interventions were evaluated alone and in combination for different regions of the world. The results of this evaluation will be summarized in this section for a better understanding of the different strategies available to reduce CVD risk factors as well as its cost-effectiveness.
•
Blood pressure interventions Population wide salt reduction is a very cost-effective intervention. This
intervention has two possible approaches. One involves cooperation between government and the food industry to include appropriate labeling about salt content on food products, and commit a stepwise reduction of salt in processed food of common consumption, which could be achieved through multi-stakeholder initiatives such as the development of voluntary codes of conduct. The other approach is based on legislative action to ensure a reduction of salt content in processed food and appropriate labeling, this requiring also collaboration between multiple stakeholders, but with the addition of quality control and enforcement. In this intervention the costs are higher than in the voluntary version, but the effects on salt intake are likely to be higher as well. Therefore, legislation was considered potentially more cost-effective than voluntary agreements with industry mostly because it is assumed that legislation with enforcement will lead to a greater reduction in salt intake than voluntary agreements do, however, the trade-off between legislation and voluntary agreements is likely to depend on the national context. Individual-based strategies requiring drug treatment (beta-blockers and diuretics), outpatient visits for health education and visits to a health provider for 38
medical check-ups as well as several blood tests per year are cost-effective if the threshold includes individuals with systolic blood pressure (SBP) of 160 mmHg and above. If the threshold is lowered to 140 mmHg more individuals will benefit but the cost will be higher, increasing the number of people suffering side-effects from treatment as well. Whether this strategy is cost-effective or not in all settings varies with factors such as epidemiology, tests performed and costs of drugs, tests and health provider’s visits. The combination of individual treatment and population based approaches to reduce blood pressure are cost-effective, but a focus on blood pressure alone is unlikely to be the most appropriate approach to reduce the risks associated with cardiovascular disease.
•
Cholesterol interventions Population-wide strategies to reduce cholesterol including health education
through mass media (broadcast and print media) are very cost-effective, however the total impact in terms of DALYs gained is relatively small, which can be explained by the short period of follow-up of the studies analyzed. The World Health Report outlines that perhaps the long-term effect over generations could be greater since overall cultural changes in dietary habits might be self-reinforcing. Individual-based interventions including treatment and education are very costeffective since the drug required (statins) is now available at very low cost and is rather effective. This intervention needs also outpatient visits for health education and visits to a health provider for evaluation, as well as laboratory tests. This intervention was evaluated with thresholds of cholesterol levels above 6.2 mmol/l (240 mg/dl) and 5.7 mmol/l (220 mg/dl).
The total population impacts in terms of DALYs averted is
relatively large, although slightly smaller than the benefits gained from treating hypertension. The incremental cost-effectiveness of lowering the threshold from 6.2 to 5.7 mmol/l (240 to 220 mg/dl) is not in the very cost-effective category.
•
Absolute risk approach interventions To evaluate each individual's risk of a cardiovascular event in the next ten years
provides an alternative to focusing on cholesterol or blood pressure levels separately. People with an estimated risk of a cardiovascular event over the next decade that exceeds a given threshold receive drug treatment for multiple risk factors, visits to a 39
health provider for evaluation, outpatient visits for health education and laboratory tests regardless the levels of each single risk factor. Four different thresholds were evaluated: 5%, 15%, 25% and 35%. Individual risks of a cardiovascular event for this analysis were based on age, sex, body mass index, cholesterol and systolic blood pressure levels and smoking status, nevertheless risk assessment based only on age, sex, smoking status and body mass index would reduce the costs of implementing the intervention in lowresource settings without an extensive infrastructure. The absolute risk approach for a threshold of 35% is very cost-effective in all settings, and more cost-effective than the alternative of treatment based on blood pressure and cholesterol levels alone. As the threshold is lowered, the health benefits increase but so do the costs, resulting more and more expensive to obtain each additional unit of health benefit. The exact point at which policy-makers might choose to set the threshold varies according to the setting, but to take into account other factors besides cost-effectiveness is necessary. In some settings moving to a 5% threshold might be cost-effective even taking into account the increase in side-effects. Overall, the potential to reduce the risk of cardiovascular events through this intervention is very impressive. Population-level effects exceeding a 50% reduction in events are possible. Many different combinations of the interventions considered above for reducing blood pressure and cholesterol levels are possible and were assessed, such as individualbased treatment and education for systolic blood pressure and cholesterol, and a combined population-wide and absolute risk approach intervention. The World Health Report (2002) states that the most attractive strategy among all those evaluated appears to be the combination of salt reduction at a population level through legislation or voluntary agreements with health education through mass media focusing on blood pressure, cholesterol and body mass, plus the implementation of an absolute risk approach for the management of cardiovascular disease risks. The strategies described are mainly focused on blood pressure and cholesterol, but according to the report, interventions aiming to increase physical activity or fruit and vegetable intake, should also be considered in the development of an overall strategy to deal with cardiovascular disease risks. Where resources are scarce prime attention should be given to prevention and promotion, combined with the less intense individual treatment options.
40
The World Health Report (2002) outlines that the results described are an example of what would be achieved “if the interventions were undertaken in a relatively efficient manner”, assuming capacity utilization of 80% in most settings. Another important issue regarding cost-effectiveness of interventions is the suggestion made by The Commission on Macroeconomics an Health, which points that “interventions costing less than three times GDP per capita for each DALY averted represents good value for money”, and if a given country can not afford them from its own resources, the international community should seek ways of providing them with the necessary support. A very important component of any strategy includes interventions for smoking cessation as well as a comprehensive approach to tobacco control. Due to its complexity and because it affects not only cardiovascular diseases but also other important causes of burden of disease, the strategies for tobacco control will be treated separately further in this thesis.
2.2.3 Risk reduction and behavior change Most strategies for risk reduction include a component of behavior change, which depends on many factors such as personal, community and health system characteristics. Behavioral change first requires understanding, as social scientists claim. A wide range of individual preferences or characteristics influence how people translate understanding into health behaviors, such as how averse to health risks individuals are and the value given to possible future health decrements when compared with other choices in their lives, like wealth and lifestyle. Preferences as well are influenced by personal level of information and advertising and marketing. The subjective assessment of personal risk of disease based on an individual's interpretation of epidemiological and other types of data also influences individual’s preferences to a large extent. It must be taken into account that a cultural concept of risk perception within a society influences an individual’s perception of risk. With regard to health risks individuals and societies sometimes prefer to enjoy the benefits of an activity at present time without thinking about the possible health costs in the future. 41
High consumption of fast food, for instance, is perceived by some people to give current pleasure despite the risk of CVD, to which they give less weight because it will happen in the future. There is considerable variation with regard to the rate at which people value and assess adverse events that might happen in the future. This is especially important for smokers since some research indicates that they “discount the future” more highly than non-smokers, which means that smokers give less weight than nonsmokers to the probability of tobacco-related adverse health events that might occur in the future (e.g. suffering a stroke or lung cancer in 20 years). Therefore, the effectiveness of behavioral modification interventions is clearly influenced by variations in how people perceive the future, but also depends on community-related factors such as availability and affordability of healthy food as well as health systems characteristics. The way a health system is financed (user charges or social health insurance) and organized (publicly funded system or managed care) as well as health provider characteristics also influence behaviors and through them, the costs and effectiveness of interventions. A very important determinant of health behavior is culture, and the social support networks available, also called social capital (The World Health Report, 2002).
2.3
Selecting strategies Rose (in Hunt & Emslie, 2001) favored almost twenty years a go the population
approach for accomplishing substantive and sustainable reductions in the risk of chronic disease. In this regard he explains that “etiology confronts two distinct issues: the determinants of individual cases, and the determinants of incidence rate…the corresponding strategies in control are the high-risk approach, which seeks to protect susceptible individuals, and the population approach, which seeks to control the causes of incidence. The two approaches are not usually in competition, but the prior concern should always be to discover and control the causes of incidence”. The global distribution of risk factors like serum cholesterol, blood pressure, body mass index and tobacco consumption have shifted rightwards over the last 30 years despite the reported risk reduction in developed countries.
The population-
attributable risk of the total world’s population for chronic diseases has therefore risen, reflecting the fact that the reduction of risks in industrial nations was more than offset 42
by the augmentation of risk in the developing world. This enhances the imperative need of CVD risk reduction in developing countries (Reddy, 2002). There are successful experiences in CHD mortality reduction from different settings in the developed world: U.S., New Zealand as well as European countries such as U.K. and The Netherlands. Risk factor reduction accounts for about 60% of the reduction in U.K. and about 50% in the other countries, however the relative contribution of treatments to both reduction in mortality and risk factors is quite high. In The Netherlands the contribution of secondary prevention to the fall in CHD mortality was 46% (Bots & Grobbee, 1996) while in U.S. this peaked up to 71% (Hunink et al., 1997). New Zealand and U.K. attribute respectively 46% (Capewell et al., 2000) and 40% (Unal et al., 2004) of the reduction to medical treatments. The case of Finland is quite different than the previous examples, where only 30% of the CVD mortality rate fall was attributable to treatments (Vartiainen et al., 1994). The fact that the Finnish comprehensive national prevention program achieved particularly large risk factor reductions has drawn the attention of several researchers on the subject (Capewell et al., 2000; Sellers et al., 1997; Yusuf et al., 2001; Part II; Ebrahim & Smith, 1997; The World Health Report, 2002), being its strategy of multiple risk factor intervention methodologically criticized by Yusuf et al.; Part II (2001), Ebrahim & Smith (2001), Nilsson & Berglund, (2000), Leeder et al. (2004) among other authors of the literature reviewed for this thesis, arguing that causal relationships are difficult to establish with this type of study. Medical treatments therefore have had a proved substantial impact on CVD mortality rates in the developed world, and particularly secondary prevention, which makes unlikely that developed countries strategies for risk reduction could be replicated in developing countries. The general disarray of public health services as well as limited resources available to health services in most developing countries imply that prevention models that have worked in wealthy countries have scarce relevance in the developing world (Beaglehole et al., 2001). Since the majority of CVD arise from the large segments of the population who exhibit medium or low levels of risk, prevention efforts focused solely on high-risk people reduces the risk only in a limited number of individuals an therefore cannot eradicate the population burden of CVD (Sellers et al., 1997).
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2.4
Population-based approach to primary prevention: How to change population’s behavior According to Beaglehole et al. (2001) “if the goal is to significantly increase the
proportion of the population at low risk status, the only strategy with this potential is the population-wide approach to primary prevention”. Population-based lifestyle-linked primordial and primary prevention strategies are especially relevant since they can avoid much of the economic and biological costs of pharmacological interventions used in industrial countries, where the initial focus was on reduction of elevated risk factors rather than on preventing its rise (Reddy, 2002). However, the population approach to primary prevention delivered by several community-based randomized intervention trials targeting multiple CVD risk factors has not been widely qualified as successful, and has reported variable results (Sellers et al., 1997). This view contrasts sharply with the very well known success reported from the North Karelia program in Finland (Vartiainen et al., 1994) and a program carried out in the island of Mauritius (Uusitalo et al., 1996). Because of these contradictions, further adoption by developing countries of community-based programs similar to those undertaken during the 1970s and 1980s in the developed world has been questioned.
2.4.1 Multiple risk factor interventions During the 1970s and the 1980s several community-based programs were carried out in developed countries, of which the North Karelia study in Finland was the more prominent.
These interventions used education or environmental change to
promote and facilitate life-style and behavior change (dietary modification, quitting smoking, and increasing physical activity). Ebrahim & Smith (1997) carried out a meta-analysis and systematic review of 14 randomized controlled trials of primary prevention of CHD by means of multiple risk factor interventions that used counseling and education with or without pharmacological treatments in general populations, occupational groups and high risk groups. The results revealed that multiple risk factor interventions were ineffective in achieving reductions in total CHD morbidity or mortality when used in general or workforce populations of middle aged adults. The authors suggested that interventions 44
may be more effective in populations with particularly adverse risk factor profiles due to the strong associations observed between baseline levels of risk factors and net falls. They concluded that people at high risk were more likely to benefit from counseling, education and effective drug treatment, and therefore “targeting of current health promotion activities to people at high risk would be valuable”. With regard of the success reported in Finland they state that “the trends in both risk factors and mortality from coronary heart disease observed in North Karelia and comparison regions show similar patterns occurring at the same time, suggesting that the interventions in North Karelia were not instrumental in causing the improvements observed”. Cupples & Mc Knight (1999) results of a five year follow up of patients who took part in a randomized controlled trial showed that at the end of five years of a personalized health promotion program based on primary care for patients with angina, the benefits reported regarding exercise and prophylactic consumption of drugs were still evident but smaller. This might indicate that even though health education has a better effect in high risk patients’ health related behavior; it needs to be constantly reinforced to maintain behavior change. Another view of the success occurred in Finland, where the difference in CVD incidence between the two regions compared for the study (North Karelia and Kuopio) became less evident after the first five years, is the one provided by Leeder et al. (2004), where this phenomenon is attributed to a behavior change in the entire country. They explain that as dietary preferences changed in the whole country, not only in the region intervened (North Karelia), the food industry perceived new opportunities and developed products with less oil, agriculturalist developed a new type of rapeseed plant that was well sold and cooking with vegetable oil became popular in Finnish kitchens, increasing the market proportion of unsaturated fat, and salt reduction being also adopted by food producers. This analysis, where the changes in environmental conditions (better availability of healthy food through population-based measures) are attributed to changes in population’s dietary preferences might also been looked in the other way around, meaning that more availability of healthy products allowed a behavior change in the entire population. Probably nationwide legislative means to change environmental conditions (promoted by the community-based intervention performed in North Karelia) could not exclude a single region even if it is under intervention. Nevertheless, why people in the control group, and therefore without intervention, change their dietary preferences give a clue with regard to the utility of 45
interventions to change behavior and the difficulty to establish cause-effect relationships from multiple risk factors interventions. Another meta-analysis was carried out by Sellers et al. (1997), aiming to understand the variability in the effectiveness of community-based programs that used a population strategy of prevention. They concluded that the effects of community-based programs “are a function of the nature of the intervention that is implemented and the population that is exposed to the intervention as well as the way in which the intervention was evaluated”. Of the consulted authors, Yusuf et al.; Part II (2001), Ebrahim & Smith (2001), Nilsson & Berglund, (2000), Finnegan et al. (1998) and Cupples & Mc Knight (1999) agreed that in populations at low risk of CVD, multiple risk factor interventions studies have failed to provide strong evidence of reduction in morbidity or mortality from individual or family advice on health behavior modification. This failure probably reflects the fact that the model used for intended behavior change might not be the most adequate.
Sellers el at. (1997) explain in their meta-analysis that the model for
combating some infectious diseases through community interventions was partially adopted to fight against chronic diseases. The population was informed about the dangers of certain life-styles, and social policies and social structures were modified to complement the intended behavior change. According to Hunt & Emslie (2001), “modification of lifestyle was equated more with the avoidance of disease than the lowering of risk”. This might be partly in response to the prevailing view during the 1980s, where lack of behavioral change was explained by lack of knowledge or irrationality.
Regrettably many scientists still embrace this view, unaware of the
complexities that lie behind behavior change and influencing policy makers and professional community’s view. One of the many examples is the article published by Reddy at Public Health Nutrition (2002). Being an expert in the subject of CVD risk reduction, with several other publications in prestigious journals, after a careful and brilliant analysis of the effects of industrialization and globalization on populations’ cardiovascular health, Reddy states that “it must be recognized that the power of determining the desirability and the direction of change rests with the people. Markets are not autonomous entities and can be molded by consumer consciousness…the power of the people to determine their destinies must also extend to health-promoting behaviors”.
46
In section 2.2.3 were described all the relevant factors that influence individual’s behavior with regard to risk reduction, and unless they are considered is likely that any program aiming to change behavior will fail. Given the fact that CVD exhibits a clearly marked inverse social gradient, models of disease etiology that incorporate social factors might be more useful for cardiovascular health achievement (Dressler & dos Santos, 2000). As was pointed out in previous sections, the selection of a strategy depends largely on the setting where the interventions will take place, being necessary to take into account political, economic, cultural and social context of the population at risk.
2.4.2 Environmental change While interventions aiming to change behavior have produced relatively small results in risk factors, mortality and CVD-related behavior on permanent basis, population-based interventions that foster environmental changes are more likely to succeed (Sellers et al., 1997; Ebrahim & Smith, 1997; Ebrahim & Smith, 2001; Beaglehole et al., 2001). Restricting smoke in public places as well as increased taxes for tobacco and alcohol, reductions in salt content of processed food and saturated fatty acid in cooking oil are examples of low-cost prevention programs that can be implemented in less industrialized nations. Murray et al. (2003) points that government action to stimulate a reduction in the salt content of processed food is a cost-effective strategy, and could avert over 21 million DALYs per year. A net fall of 15% in mean blood cholesterol levels was observed in Mauritius after the composition of cooking oil was modified through government actions from palm oil (high in saturated fatty acids) to wholly soya bean oil (high in unsaturated fatty acids) (Uusitalo et al., 1996). In the WHO-MONICA project, the greatest contributions to the decline in CHD came from the population-wide approach to primary prevention. The decline was attributed mostly to the reduction of population blood pressure levels due to reduction of salt intake and, to a lesser extent, the better management of hypertension (Kuulasmaa et al., 2000).
47
Experiences in the U.S. and other developed countries indicates that policy interventions have a considerable greater impact on tobacco use decisions at the societal level than do interventions that target individuals (Mensah et al., 2004). With respect to addictive substances like nicotine, the consumer’s freedom of choice is limited even if they are aware of the danger, and in the case of children and teenagers in particular, their capacity to assess the information about the effects of tobacco over health is limited; therefore, they can not properly assess the costs and benefits of their choice. Smoking also damages non-smokers, imposing them indirect non-consented costs. These conditions, described by The World Bank (1999) as a failure to meet free market standards, provide a rationale for demand-reduction interventions (Bettcher & Subramaniam, 2001). The Framework Convention on Tobacco Control (FCTC), adopted by consensus in May 2003 in the 56th World Health Assembly and negotiated among WHO Member States over four years, is an international treaty directed towards the control of tobacco use, including aspects such as advertising, promotion and sponsorship bans, packaging and labeling restrictions, price and tax measures, youth’s restricted access to tobacco products, passive smoking and smoking-free environment and treatment of tobacco dependence (The World Health Report, 2003). The World Bank (1999) indicates that demand can be reduced by around 7% with comprehensive advertising and promotion bans. Limited or partial bans, such as the proposed by the tobacco industry have little or no effect (Myers & Wilkenfeld, 2001). A useful tool for environmental changes measurements is proposed by Cheadle et al. (2000), based on community level indicators (CLIs). Examples of CLIs include store shelf-space measures (e.g. percent of shelf space that is low fat milk), characteristics of restaurant non-smoking areas (e.g. percent of seating that set aside as non-smoking), as well as walking and bike paths. The indicators were grouped in four categories: policy and regulation, information, environmental change and behavioral outcome. Policy and regulation indicators include laws and ordinances for tobacco use, policies related to physical education for physical activity and guidelines for menus and food preparation for diet. Information indicators included information at the point of purchase
as
well
as
information
provided
by
health-related
professionals.
Environmental change indicators for tobacco included limitations on access to tobacco products and availability of no-smoking areas in a variety of settings; for physical activity were focused on the availability of facilities and for diet on the availability of healthy products. Behavioral outcome indicators included sales data and observations in 48
stores. Although still in validation process at publication date, this might represent useful indicators of environmental characteristics that make healthy choices possible as well as assess environmental changes occurred within a community. The Mauritian study emphasizes the important role of governments in population approaches to prevention. The support of the international community plays a crucial role as well, being the latter especially relevant for developing countries. Without international support and regulation of the international trade of food, alcohol and tobacco, developing countries’ governments can hardly take difficult decisions about tobacco, alcohol and food pricing and its availability, being this issues, according to Ebrahim & Smith (2001) “a more powerful determinant of cardiovascular disease risk than the failure of individuals to heed health education messages. People eat, smoke and drink what is affordable and available to them”.
2.5
Individual-based
approach
to
primary
prevention
and
secondary
prevention: targeting people at high risk The evidence gathered from community-based programs analysis and from developed countries CVD mortality reduction data suggests that the high risk approach to primary prevention, whether for lifestyle or pharmacological interventions, and especially secondary prevention in coronary heart disease might be more useful in the short term to reduce CVD mortality. To lower blood pressure decrease the risk of a cardiac event in people with manifested CHD and studies have provided evidence of benefit of blood pressure reduction on the risk of stroke recurrence among patients with a history of cerbrovascular disease. In people with diabetes, available evidence indicates that gliycemic control influences the rates of long-term cardiovascular complications. A combination of medicines to lower blood pressure and cholesterol levels might achieve substantial reduction in CVD mortality among these patients. To simplify the management of individuals who need medication for CVD a combination pill (Polypill) has been recently proposed by Wald and Law (2003), that contains three drugs to lower blood pressure (hydrochlorothiazide, atenolol, enalapril), one for cholesterol (simvastatin), folic acid to reduce homocystein levels, which has influences in atherosclerotic disease development, and aspirin, that improves blood circulation by influencing the formation of thrombus. Based on the fact that in U.K. 96% of people 49
who die of CVD are aged 55 and over, these authors reasoned from clinical trial data that if everyone aged 55 and over, or younger if at high risk or with established CVD, took the Polypill, ischemic heart disease events could be reduced by 88% and stroke by 80%. Wald and Law argued that treating everyone who is 55 and over is therefore justified without measuring risk factors before treatment or monitoring the effects of treatment. They state that this pill “would have a greater impact on the prevention of disease in the Western world than any other single intervention”. As is was expected, such statement generated much polemic among researchers in the field, whom opinions has been mostly negative, since Wald and Law underestimated issues such as the value of epidemiological research in CVD, diagnostic tests, adherence to therapy and adverse effects among others (Osmun et al., 2003). Most authors highlighted the issue of medicalization and its consequences. Ironically, Smith (2003) states in this regard that “the BMJ last year published a theme issue questioning the medicalization of birth, death, unhappiness, and risk. Now we are publishing studies that argue that everybody should take pills from 55. But do doctors need to be involved? We could do away with the screening…maybe too we could buy the pills in supermarkets and pubs”. Besides pharmacological measures for secondary prevention, lifestyle measures such as stopping smoking, encouraging a healthy diet and exercise can also significantly contribute to reduction in cardiovascular mortality in people with established CVD. With regard to diet, randomized controlled trials have shown that advising people with established CHD to eat more fish, fruit and vegetables, bread, pasta, potatoes, olive oil and rapeseed margarine may result in a substantial survival advantage. Despite substantial benefits and generally low treatment costs, appropriate measures for secondary prevention after myocardial infarction are implemented in less than half of eligible patients in developed nations (WHO PREMISE, 2003). In the United Kingdom the ASPIRE study (Action on Secondary Prevention through Intervention to Reduce Events) revealed that 10% to 27% of patients were still smoking cigarettes, 75% remained overweight (women more than men), and approximately a quarter of patients remained hypertensive. Of the 2583 patients surveyed, only 25% of smokers received any recommendation to stop smoking and only 50% of patients diagnosed with high serum cholesterol received therapeutic intervention. Among patients who were receiving lipid-lowering drugs, most remained hypercholesterolemic six months following hospitalization for coronary heart disease (Bowker et al, 1996). EUROASPIRE extended this research to 9 European countries, 50
and found similar gaps between clinical recommendations and practice in their first survey in 1995-96, which were maintained to the time of the second survey in 19992000 (EUROASPIRE II Steering group, 2001). Due to inequitable and inaccessible health care systems, limited resources for health care workers, and investment of scarce resources in interventions that are not cost-effective, the secondary prevention coverage and treatment gaps are probably worse in low- and middle-income countries. Since a substantive part of direct costs of secondary prevention programs are attributed to drug costs, adequate delivery of secondary prevention programs is heavily dependant on national drug policies and rational use and access to drugs. Some actions recommended by WHO for rational use include treatment guidelines with essential drug lists and regular evidence-based update of such lists. The use of generics, to increase public funding for cost-effective drugs and to expand drug benefits in health insurance might guarantee affordable prices and therefore access, as well as to encourage competition (WHO PREMISE, 2003). Cost-effectiveness of different therapies might, however, depend on the setting and probably negotiations between governments and pharmaceuticals. Some factors related to patients, such as compliance to the prescribed treatment and modification of lifestyle also play an important role in the success of secondary prevention interventions, as well as factors related to the health care system such as the appropriateness of care, health insurance and cultural barriers between physicians and patients (Steinbrock, 2004). WHO (2001) highlights the importance of adherence to therapies as a primary determinant of treatment effectiveness. The consequences of nonadherence to long-term therapies for chronic conditions involve poor health outcomes and increased health care costs because of more use of sophisticated and expensive health services caused by disease exacerbation. In developing countries poor adherence to treatment also results in waste and underutilization of already limited health care resources. Adherence has traditionally being understood as “the extent to which the patient follows medical instructions”, but this definition is insufficient in the case of chronic conditions that require behavior modification in addition to taking prescribed medication.
A more comprehensive definition for adherence to chronic disease
therapies was adopted by the WHO Adherence Meeting (2001): “The extent to which a person’s behavior, taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider”.
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There is a trend to focus on patient-related factors as the cause of low adherence; nevertheless, provider and health system-related factors can also have an effect over it. Making patients solely responsible often reflects a lack of understanding of how other factors affect people's behavior and their capacity to adhere to treatment. A number of demographic and socioeconomic factors might influence adherence, including distance from treatment center, cost of transport or medication, SES, literacy level, educational level, and cultural beliefs about illness and treatment (WHO, 2003*).
2.5.1 Health system – related factors Many health system characteristics affects adherence to chronic conditions’ therapies, including inadequate reimbursement by health insurance plans, poor medication distribution systems, a lack of knowledge and training for providers on how to manage chronic diseases and to improve adherence, short consultations, and a weak system capacity to educate patients and provide follow-up. The health care system might potentially improve patients' adherence behavior in a number of ways: health care systems control access to care through mechanisms such as providers' schedules, length of appointments, allocation of resources, fee structures, communications and information systems, and organizational priorities. For example, with systems that do not reimburse providers for patient counseling and education, there is a serious threat to interventions that focus on adherence. The lack of adequate care for chronic conditions poses a special burden to poor families, increasing disparities in health (WHO, 2003*). The observed disparities in cardiovascular health care contribute to the current unequal distribution of CVD among social classes. (Lorant et al., 2002; Mc Alister et al., 2004; Cooper et al., 2000), being the inverse relationship between socio-economic status and CVD well known, and although multiple factors influence this distribution, some factors might be subject of modification after being identified. These factors were summarized by Mc Alister at al. (2004) in four main issues, of which two were already discussed in previous sections. The other two are: reduced access to specialist care and suboptimal application of proved efficacious therapies. Since half of the factors that affected CHD mortality among socioeconomically deprived groups in this study were related to equity in health care, is likely that CHD mortality could be reduced in the
52
same proportion if these factors were modified. Although a 50% reduction in mortality by this means is attractive but in reality unachievable, small improvements in the abovementioned factors could produce better results among low SES groups. Disparities in cardiovascular care have been well documented (Lorant et al., 2002; Steinbrock, 2004; Cooper et al., 2000), including a variety of aspects. The study of McAlister et al. (2004) focused on examining whether there are socioeconomic gradients in the incidence, prevalence, treatment and follow up of patients with heart failure in primary care in Scotland. The findings revealed that the incidence of heart failure diagnosed in general practice is significantly higher in individuals of low SES (44%) and subsequent follow up less frequent, being 23% less prone to see their general practitioner on an ongoing bases. Prescribed treatment did not show differences across socioeconomic gradients in this study, however, in health care systems where costs containment strategies include patients’ share of medication costs or medication is not enough to cover the needs, which is the case of most developing countries, prescription of treatment as well as adherence to therapies will show great differences among social classes. Related findings were reported by Lorant et al. (2002), who concluded that inequity in the general practice setting regarding CVD preventive medicine (cholesterol screening) was higher than inequity in health care, and inequity in the specialty setting was higher than in the general practice, although there were no significant differences between preventive medicine and health care in the latter. What lies behind these facts might be that low SES patients may seek health care in hospital emergency rooms rather than attend their primary care physicians, also with a more fatalistic behavior, these patients often consult non-professionals for health care (Mc Alister et al., 2004). Probably with a better understanding of the perceptions of risk as well as concepts regarding health and causes of cardiovascular illness, culturallysensitive strategies could target socioeconomically deprived groups in order to improve their utilization of health care. A well evaluated strategy for secondary prevention of CVD are structured care programs implemented in some developed countries such as multidisciplinary cardiac rehabilitation programs in Canada (Mc Alister et al., 2001) and nurse-led clinics implemented at primary care in U.K. (Murchie et a., 2003; Campbell, 2004; Dalal et al., 2004), which have shown improvements in medical and life-style components of secondary prevention and might led to less coronary events and hospitalization rate. McAlister et al. (2001) reviewed 12 randomized trials of secondary prevention 53
programs carried out in U.K., concluding that such programs for disease management improve patients care and quality of life and reduce admissions to hospital, although “the programs’ impact on survival as well as cost-effectiveness remain uncertain”. No further information posterior to 2001 was found in several databases consulted regarding cost-effectiveness analysis and survival rate of the programs as a whole, only for individual drugs, combination of them and other procedures in isolation.
2.5.2 Patient-related factors Specific condition-related factors can affect patient’s adherence. These might include severity of symptoms, level of disability, and rate of progression of the disease. Therapy-related factors influence patient’s adherence as well, such as the complexity of the medical regimen, duration of treatment, immediacy of beneficial effects, level of side effects, and availability of medical support. The resources, knowledge, attitudes, beliefs, and expectations of patients will also have an impact (WHO, 2003*). The obstacle most frequently described by the literature for an appropriate secondary management of CHD was patients’ life-style modification. Smoking, alcohol consumption and obesity were the most prevalent, which De Bacquer et al. (2003) attributed to blood pressure and cholesterol lowering drugs. Correlation between educational status and adverse lifestyle profile was observed (De Bacquer et al., 2003; Baltali et al., 2002), being patients with higher education at lower global coronary risk than those with lower education (Mayer et al., 2004). Gender differences were observed as well, being women less likely to smoke and drank less alcohol (reflecting the general population pattern), but more physically inactive and more obese than men (Flanagan et al.,1999; Baltali et al., 2002). The studies were carried out in patients aged > 70 (Flanagan et al., 1999; Baltali et al., 2002; Mayer et al., 2004) and in working age patients (Sumanen et al., 2004). The hypotheses given by Flanagan et al. (1999) for the observed differences in their study were poor provision of information or patients’ reluctance to adopt the advised life-style. In this respect Clark et al. (2002) performed a qualitative research that examined the health staff perspectives about motivation to change of patients attending an existing program in Scotland. The secondary care staff focused on the importance of patients’ factors, whereas primary care staff referred more to the 54
cumulative effects of social and cultural factors. According to Murray et al., (2000) social and cultural factors are closely related to patients’ perceptions of cardiovascular risk and therefore health behavior. Concepts like fate, luck and destiny play a part in explanations about cardiovascular illness and death, mostly related to the ‘lay theory of coronary candidacy’. The ‘candidate’ for a heart attack is physically inactive, heavy smoker with unhealthy eating habits and a man. Exceptions to the candidacy system (‘it never seems to happen to the people you expect to happen’, or the ‘last person’) reveals that according to the lay theory, candidacy only indicates increased risk of CVD, while death from a heart attack is fate or randomness (Davidson et al., in Murray et al., 2000 and Hunt & Emslie, 2001). These concepts might be useful to understand the observed gender differences and the relative failure in lifestyle modification in patients with manifested cardiovascular disease as well as in the general population. Perception of risk and social class might also be associated with the most common problem in the high-risk approach to primary prevention, which is detection of individuals at risk. It is possible to conclude that in order to achieve good results from secondary prevention interventions it is necessary to adapt services to local socio-economic conditions, and to take cultural perceptions into account for the design and implementation of primordial, primary and secondary interventions.
2.7
Parameters for the selection of strategies An adequate and tailored balance of primary and secondary prevention is the
goal to reach for an adequate formulation of CVD policy and CVD preventive policies in order to meet the population needs. For this purpose a good coverage and quality of vital statistics systems and an adequate surveillance system are essential to select appropriately among the different interventions available. The estimation of CVDrelated burden of disease and its secular trends, and the estimation of the levels of established CVD risk factors in representative population samples will provide relevant data to identify risk factors that require immediate intervention and establish the need of preventive actions, to inform policy-makers and to monitor the progress of prevention programs. The disease surveillance data are necessary for planning and evaluation of the impact of health interventions on CVD outcomes, since the main objective of
55
prevention programs is to reduce the population burden of disease, not only population risk factors level reduction (Beaglehole & Yach, 2003). Some aspects and potential pitfalls that are necessary to take into account for an effective CVD policy and CVD preventive policy formulation were described by Beaglehole & Yach (2003): • Advocacy for CVD prevention and control from a public health perspective, because potential advocacy groups are commonly originated in specialist organizations, who place treatment at the centre of health policy debates and funding priorities. • Capacity and resources to plan and manage a non-communicable disease prevention and control program. The institutional response to capacity development has not kept pace with the epidemiological transition. • Partnership and interaction with international consumer groups and commercial food multinationals to achieve progress in improving the quality of food and access to healthy food. • Reorientation of Health Services to coordinate non-communicable disease risk reduction, care and long-term management. • A frame of global norms and standards to both legally binding (tobacco) and nonbinding (food labeling) across many spheres to balance influences of powerful actors. A good example of this is the FCTC.
2.6.1 Selection of strategies for CVD prevention and control in developing countries It is possible to infer from previous sections that because of reasons like limited financial resources, health systems organization and prevailing inequities in access to health care, the strategies to reduce the burden associated with CVD in developed countries can not be replicated in the developed ones. Strong market forces and weak regulatory structures also difficult the control of tobacco and alcohol, worsening the situation. Despite these difficulties, public health professionals, policy makers, local governments and international organizations must address, because of ethical reasons, the toll of CVD in developing countries promptly. Ischemic heart disease alone is anticipated to increase by 120% for women and 137% for men in developing countries between 1990 and 2020, compared to age-related
56
increases of between 30% and 60% in developed countries. If the current status remains unchanged in the next 30 years, population growth alone will lead to major increases in CVD in developing countries, which might severely impact workforce productivity and economic progress. Cardiovascular mortality rates among people of working age in India, South Africa and Brazil were one-and-a-half to two times higher than those in the US. In South Africa, despite the predominance of HIV/AIDS, 12% of men aged between 35 and 44 died from cardiovascular disease while the figure for women was 17.2%. In India, 28% of the five million people who die of cardiovascular diseases every year are under 65. This was even higher than the equivalent figure for U.S. fifty years ago, before CVD became a public health priority (Leeder el al., 2004). A recent study involving 52 countries, representing every inhabited continent, revealed that abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits and vegetables, alcohol, and regular physical activity account for most of the risk of myocardial infarction worldwide in both sexes and at all ages in all regions. The authors suggests that “approaches to prevention can be based on similar principles worldwide and have the potential to prevent most premature cases of myocardial infarction” (Yusuf et al., 2004), however, as was discussed in previous sections (1.4.2, 1.4.3, and chapter 1 conclusions), the social, economic, political and cultural context has a great influence over the course that the CVD epidemic follows, which needs to be taken into account when planning and selecting strategies for prevention and control of CVD in the developing world. Developed and developing countries’ CVD determinants are similar, but their dynamic has been quite different, as was explained in section 1.7.3. The urbanization process, one of the main CVD determinants for both developed and developing countries, evolved in the latter on settings with considerable international debt, high poverty levels and therefore restricted resources for public health responses, in opposition to the developed countries’ prospering economies where urbanization occurred. On the other hand, the timing for prevention efforts commencement might condition the acceptance of lifestyle modification counselling because of the different levels of community awareness of the potential harm of CVD. In the developed world, prevention started at the epidemic’s peak, while the developed world’s major concerns are still communicable diseases and under nutrition, so it is likely that lifestyle modification messages will not be paid proper attention.
57
Although based on the developed world’s experiences, the selection of strategies for CVD prevention and control in developing countries should ideally be based upon the evidence gathered from context-specific research, and taking into account affordability, local culture and the developing country position within the global economy, as was mentioned in chapter one conclusions.
2.6.2 Research on CVD prevention strategies Research on emerging or ‘new’ risk factors (inflammatory markers, homocisteyne levels) might be relevant for prevention in both developed and developing countries, and genetic factors research is likely to improve the understanding of susceptibility to disease at individual level as well as the interactions of the environment with individual risk determinants, however this research consumes a great share of the research funds available (Beaglehole et al., 2001). Research reveals that most CVD risk is environmentally determined, therefore it would be prudent and coherent to privilege funding for research aiming to clarify the determinants of risk factors at societal level and its susceptibility to modification through governmental or social policies. An important focus of research should be the determinants of CVD inequalities, more of concern of the social, economic and cultural domains and not easily investigated by traditional epidemiological methods (Beaglehole et al., 2001). Changes in diet, physical activity and smoking have occurred in contexts of culture change, were individuals who had been socialized in one culture are confronting another, leading to situations of confusion and frustration in social interaction, a stressful condition that repeated over the years is conducive to disease (Cassel, in Dressler & dos Santos, 2000). May et al. (2002) reported that psychological distress is a predictor of fatal ischemic stroke after adjustment for body mass index, systolic blood pressure, smoking, heavy drinking, social class and marital status. Rosengren et al. (2004) found strong evidence that the presence of psychosocial stressors is independently associated with increased risk of acute myocardial infarction. Although with a clearly marked medical focus toward research, the findings of these authors are useful for populations worldwide, since they sampled people from 52 developed and developing countries, in the frame of the INTERHEART study. Long-term exposure to occupational stress, such as the strain 58
of a demanding job or lack of job security, increases risk for coronary heart disease, hypertension, and stroke, and having few social connections and social resources are linked to all-cause and CVD mortality, especially in men (Mosca et al., 2002). Lindström et al. (2003) found that low levels of social participation, which constitutes the formal social networks and formal social activities within the social capital literature, such as study circles of other organisations than at work, church, sports event and gathering of relatives, were significantly associated with daily smoking. Further research by the same author indicates that both social participation and daily smoking are associated with psychosocial work conditions and unemployment (Lindström, 2004). “Social capital is a characteristic of social groups, rather than individuals, and is born of shared experience which fosters mutual trust and reciprocity, being a collective resource that may accumulate over time and facilitates the accomplishment of objectives that would otherwise be unlikely”, and although its utility for health policy formulation is considered problematic and its measurement is subject to debate, it is considered by health researchers as a pathway to explain the adverse health outcomes associated with income inequality (Shortt, 2004), which is the case of cardiovascular health outcomes. According to Lomas (1998) “Public health professionals and epidemiologists have an ethical and strategic decision concerning the relative effort they give to increasing social cohesion in communities versus expanding access for individuals to traditional public health programs”. For a change of focus from individual-level causal models to models of social structure integration (or disintegration), epidemiologists might confront problems related to measurements, study design and analysis that allow the understanding of the link between social capital and health. Hopefully the relevance of social capital for research might grow among the scientific community and this would therefore be transmitted to developing countries’ researchers. Probably great health outcomes could be achieved with social capital network-building in both developed and developed nations, in CVD outcomes as well as other health indicators, but for this to be a reality there is still a long way to run. Being most health research covered by MEDLINE database, its indexing of social sciences, and economic and health systems research is poor (Mendis et al., 2003). For social research to be utilized in the policy process, however, much needs to be done as well as researched in health policy development. 59
2.7
Impediments to prevention and control of CVD Despite the growing evidence of the epidemiological and economic impact of
CVD, an adequate management of the problem is difficult, especially in developing countries where the projected burden of disease shows alarming figures (Leeder et al, 2004). Yach et al. (2004) analyzed the main aspects and stakeholders involved in the global response to chronic disease prevention and control. Stakeholders include governments, the World Health Organization and other United Nations bodies, academic and research groups, nongovernmental organizations, and the private sector. In their analysis the authors cite several examples that evidence the need to place chronic diseases prevention and control higher in the political agenda. Because of its relevance they will be outlined bellow:
•
Heads of State Being health recognized as a global challenge by heads of state of the G8
countries at their Summit in 2000, they agreed to mobilize resources leading to the establishment of the Global Fund for HIV/AIDS, Tuberculosis, and Malaria. No subsequent commitment has been made for chronic diseases. Similarly, the G77, representing heads of state from approximately 130 developing countries, when discussed global health issues at the thirty-four meeting in Geneva in June 2003, their focus was on communicable diseases, although they did support the FCTC.
•
Health Ministries The capacity of 185 countries to prevent and treat chronic diseases was assessed
by the World Health Organization in 2001, and although there was a high level of awareness about chronic diseases among health ministry officials, only thirty-nine percent of countries reviewed had budget lines for chronic diseases.
•
The World Health Organization With the important exception of tobacco control, financial resources of the
World Health Organization for chronic disease control are small. WHO Headquarters spends only $0.50 on chronic diseases per death per person compared with $7.50 for leading communicable diseases. 60
•
Academic Health Centers and Research Institutions The primary focus of Schools of public health is on communicable diseases, as a
survey of the core requirements of the curricula of members of the Association of Schools of Public Health indicates. Although Johns Hopkins, University of North Carolina, and Yale now address obesity in their nutrition courses and Yale teaches chronic diseases and has an international tobacco seminar in its introductory global health course, their main concern when training health professionals from developing countries is on infectious diseases and primary health care. International committees convened by the Global Forum on Health Research recommend that greater support should be given to chronic disease research specific to developing countries, however the exponential growth of funding over the past decades has not been proportionally allocated to the growing burden of chronic disease, with most research support focusing on infectious diseases as revealed by a review carried out by Alano et al. (2003) (quoted by Yach el at. (2004)), which showed that total health research funds spent on chronic diseases was 7.4% in Cuba, 2.3% in Kazakhstan, and 14.4% in the Philippines. Nevertheless, efforts to focus more research on chronic diseases do exist. The Fogarty International Center has begun to allocate one third of its resources to chronic disease research and training programs in the developing world, and research funding agencies in India, Mexico, and South Africa are devoting increasing budgetary resources to chronic diseases.
•
Donors Official development assistance for health has increased; however, these trends
have been almost entirely absorbed by HIV/AIDS in sub-Saharan Africa. Official Overseas Development Aid to the health sector in 2002 reached $2.9 billion, of which 0.1% was officially allocated to chronic diseases. Private investment in global health far exceeds government assistance, but most target infectious diseases and humanitarian needs. There has been modest support for tobacco control from the UN Foundation, the Rockefeller Foundation, and the Soros Foundations, but this is now declining. The Bill and Melinda Gates Foundation does not include chronic diseases in its portfolio, and although several US foundations support innovative domestic chronic disease research and training programs, they provide little support for such programs internationally.
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•
World Bank and Regional Development Banks The World Bank over the last 5 years provided $4.25 billion in loans to countries
for the health sector work, of which about 2.5% was allocated to non-communicable disease prevention and control programs, all in Eastern Europe. The Bank's Poverty Strategy Reduction Papers present no strategies to address chronic diseases, and in particular smoking. The Regional Development Banks have policies on health, but only the Asian Development Bank includes chronic diseases, however a review carried out for the Asian Development Bank in 1999 recommends that subsidies for chronic diseases would be better spent on the prevention and treatment of communicable diseases, being the rationale for this decision that the cost of treating chronic disease is most likely to accrue to individuals and, as such, should be left to the private market.
•
Global Nongovernmental Organizations Nongovernmental organizations have a wide geographic spread and have the
ability to build capacity, especially in developing countries, however there has been no concerted effort on chronic diseases. International consumer group input is not adequate; initiatives such as sustainable development and corporate social responsibility have not been applied to chronic diseases.
•
Health and Development Initiatives United Nations health and development reports play a major role in setting
priorities for global health. Persistent problems that hinder development, such as infant and maternal mortality, malnutrition, and HIV/AIDS have received priority in the poorest countries. But the emphasis on communicable diseases has excluded consideration of chronic diseases in low-middle and middle income countries. The UN Population Fund does not mention chronic diseases in its strategy on population and development and UN Children's Fund's goal-setting program, ‘A World Fit for Children’ does not include risk factors for chronic conditions among the 25 action points proposed to promote healthy lives. Yach et al. (2004) stresses that up-to-date evidence related to the nature of the burden of chronic diseases is not in the hands of decision makers, and strong beliefs persist that chronic diseases afflict only the affluent and the elderly, that they arise 62
solely from freely acquired risks, and that their control is ineffective and too expensive and should wait until infectious diseases are properly addressed. To address these impediments and place chronic diseases higher on the health agenda of key policymakers, providing them with better evidence about risk factor control, a multisectoral policy approach supported by research is necessary to reverse the negative trends in the global incidence of chronic disease. This is especially important for developing countries because of the projected burden of CVD in these nations and the linked economic and social consequences.
To strengthen and support developing
countries’ researchers capacity in the field is essential, because solutions proposed by developed nations’ researchers for the developed world, although made by experts and scientifically carried out, suggests impracticable solutions for low and middle income countries. Leeder et al. (2004), based in the fact that elected democracies have recently increased in number in the developed world, states that adequate policies to manage CVD through taxes and regulations can be achieved by people’s pressure, stressing that “in an open society, policy makers can mandate to their ‘hearts’ content, but the people may or may not respond. The levers of change are no longer in the hands of ministries, but individuals”. This view might reflect on one hand that political sciences knowledge and models to bring issues into the health policy agenda were ignored or are not part of the researcher’s concerns, although this is unlikely since most of them have an impressive background on public health. On the other hand, the above-mentioned opinions may reflect a developed nation’s citizens understanding of the concept of democracy, civil rights and concerns. Individual decisions and health itself in all levels of society are affected by social and economic factors, especially in settings with high rates of unemployment, where the effort put into work is inadequately rewarded, stress levels are high and social support is low (Wilkinson & Marmot, 1998), which is the case of most democratic low and middle income countries. Regrettably, cardiovascular disease research productivity of developing countries is low. Of the existing scientific publications in the subject in MEDLINE in 2001, only 8% corresponded to developing countries, being no publications from 82 developing nations of WHO member states, opposed to the high scientific output related to CVD of developed countries. “The poor research productivity of developing countries is both a consequence and a contributory factor for the widening gap between the health of the rich and the poor, and indicates the generally weak capacity of developing countries in all areas of non-communicable disease policy, advocacy, 63
legislation, and strategy. Urgent action at global and national levels is needed to narrow this gap” (Mendis et al., 2003).
2.8
Conclusions Because conventional risk factors (whether biological or behavioral) account for
much of the CVD-attributable morbidity and mortality, to target risk factors may reduce the burden of disease considerably. The approaches toward CVD risk factors can be either to reduce its prevalence or control its incidence. Most interventions up-to date have adopted the former, achieving good results in CVD mortality reduction in developed countries through secondary prevention and the high risk approach to primary prevention. Although proven effective, this approach is quite expensive. Since most of the CVD risk is environmentally determined, to control its incidence through primordial prevention and the population approach to primary prevention should have priority, especially in developing countries, because of resource constraints and lack of capacity within health systems to provide effective care. Cultural, economic and social factors within the environment play an important role in the success of interventions, being health behavior heavily influenced by them. Research has proven that to educate people about healthy lifestyles is insufficient, being necessary a supportive environment that allows healthy choices or impedes unhealthy ones. To decrease CVD mortality and decrease the proportion of population at risk in developing countries, where the projected burden of disease might have a great negative impact in terms of work productivity and economic growth, a comprehensive strategy that includes interventions for people at risk as well as the population as a whole is necessary. Population wide approaches, usually based on legislation, bans and taxation could yield good results in a cost-effective manner in developing nations, however, they need governmental support and involve international trade agreements, therefore global commitment of the international community on CVD prevention is essential. Regrettably, it seems that beliefs relating the developing world with communicable diseases still exist among influential groups, impeding prevention and control of CVD.
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Because the solutions proposed to developing countries with regard to the subject by developed countries’ researchers might be difficult to apply, to strengthen research productivity in the developing world, especially on the social determinants of health and observed CVD inequalities, seems crucial to develop effective and feasible solutions. Due to the need of immediate action, the existing knowledge should be properly used for developing CVD prevention and control policies, paying attention to the already identified pitfalls. Advocacy, key partnerships and multi-sectoral collaboration are a must in this great endeavor.
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Chapter 3
The World Health Organization initiatives for CVD prevention and control
3.2
Preface During the early 1980s, WHO wanted to contribute to the existing non-
communicable disease prevention initiatives, however, to implement programs directly was out of the scope of the organization due to limited financial resources and lack of trained personnel to carry out plans on a global level. Because of these limitations, WHO’s cooperation consisted in gathering the world’s experts in prevention of noncommunicable disease in Geneva and Copenhagen, to design international policy for establishing effective programs worldwide. As a result, the global Inter Health and CINDI (country wide integrated non-communicable diseases intervention) programs were created. Based on CINDI, the Pan American Health Organization (PAHO), which is the American branch of WHO, then created CARMEN (conjunto de acciones para la reducción multifactorial de las enfermedades no transmisibles, words in Spanish for: set of actions for the multifactorial reduction of non-communicable diseases). In this way, WHO established an international policy, collaborating with their expertise to initiate programs worldwide with each country’s own resources. These programs emphasized the importance of multifactoral approaches when working on a global level, the need to involve organizations at the national and community level, and the significance of setting global policy with common protocols and guidelines and then enabling groups to implement programs accordingly (CDC, 1997). Since then, and because of the rising global burden of non-communicable diseases (NCDs), WHO’s work has evolved developing strategies and setting policies to tackle the problem, creating in 2004 the Department of Chronic Diseases and Health Promotion (CHP) to effectively respond to this growing public health problem. Specifically regarding CVD prevention and control, in 2002 WHO proposed a package to manage CVD in low-resourced settings, which targets high risk individuals but remarks the importance of environmental change.
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The evolution of the work of WHO on NCDs prevention and control will be further described in this chapter, and the main aspects addressed by the international networks of programs. The proposal of the World Health Organization for CVD management in under-resourced settings will be described in detail, its main barriers to implementation explained and its feasibility assessed. Conclusions will be drawn taking into account the issues addressed in chapter 2.
3.2
Evolution of WHO’s strategies for prevention and control of NCDs In 1998, the need to provide an effective public health response to the threat of
NCDs was recognized by the World Health Assembly (WHA), when the DirectorGeneral of WHO was requested to prepare a global strategy for NCDs prevention and control (Resolution WHA51.18). This strategy was developed and formally adopted by the 53rd WHA in May 2000 (Resolution WHA53.17).
Its proposal included the
development of networks of national programs in order to disseminate information, exchange experiences, and support regional and national initiatives for prevention and control of NCDs. The WHA 2000 requested Member States to develop national policy frameworks and to promote community-based initiatives for the prevention of NCDs through comprehensive risk-factor approaches based on the best evidence available. For strengthening integrated NCD prevention and control, particularly in low and middle-income countries, and for the networks to work in line with the Global Strategy, the Global Forum on NCD Prevention and Control was initiated, being its first meeting convened at WHO headquarters in Geneva from 12-13 November 2001. The meeting defined the objectives, functions, key areas and methods of the Global Forum on NCD prevention and control, and developed conclusions and recommendations. It was established in the Global Forum meetings that the comprehensive integrated NCD prevention and control policies should be discussed under four principal headings: health services and chronic care; risk factor interventions and health promotion in general; surveillance, monitoring and evaluation, and research and evaluation. Research should specifically include human genetics, nutrition and diet, matters of particular concern to women, and development of human resources for health In 2002, at the 55th WHA, the Resolution WHA55.23 mandated WHO to develop a global strategy on diet, physical activity and health by 2004, and to support 67
further research into ways of ensuring healthier lifestyles for all. The resolution also called on Member States, through essential public health action, to reduce NCDs behavioral risk factors (WHO, 2003**). At the 57th WHA, in May 2004, Member States endorsed the WHO Global Strategy on Diet, Physical Activity and Health, which emphasizes the need to increase physical activity levels and consumption of fruits and vegetables; and to limit saturated fats and trans-fatty acids, salt and sugar consumption. It also addresses the role of prevention in health services and surveillance systems, as well as issues that affect food and physical activity choices, such as consumer education and communication including marketing, nutrition labeling, food and agriculture policies, fiscal policies, regulatory policies and school policies.
In this assembly was also adopted a resolution
encouraging all member states to strengthen existing policies and programs related to health promotion and healthy lifestyles, giving priority to children and young people. This resolution calls to focus on poor and marginalized groups, and to give attention to prevention of alcohol-related harm. One of the main achievements of WHO is the FCTC (described in section 2.4.2), which closed for signature in July 2004, one year after being adopted by the Member States at the 56th WHA (WHO, 2004).
3.3
WHO Global Strategy for NCD Prevention and Control The Global Forum meetings have established the importance of the networks,
based on the experiences of programs such as CINDI and CARMEN, calling for effective prevention of NCDs (priority was given to CVD, cancer, diabetes and chronic respiratory disease) by targeting behavioral risk factors (unhealthy diet, tobacco use and physical inactivity). The specific objectives of the global forum include: 1. Encourage the development of national integrated NCD prevention and control strategies and programs, including community-based initiatives, surveillance and demonstration projects. 2. Support regional networks through collaboration and partnership with government agencies, NGOs and research and academic institutions.
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3. Promote collaborative research to evaluate integrated NCD prevention and control programs. 4. Identify best practices and disseminate results. 5. Set and maintain standards through the sharing of information and protocols. 6. Increase awareness of the need to invest in NCD prevention and control initiatives, and ensure that NCD prevention is placed at the top of the agenda of health care policies. 7. To contribute to training and capacity building, and develop guidance packages for NCD prevention and control, particularly in low and middle-income countries. Currently, the existing national networks are the European CINDI, which has 30 countries and the American CARMEN, with eight countries. The African region NANDI, the Eastern Mediterranean EMAN, and the South-East Asia and Western Pacific regions MOANA networks started operations recently (WHO, 2003**).
3.3.1 The Inter Health, CINDI and CARMEN programs WHO’s division of NCDs established in 1986 Inter Health, an international collaborative program with the goal of reducing risks for NCDs through multiple risk factors intervention. Its main role consisted in guidance and technical assistance to participating countries for establishing and monitoring demonstration projects, with strategies that emphasize community involvement, health promotion and maintenance activities, and behavior interventions.
The latter were conducted through existing
primary health care systems and other community structures. Inter Health member nations included Australia, Chile, China, Finland, Japan, Mauritius, Russia and United States, among others. Interventions were designed according to each country’s cultural, environmental, social and demographic characteristics, and once developed were introduced in demonstration communities as health education, health promotion and treatment programs. Program development was supported by WHO collaborating centers established in Finland, the United States, Australia, and the United Kingdom (CDC, 1997). The Inter Health Program ended with the recent development of regional networks (Nissinen et al., 2001).
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Almost at the same time as the start of Inter Health, WHO's European Regional Office launched CINDI Program following the example of the North Karelia Project and other health promotion and disease prevention programs in North America and Europe. CINDI’s main goal is “to simultaneously reduce common risk factors and achieve health improvement through the reduction of morbidity and mortality due to NCDs”, with hypertension, nutrition, smoking, elevated blood cholesterol and programs targeting youth as priority areas. To achieve its goals CINDI utilizes mechanisms that parallel those used in the North Karelia Project: •
Integrated activities by building on existing infrastructures and resources in health promotion, disease prevention and basic health care services.
•
Community outreach through mass media and public education.
•
Professional education and intersectoral cooperation between, and involvement of health and other service sectors.
•
International collaboration to share implementation experiences, results, and additional research.
•
Rigorous evaluation and research methods.
•
Policy tools to measure and effectively market evaluation results to policy makers at the local and national levels in an effort to achieve consensus and secure support. Each CINDI program follows a common protocol and common guidelines for
design, implementation, monitoring, and evaluation as they move from smaller demonstration projects to a national intervention (PAHO, 2003). Following CINDI, in 1995 was initiated CARMEN, developed by PAHO in response to an increased awareness among Member States with regard to the burden that NCDs represent. CARMEN was designed after CINDI, however it takes into account specific characteristics of Latin American and Caribbean nations. Interventions are implemented through the development of policy and practical guidelines for more cost-effective management of risk factors, professional education to reorient health services toward prevention, and marketing for political, corporate and social support for the project.
An official request for membership must be submitted by interested
countries to join CARMEN, being also necessary to design an action plan for implementation of interventions and devise an evaluation plan that follows a CINDI protocol.
The impact of the program is determined based on data on essential
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indicators, collected every 3 to 5 years by each participating country. Given the fact that significant health effects may be observed after 15 or more years, to relate the data to other program activities requires long-term observation. In the mean time, process evaluations assess how interventions work, examine cost-effective approaches to their implementation, and document their intensity and scope (CDC, 1997).
3.3.2 WHO Department of Chronic Diseases and Health Promotion (CHP) The CHP was formed in 2004 in response to the rising burden of chronic diseases and the public health challenges that they present. This department resulted from the merger of two departments, chronic disease management, and chronic disease prevention and health promotion, and the cross-cutting surveillance activities This merger was prompted by the need to strengthen and rationalize the cluster's chronic disease and health promotion activities in light of the following factors: •
The growing social and economic burden of chronic diseases in low and middleincome countries, especially those undergoing rapid economic transition.
•
The existing knowledge base on the shared causes of chronic diseases and their preventive potential.
•
The gap in implementation of this knowledge and with health promotion knowledge in general.
•
The demand for WHO to provide greater leadership and support to countries for the prevention and management of chronic diseases and health promotion (WHO,2004). CHP's work focuses on supporting Member States to develop, fund and
implement policies and programs, with the aim of: •
promoting health
•
reducing population risks
•
managing chronic disease risk
•
preventing disabilities
•
measuring progress
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The department is divided into four core areas of work under the Director.
The Global Forum on integrated NCD prevention and control belongs to the area of health promotion; and the Global Strategy on diet, physical activity and health to the primary prevention of chronic diseases area. The area of chronic diseases prevention and management is in charge of the WHO cardiovascular diseases program. The mission of this program is “to provide global leadership in the prevention and control of CVDs, and to assist Member States reduce the toll of morbidity, disability and premature mortality due to CVDs”. In this regard, the goal of the WHO Global Strategy is “to effectively control CVD risk factors and to reduce the burden of the fast growing CVD epidemic, particularly in developing countries”. The WHO Program on CVD is concerned with prevention, management and monitoring of CVD globally. It aims to develop global strategies to reduce the incidence, morbidity and mortality of CVD by: •
Effectively reducing CVD risk factors and their determinants
•
Developing cost effective and equitable health care innovations for management of CVD
•
Monitoring trends of CVD and their risk factors
(WHO NCD web site)
3.4
Cardiovascular disease management package According to WHO (2002), in order to achieve the greatest impact from CVD
prevention and control activities, a paradigm shift from the “treatment of risk factors in isolation to comprehensive cardiovascular risk management” is required.
For this
purposes, a CVD-risk management package for low-resource settings that targets high 72
risk individuals (individual approach to primary prevention and secondary prevention) was developed by WHO in collaboration with experts, aiming to “enable cardiovascular risk management in under resourced settings through affordable approaches and rational resource allocation; promote evidence-based non-pharmacological treatment and the use of generic drugs for managing cardiovascular risk; empower patients and their families to cope with a long-term illness through self-management protocols; inform policy makers of the need and feasibility of managing cardiovascular risk in less wellresourced settings”. Primarily, the package has been designed for the management of cardiovascular risk in individuals detected to have hypertension through opportunistic screening; however, it might be adapted for its use with diabetes or smoking as entry points. The rationale for this decision is that clinical indicators such as age, sex, smoking habits, history of premature CVD in the family and presence or absence of hypertension are simple and feasible risk-assessment methods in low resource settings. Cholesterol measurement as a variable for the risk stratification system proposed may not be readily available or be unaffordable in some settings. Figure 3 and 4 show an example of the risk associated with multiple risk factors profile utilized by WHO (2002) as a parameter for risk stratification and the need of a comprehensive risk assessment for targeting individuals at highest risk, improving therefore efficiency of the intervention, since for the same number of people receiving treatment, more people are likely to benefit. Given the importance of risk stratification to identify the group of patients most in need of treatment, epidemiological data on the absolute risk that patients in various categories would experience is crucial. Regrettably, these data do not exist in virtually all developing country settings, and under such conditions risk stratification might serve only a more limited purpose, serving as a ‘rule of thumb’ method for triaging the patients who are most in need. Approximations and inferences were made from existing data from developed countries (WHO, 2002).
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Figure 3: Increased cardiovascular risk associated with multiple cardiovascular risk factor profile
CHD
70 60
CHD among Low and High Risk
50
Men in the MRFIT
40 30 20 10 0
SBP* :
142
Chol*:
245
No
No
Yes
Yes
Smoking:
*SBP: systolic blood pressure; Chol: Cholesterol levels Source:Hedner,.T (1998) Treating hypertension-effect of treatment and cost-effectiveness in respect to later cardiovascular diseases. Scandinavian Cardiovascular Journal. 47:531-35
Extracted from WHO (2002)
Figure 4: The need for comprehensive risk assessment
25% cardiovascular risk reduction Rate per 1000 120
120
}
100 80 60
25 prevented per 1000 treated
100
Untreated Treated
80 60
40
40
20
20
0
0
high risk e.g. diabetes
}10perprevented 1000 treated low risk e.g. no diabetes
Source:Hedner,.T (1998) Treating hypertension-effect of treatment and cost-effectiveness in respect to later cardiovascular diseases. Scandinavian Cardiovascular Journal. 47:531-35
Extracted from WHO (2002)
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The package is meant to be implemented in a range of health-care facilities in low- and medium-resource settings, in both developed and developing countries, and for this purpose it has been designed for three scenarios that might reflect the resource availability status commonly found in such settings. Before implementing the package, the health-care centers in primary, secondary and tertiary health-care levels should be categorized into one of the scenarios, depending on the level of available facilities. The minimum conditions that characterize the three scenarios, in terms of the skill-level of the health worker and the diagnostic and therapeutic facilities and health services available, are described in Table 1 (WHO, 2002*). After the health centers are categorized according to the table, the respective protocols and referral pathways should be used for CVD risk assessment and management (the protocols will not be further described since it is irrelevant for this thesis). While the basic elements of the package remain the same across the three scenarios, the specific thresholds for clinical intervention differ across the three resource settings, according to the level of personnel and facilities available. Some of the key components of the package are the core module, which contains protocols for assessing and managing cardiovascular risk and for counseling on diet, physical activity and smoking cessation in the three scenarios; a training manual containing protocols for training health care providers to implement the package and a self-management module, which is a collection of educational materials and patient self monitoring protocols for helping patients and families to manage cardiovascular risk.
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Table 1: Characteristics of the three scenarios in the WHO CVD-Risk Management Package Resource availability Human resources
Equipment
Generic drugs
Other facilities
Skills of health care worker (training required for implementing package)
Scenario one
Scenario two
Non physician health worker
Medical doctor or specially trained Medical doctor with access to full nurse specialist care
Scenario three
- Stethoscope - Blood pressure measurement device - Measuring tape or weighing scale - Optional: test tubes, holder, burner, solution or test strips for checking urine glucose
- Stethoscope - Blood pressure measurement device - Measuring tape or weighing scale - Test tubes, holder, burner, solution or test strips for checking urine glucose and albumin
- Stethoscope - Blood pressure measurement device - Measuring tape or weighing scale - Electrocardiograph - Ophthalmoscope - Urine analysis - Blood analysis: fasting blood sugar, electrolytes, creatinine, cholesterol and lipoproteins Essential: thiazide diuretics - Thiazide diuretics - Thiazide diuretics Optional: metformin (for refill) - Beta blockers - Beta blockers - Angiotensin converting - Angiotensin converting enzyme inhibitors enzyme inhibitors - Calcium channel blockers - Calcium channel blockers (sustained release (sustained release formulations) formulations) - Reserpine and methyldopa - Reserpine and methyldopa if the above if the above antihypertensives are antihypertensives are unavailable unavailable - Aspirin - Aspirin - Metformin (for refill) - Insulin - Metformin - Glibenclamide - Statins (if affordable) - Angiotensin receptor blocker (if affordable) Referral facilities Referral facilities Access to full specialist care Maintenance and calibration of Maintenance and calibration of Maintenance and calibration of blood pressure measurement equipments equipments devices Ability to: Ability to: Ability to: - Take relevant history - Take relevant history - Take relevant history - Measure blood pressure - Measure weight - Check urine albumen and - Counsel on diet, physical - Check urine albumen and sugar activity and cessation of sugar - Measure blood pressure tobacco use - Measure blood pressure - Diagnose target organ - Recognize the need for - Diagnose target organ damage and complications referral damage and complications of hypertension through of hypertension through history and clinical - Prescribe thiazides, oral hypoglycemic agents history and clinical examination examination - Record an ECG and read - Ability to follow up hypertensives with and - Counsel on diet, physical and interpret it without diabetes activity and cessation of - Counsel on diet, physical tobacco use activity and cessation of - Recognize the need for tobacco use referral - Recognize the need for - Manage and follow-up referral hypertension and follow-up - Link with scenario 2 for diabetes referred patients - Manage and follow-up hypertension, diabetes and their complications
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The protocol-based interventions will be applied as it follows according to the scenario: • Scenario one: (Non physician health worker) -
Protocol for assessment and management of cardiovascular risk
-
Protocols for counseling on diet, physical activity and cessation of tobacco use
-
Patient record card
• Scenario two: (Medical doctor or specially-trained nurse) -
Protocol for assessment and management of cardiovascular risk
-
Protocol for management of cardiovascular risk
-
Protocols for counseling on diet, physical activity and cessation of tobacco use
-
Patient record card
• Scenario three: (Medical doctor with access to full specialist care) -
Protocol for assessment and management of cardiovascular risk
-
Protocol for management of cardiovascular risk
-
Protocol for management of cardiovascular risk in diabetics
-
Protocols for counseling on diet, physical activity and cessation of tobacco use
-
Patient record card
Because of the existing variability of conditions across countries and/or geographical areas, the tools of the package may need to be adapted to local needs (WHO, 2002*). Under the opinion of its authors, for the package to have a reasonable chance of success, the following features were incorporated: • Affordability: The package is considered inexpensive enough for less affluent patients to access and for less well-resourced public health systems to sustain. • Acceptability: Based on scientific evidence, the tools of the package are qualified as simple and user-friendly, so it will be satisfactory to individual patients, health care providers and society at large.
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• Accessibility: The available infrastructure in less well-resourced settings will be able to deliver the package, as was stated. • Applicability: The package is considered flexible and susceptible to be applied in a range of less well-resourced settings, provided supportive policy changes and feasible health system reorganization. • Achievability: The package was developed to deliver desired results when applied with appropriate changes in policy and health care organization. WHO (2002) outlines that for the package to reach its full potential in achieving better health outcomes, “many changes must be brought about in health policy, health systems, health providers, patients and their families”. They emphasize that community mobilization and participation are essential components for the successful implementation of the package and for the sustainability of the program, which represents, under their perspective, a challenge for patients in adhere to the program as well as for health workers whom need to improve their skills through a training program. Tools for improving adherence will be included in the package and is expected that patients will be supported and monitored by health care providers, this representing another challenge to them. Although the package is designed to target high risk individuals because of resource considerations, measures to address low risk individuals through population strategies are “imperative”, according to its authors.
3.4.1 Barriers for the implementation of the package An important barrier identified for the package’s implementation is the limited health infrastructure of low and middle-income countries, which in some cases might include scarce basic equipment such as blood pressure measuring devices (BPMDs). In this regard WHO, in collaboration with private industry and relevant partners, will explore the possibility of developing an accurate and inexpensive automatic BPMD for worldwide use. Other barriers that have been identified by the authors include lack of continuity between primary health care and the secondary and tertiary-care sectors, lack of awareness of the potential health benefits and costs savings of CVD programs, and the influence of commercial interests on resource allocation at health care systems. The 78
absence of formal policies, the focus on communicable diseases and lack of knowledge about the cost-effectiveness of CVD prevention were also identified as barriers. At patients’ level were mentioned local food traditions, the acceptability of prescribed exercise regimens and local rates of poverty and illiteracy. To strengthen the non-communicable diseases components in the medical curricula was suggested as a strategy to address the problem of human resources (WHO, 2002)
3.4.2 Assessment of the package’s feasibility Although evidence-based elaborated, many factors may act as powerful constraints for achieving successful results with the WHO CVD risk-management package if they are not properly addressed or considered before its implementation. To rely on patients motivation for self-management and adherence, especially to counseling for lifestyle modification, and to pose this as a challenge to both patients and health workers might lead to disappointing results and waist of resources. The excessive health worker’s work load of a disarrayed health system, which is the case of many developing countries, may influence practice even if they are strongly motivated, which usually does not occur due to the lack of incentives to provide effective care. Several issues have been identified as barriers to health professionals’ good practice and acceptance of evidence-based guidelines.
Clinicians and public
health professionals in many developing countries are trained in programs that incorporate traditional models of western medical education, being doctors who know a lot about pathology more respected by medical practitioners. Doctors also value the freedom to practice medicine as they consider is the best, therefore advocates of evidence-based guidelines should be aware that this might be perceived as a threat to this freedom. Knowledge also play a role, since practitioners often obtain information from drug representatives, they might prescribe regimens that are different and more expensive than those standardized in the guidelines issued by the World Health Organization or local health systems. Because of inadequate regulation, drug promotional activities often extend beyond ethical limits set by many western societies, being the situation worsened by the lack of effective policy regarding marketing approval for drugs in many developing countries. Another even greater constraint for 79
implementing effective healthcare practices is politics. Capital investment in new facilities and high technology equipment appeals to politicians and those who vote for them, even when these investments may be the least cost-effective (Garner et al., 1998). With regard to factors influencing patient’s adherence much was addressed in section 2.2.2, and unless these are taken into account, lifestyle counseling might not achieve the expected results. When knowledge, attitudes and practices regarding hypertension were evaluated by Aubert et al. (1998) in a developing country sample of 1067 non-hypertensive, unaware hypertensive and aware hypertensive adults, the results showed that despite having good basic knowledge related to hypertension determinants and consequences (possibly due to a nationwide CVD prevention program over the last years), favorable outcome expectation, positive attitudes and appropriate practices for hypertension and healthy lifestyles were exhibited by smaller proportions of participants, with little difference between the three mentioned groups. Even hypertensive persons with other concurrent CVD risk factors that knew well the detrimental effects of these other factors, reported to do little change to control them. In Seychelles, the developing country sampled by Aubert et al. (1998), no clear association between socioeconomic status and hypertension was found, despite this association being persistently found in other developing and developed countries. This might reflect, according to the authors, the early stage of the epidemiological transition in the developed country studied, where populations exhibit a direct relationship between SES and CVD risk. Probably later on in Seychelles’ epidemiological transition CVD risk will be more prevalent in low SES groups, as is has occurred in China and India (Gupta et al, (1994); Yu et al, (2000)). At this time would be interesting to carry out another study on population’s knowledge, attitudes and beliefs (if another type of intervention has not been performed) to observe whether interventions aiming to change behavior have a greater impact on higher socioeconomic status individuals’, as it was hypothesized by Yu et al. (2000), increasing therefore disparities in health. Hopefully by that hypothetic time, researchers may found the adequate path to prevention of CVD in developing countries, which for sure will be with a culturally-sensitive focus to behavior change. Ebrahim & Smith (1997) analysis’ of multiple risk factor intervention trials performed in developing countries suggested that health education messages should be targeted only to high risk individuals and not the population as a whole, which is congruent with the package’s proposed strategy, however this should be complemented 80
with Cupples & Mc Knight (1999) suggested constant provision of health education messages to high risk patients in order to achieve good results. The authors of the package are aware that the latter requires a great amount of constant patient’s supervision through multiple consultations, therefore, a great effort is needed to improve low SES patients adherence to treatments, targeting factors at patients and especially at health systems levels as it was analyzed in section 2.5, otherwise the CVD prevalence gap between socioeconomic levels is likely to increase. Other issues that should be taken into account are the factors involved in health workers’ adherence to guidelines and factors influencing patient’s behavior change. To consider an anthropological approach to behavior change instead of relying on patients’ responsibility and health workers’ commitment would yield better results. As experts, WHO (2002) outlined that the applicability of the package depends on policy changes and health systems reorganization. These essential components, however, because of its relevance, should be addressed with more detail. Perhaps the main aspects in need of reorganization at health systems should be emphasized in order to facilitate policy makers’ assessment of local conditions and information required to implement the package, as well as the main changes needed at policy level. Financial, technical and experts support from international organizations such as NGOs, WHO, and others related would be valuable to implement this secondary prevention package successfully.
3.5
Conclusions The existing WHO networks for NCDs prevention and control use community-
based interventions as one of their main strategies, following the example of the North Karelia Project, even though its effectiveness on risk factors’ reduction have been largely questioned in recent years by several authors, as was pointed out in section 2.4.1. Chapter one contents make clear that the worldwide CVD epidemic is mostly environmentally determined, and the analysis carried out in chapter 2 accordingly stresses the importance of environmental change through taxation and fiscal and legislative means, among other strategies, to control the toll of CVD, especially in developing countries. The experience of the Inter Health Program in Mauritius might 81
be considered as a demonstration of the latter. According to Nissinen et al. (2001), during the five-year period of the Inter Health Project in Mauritius, “a considerable effect on diet and serum cholesterol levels was observed as a result of nutrition policy and education interventions, although the rates of obesity and diabetes increased”. In this regard Ebrahim & Smith (2001) address that these increases suggests that lifestyle advice did not have the desired effects, being the noticeable effects over cholesterol levels due to fiscal and legislative actions on nutrition policy. The evidence shows that environmental change and treatment provision are effective strategies to reduce risk factors’ prevalence and incidence, therefore strengthening policy development on health systems reorganization and regulation, and legislation of food products, tobacco, and other related environmental issues should be a priority.
Reliance on population’s motivation whether for behavior change,
implementation of the management package or adherence to therapies could yield to disappointing results in the long term and misuse of limited resources. The fact that the problems for CARMEN implementation include “lack of economic incentives for physicians to contribute preventive health services, and resistance to the concept of integrated action” (CDC, 1997) might be set as an example of the latter. Prioritization for selecting interventions according to the best evidence available is extremely important because one of the main problems identified by WHO (2004) to address the burden of chronic diseases are inadequate resources at all levels. Interventions aiming to change behavior among the population at low risk through health education without tackling its main determinants might not be the best way to use scarce resources. Since globalization and urbanization are recognized as determinants of the rising burden on NCDs, their impact over health should be assessed globally and at local level, and global marketing of health-compromising products regulated. For this purposes would be also important to set as a research priority to study the effects of these determinants over health, which was discussed in detail in section 2.6.2, and is not included in the Global Forum research areas. The role of WHO in setting priorities and policies internationally and locally, as well as in partnership and intersectoral collaboration should be emphasized because, as was discussed in section 2.4.2, for developing countries’ governments to take decisions about tobacco, alcohol and food trade, the support of the international community is essential. The FCTC can be set as an example of the important role of WHO in setting global norms. 82
Chapter 4
Cardiovascular disease in Chile
4.2
Preface Chile has experienced a sustained economic growth in the last decades, which
together with the well known globalization and urbanization processes determined the current status of the epidemiologic transition, where mortality and prevalence rates due to diseases characteristic of underdevelopment (infectious diseases, malnutrition, etc) are very low, life expectancy have substantially increased, almost reaching figures exhibited by developed countries, and chronic non-communicable diseases (NCDs) are the main cause of death and disability. The study of the global burden of disease carried out in Chile in 1995 showed that NCDs were the main health problem in the country, accounting for 73% of the total DALYs lost (Escobar and Legetic, 2001). Among NCDs, CVD are currently the main cause of death and disability in Chile, with almost one third of deaths corresponding to this cause. Correspondently, the prevalence rates for behavioral and biologic risk factors is very high, with only a little percentage of the hypertensive and diabetic population under any kind of treatment, and among the latter an even smaller percentage have their blood pressure and glycemic levels within normal ranges. The distribution of risk factors among the population is not randomized; as it occurs in developed nations, CVD risk factors are progressively becoming more prevalent among the less educated and less affluent segments of the Chilean population. This situation and its determinants will be further described and analyzed in this chapter. Afterwards, conclusions will be drawn. The main demographic and economic insights are described in appendix A. Appendix B contains a description of the main aspects of the Chilean health system.
4.2
Cardiovascular disease indicators and CVD risk factors in Chile Murray & Lopez (in Aboderin et al, 2001) predicted that by 2020, 33.8% of
deaths in the developing world are expected to be due to CVD. This prediction became
83
a reality in Chile in 2002, where 33.1% of deaths were due to CVD. Most of these deaths were caused by coronary heart disease (29.1%), cerebrovascular disease (28.1%), and acute myocardial infarction (21.7%) (DEIS, MINSAL). There is an important variation in cardiovascular mortality throughout the country. An important factor associated with this is the different degree of population aging across the regions, which persists after adjusting for age. Differences in risk factors prevalence between regions might also explain this variation. Premature death due to this cause in Chile is low, with 56% of deaths occurring after 75 years of age (MINSAL, 2002). According to PAHO (2000), a significant decrease in DALYs lost due to CVD has been observed from 1960 to 1994 in USA, Canada, Argentina and Chile, however, the number of cases is increasing because of population aging, which represents an important burden for health services. The proportion of deaths due to CVD increased progressively from 1970 (22.3% of all deaths) to 1992 (29% of all deaths), being stabilized around 30% afterwards. This proportion is higher than the average observed in developed countries (19%) (Alabala et al., 2002) A decreasing trend in cardiovascular mortality has been observed in the last decade, with a 28% decrease in the risk of dying. There has been a greater decrease in women compared to men (32% versus 24%) (MINSAL, 2002). The specific causes of the decline in mortality are not well known; however are mostly attributed to medical progress in therapies for cerebrovascular disease and coronary heart disease. Nevertheless, mortality rates due to diabetes and hypertension have increased, revealing that these problems have not been properly addressed (Medina & Kaempffer, 2000). The decrease in cerebrovascular disease and coronary heart disease mortality rates shows a marked inverse social gradient for both, cerebrovascular disease and coronary heart disease, with higher mortality rates among those with less scholar years. For both diseases the gap in scholar years is greater in women than in men, and greater for cerebrovascular disease. In men this gap is evident for cerebrovascular disease. Mortality due to this cause is greater in men than in women among groups with more years of education; however, this relationship reverses among groups with less years of education, where women exhibit higher mortality rates. This situation might be due to differences in the incidence of the disease, differences in biological risk factors prevalence, or inequities in access to risk factors’ control and prevention and to health services (PAHO, 2000). 84
Because not all cerebrovascular disease events are fatal, and even in settings with advanced technology and facilities, the prognosis for those who have suffered an event is poor, becoming afterwards dependent on their families and /or societies (WHO, 2002).
In Chile, because of the mortality distribution already described, this
dependency situation is probably more common among the less educated, and therefore less affluent segments of the population. Due to the lack of facilities for the elderly, mostly supported by charity organizations, the support and care of the stroke victims will rely on their families. It is likely that this situation will have repercussions on the family structure and financial resources of those affected with the problem, and therefore contributing to the high stress levels characteristic of the less affluent segments of society.
4.2.1 Cardiovascular disease risk factors in Chile. Because CVD is the main cause of death in the country, it is not surprising that the prevalence of behavioral and biological risk factors is quite high. Among the latter, especial attention should be paid to the population with hypertension because they exhibit also a high prevalence of obesity and high cholesterol levels. With regard to behavioral risk factors, dietary patterns have increased its saturated fat and sugar content, alcohol consumption is very high, physical activity low, and tobacco consumption are increasing. The first national health survey (NHS), or ‘Encuesta Nacional de Salud’ carried out by the Ministry of Health in 2003 revealed that the prevalence of high global cardiovascular risk (according to the Framingham criteria) is 55%, being no differences between urban and rural.
4.2.1.1 Behavioral risk factors
•
Unhealthy diet and alcohol consumption. The Chilean economic growth have improved low income groups’ accessibility
to food, and although some poor subgroups of the population still have problems of economic accessibility to food, most dietary problems are related to excess. A study of 85
food availability at the household level in six poor subgroups carried out in 1991, 1993 and 1996 revealed an important increase in the overall caloric intake. A survey to assess food intake carried out in Santiago in 1995 revealed a very low consumption of legumes and fish (despite the large sea cost of the country), low consumption of fruits, milk and cereals and a relatively high consumption of sugar, meat, oil and fat. The figures show that from 1980 to 1995 meats and sausage consumption increased 74.5% and 182.8% respectively, while beans consumption decreased 55.5%. Despite the level of per cent energy from fat in Chile was lower than the percentage observed in developed countries, was over the recommended limit of 25% (Vio & Albala, 2000). Among low income groups, the main expenditure in food products is for meat, which contains a high proportion of saturated fat, bread and soft drinks, which are rich in sugar. In 1995 in Santiago, 70% of adults consumed less than two fruits and 59% consumed less than two portions of vegetables per day (Albala et al., 2002). With regard to alcohol consumption, its prevalence progressively grew from 60.6% in 1994 to 70.8% in 1998. In 1999, 12% of the Chilean population older than 12 years of age were heavy drinkers (MINSAL, 2002), being hepatic cirrhosis the fourth cause of death in the country (Medina & Kaempffer, 2000). Alcoholism is more frequent among men and unemployed or irregularly employed people (PAHO, 1998). The results of PAHO-CARMEN survey of risk factors’ prevalence for chronic noncommunicable diseases carried out in Valparaiso (the second largest city) by Jadue et al. (1999) reveals that although men consume more alcohol than women, according to the Framingham criteria, consumption is high for both sexes, and if the same criteria are applied to the male population, an exaggerated consumption is observed among groups between 45-64 years of age and low socioeconomic status. About 90% of consumers drink in social occasions and 9% drink being alone. Most drinkers in Chile usually consume alcoholic beverages during the weekends (Diaz et al., 2003). Heavy alcohol intake increases the risk of cardiovascular death, being important not only the amount drank but also the pattern of drinking. While heavy alcohol intake might induce hypertension (Bovet & Paccaud, 2001), a pattern of binge drinking, which usually occurs on weekends, is associated with sudden cardiac death (Britton & McKee, 2000). Although there are no studies that relate the pattern of drinking with the high proportion of acute myocardial infarction deaths in Chile (21.7% of cardiovascular deaths), there is room to hypothesize that they might be related. A study carried out by Diaz et al. (2003) revealed that in Chile a high alcohol intake (> 402.5 g/week) 86
increases the risk of hemorrhagic stroke (this type of stroke is related mostly to hypertension) more than 4 times. Because of the percentage of heavy drinkers in the country, which is an important wine producer, and the pattern of drinking in Chile, alcohol consumption should be regarded as an important risk factor for CVD.
•
Physical inactivity Different studies on representative samples show that physical inactivity in Chile
has been quite high in the last decade, showing almost no variation (Albala et al., 2002). The NHS (2003), conducted in a national representative sample, classified as sedentary to a person if he/she performed physical activity out of working hours at least 30 minutes, three times per week. According to those criteria, sedentary behavior reached 89% of the population, being greater in women (91%) than in men (88%), and decreasing as educational level and SES increase. The first national survey of quality of life and health, or ‘Encuesta Nacional de Calidad de Vida y Salud’ (NSQLH) (2000) reported that only 8% of the population performs physical activity or practices sports at least 30 minutes, three times per week, and an average of 75% does not practice any sport. The main reasons argued for not practicing sports was lack of time (32.5%), lack of motivation (23%), and health problems (21.4%), being the latter more common as age increases. Physical inactivity among children is also high. A study carried out by Kain et al. (1998) revealed that both obese and normal children spend more than three hours in front of the TV every day, which increases to four hours on holydays.
•
Tobacco consumption Tobacco consumption in Chile has evolved following the distribution trends
already described in chapter one for developing countries such as China and India, which replicate the pattern of developed countries. The prevalence of smoking has shifted from the higher to the lower socioeconomic groups, and is increasing mostly among youth and women; however it is more prevalent in urban than rural populations, in opposition to the urban-rural distribution exhibited in most developed countries. From 1971 to 1984 smoking prevalence increased from 36% to 41%, being higher among people in the highest socioeconomic group (40.4%) compared with those in the lowest strata (19.8%). The National Household Survey of 1990 reported a higher 87
prevalence of smoking among urban adults (33%) compared with rural adults (23.1%), being also more prevalent among men (50.7% for men and 37.2% for women, 43.7% overall) and among the group aged 30-34. The prevalence of smoking among pregnant women was found to be 26.4% (WHO, 1997). The 1994 survey revealed the first changes in the Chilean’s smoking patterns, where a slight decrease in the prevalence among men (47% to 44%) and an increase in prevalence among women (36% to 41%) were observed (PAHO, 1998). Alvarado & Talavera (2003) analyzed the data of the population–based survey that since 1994 is performed every two years by the National Council for the Control of Addictive Substances, or ‘Consejo Nacional para el Control de Estupefacientes’, (CONACE). This survey includes national samples of people aged 12-64. From 1994 to 2000 the overall prevalence rate grew from 45.8% to 48.7%, and although women exhibited lower prevalence rates, their growth rate (9.39%) more than doubled the growth rate observed among men (4.14%). With regard to incidence, a growing trend is observed between 1996 and 2000, being the growth rate considerably higher for women (38.46%) than for men (5.98%). The 2000 survey shows similar prevalence rates between the different socioeconomic strata of the population; however, the evolution within each category between 1994 and 2000 has been quite different. The high SES group exhibits a decrease in the prevalence rate of 11.41%, while the lowest SES group shows an increase of 34.35%. Table 2 illustrates this evolution.
Table 2:
Prevalence of smoking by socioeconomic level in Chile between 1994 and 2000 (CONACE)
Socioeconomic level
1994
1996
1998
2000
High
52.6%
55.3%
42.9%
46.6%
Medium-high
47.0%
44.0%
46.6%
48.8%
Medium
46.2%
47.3%
48.1%
49.2%
Medium-low
44.8%
49.0%
47.5%
48.5%
Low
36.1%
42.8%
48.8%
48.5%
Total
45.8%
47.5%
47.1%
48.7%
Extracted from: Alvarado, R., Talavera, G. (2003) The tobacco epidemic n Chile: its evolution during the last decade. Rev. Chil. Salud Pública. 7(2): 69-73
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The analysis made by Alvarado & Talavera (2003) revealed that the group aged 19-25 showed the highest prevalence rates between 1996 and 2000, while the lowest prevalence rates were exhibited by the groups aged 12-18 and 45-64. Regrettably, between 1994 and 2000 the figures show that the groups with the lowest prevalence rates show the highest growth rates: 16.88% in the group aged 45-64 and 13.91% in the group aged 12-18. A study carried out by Valdivia et al. (2004) in a representative sample of 15,119 students with less than 18 years of age report similar findings. Their study revealed that the mean age for the first contact with smoking was 12.3 years and for the starting of the habit, 13.2 years. High prevalence rates were detected mainly in women and students of lower socioeconomic level. The authors conclude that in Chile the risk for smoking starts early during school life, being greater for smokers’ children. Of special importance for the risk of smoking in childhood was current or irregular smoking habit of the mother. The most recent data, from the NHS (2003), confirms the above-mentioned trends. Chile exhibits an overall smoking prevalence rate of 42%, with the highest consumption among youth (55% in the group with less than 25 years of age). Smoking prevalence in rural areas is lower (35%) than the observed in urban areas (44%). On average, women smoke less than men (49% and 66% respectively). There were no significant differences by SES in smoking rates, however, among women smoking rates tend to increase as SES does.
People with less than eight scholar years smoked
significantly less (25%) than people with more than 12 scholar years (47%).
4.2.1.2 Biological risk factors
•
Overweight and obesity Over the past two decades Chile evolved from high undernutrition and low
obesity rates, to the virtual eradication of undernutrition and high obesity prevalence in all age groups. Undernutrition rates among children under the age of 6 years have shown a sustained decrease, being currently very low, and a decrease in the rate of stunting has been observed, as well as a decline in the prevalence of low birth weight (under 2500g), currently about 5% of all births. On the other hand, obesity prevalence has doubled in pre-school and school-aged children over the past decade, reaching prevalence rates of 17% for boys and 18.6% for girls in 2000, as shown in figure 5. The 89
situation of pregnant women has also evidenced dramatic changes. The prevalence of undernourished mothers decreased from 26% in 1987 to 14.1% in 2000, while obesity increased from 12.9% to 32.7% among this group in the same period (Albala elt al., 2002). In Chile there is a close relationship between obesity in mothers and in their off springs (Bunout & Escobar, 2000) A progressive rise in obesity rates among adults is also observed in the last decades. Two surveys conducted in 1988 and 1992, with the same methodology among representative samples in Santiago revealed marked increases in obesity rates, being this higher among women (Berrios et al., 1990; Berrios, 1994) Various studies have estimated obesity prevalence rates among females from 23% to 25%, while males’ obesity ranges from 13% to 18% (PAHO, 1998).
Figure 5 Prevalence of obesity in first grade school children in Chile 1986-2000 (Obesity defined as weight/height > 2 SD of the National Center for Health Statistics (NCHS), WHO reference)
Source: Albala, C., Vio, F., Kain, J., Uauy, R. (2002) Nutrition transition in Chile: determinants and consequences. Pubilc Health Nutrition. 5(1A): 123-128
The PAHO-CARMEN survey carried out in Valparaiso by Jadue et al. (1999) reported that 60% of the population was overweighed (BMI ≥ 25) and 19.7% was obese (BMI ≥ 30). Both overweight and obesity increased with age, were more prevalent in
90
women than in men, and among women of low SES, where obesity prevalence reached 28.9%. The most recent data from the NHS (2003) confirms the rising trend for both overweight and obesity. Although women exhibit higher rates of obesity (25%) compared to men (19%), the figures indicates that overweight prevalence rates among men are higher (43.2%) than among women (32.7%).
This study did not show
significant differences in obesity rates by SES, although there is an increasing trend as SES decreases, however the differences observed by educational level were quite significant and especially among women, where the prevalence of obesity among the group with low educational level more than doubled the prevalence rate found among the groups with high educational level (34.9% and 15.3% respectively). The 2.3% prevalence rate of morbid obesity (BMI ≥ 40) among women with poor education of low SES is quite alarming. While overweight is slightly more prevalent in rural areas, obesity is higher in urban areas.
•
Hypertension Hypertension in Chile is the main cause for medical attention at the primary
level in the public sector, and reaches approximately 10% of the total consultations. Various studies carried out from 1986 to 1997 have examined the prevalence of hypertension in the country (systolic pressure ≥ 140 mm hg and/or diastolic pressure ≥ 90 mm hg), revealing that there is a high proportion of hypertensive people, which is higher in rural than in urban areas (Berrios et al, 1990, Jadue et al., 1999; Vega et al., 1999). In the PAHO-CARMEN risk factors study conducted in Valparaiso, the adjusted prevalence of hypertension was 11.1%. Prevalence rates increased with age, and although women exhibited lower rates at younger ages, this trend reverses after 44 years of age, reaching 27.4% in the group aged 55–64. As observed with obesity distribution in the same study, prevalence rates are higher among low SES individuals, being greater among women (15.1%) (Jadue et al., 1999). It is known that high levels of salt consumption increase the risk of hypertension, and in this regard it is noticeable that the results of the CARMEN survey reported by Vega et al. (1999) show that 16.5% of those interviewed, and 9.5% of the population sampled for the NSQLH (2000) added salt to their meals before determining the need.
91
The NHS (2003) shows an overall prevalence of hypertension of 33.7%, with 33.3% urban and 39.6% rural.
These figures are probably overestimated because
corresponds to two blood pressure measurements in the same day over the above mentioned levels considered as normal, not a diagnosed hypertension, however are indicative of population trends. The prevalence rate also considers individuals who reported being under pharmacological treatment for hypertension but with normal blood pressure levels. Hypertension prevalence rates increases with age and are greater among men than among women at almost all ages (30.8%, and 36.7% respectively). In population over 65 years of age, women exhibit higher prevalence rates.
As with obesity
prevalence rates, there are no statistically significant differences by SES, but an increasing trend is observed in the lower strata, however there are considerable differences according to the educational level. The prevalence rate of hypertension among women with less than 8 years of education is more than five times greater than the prevalence rate found in their more educated counterpart (53.3% versus 9.1%). For men this difference is smaller, with a prevalence rate of 56.5% among low educated men versus 31.7% among men with more education. Among the population with hypertension the prevalence of elevated blood cholesterol, overweight and obesity and physical inactivity was higher than among the non hypertense ones for both men and women after adjusting for age, sex and educational level, however, physical inactivity did not reach statistical signification after the adjustment. The exception to this higher prevalence of CVD risk factors among the people with hypertension is smoking, which was less prevalent in this group. Among the population with hypertension, only 11.8% were controlled, which means that exhibit adequate blood pressure levels. With regard to hypertension treatment, knowledge about their condition and blood pressure levels control, the situation is different for men and women, which is illustrated in figure 6.
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Figure 6: Knowledge, treatment and control of hypertension in Chile (2003)
80% 70%
74,70%
59,80%
60%
54,60%
50% 40%
46,80%
36,30%
30% 19,10%
20%
11,80% 20,40%
10% 5,40%
0%
Knowledge
Treatment Country
Men
Control Women
Extracted from: Ministry of Health of Chile (MINSAL). The National Health Survey 2003
•
Diabetes and Metabolic syndrome Type 2 diabetes is the primary or associated cause in a rising number of hospital
admissions in the country. In 1990, 11,650 patients were hospitalized for diabetes mellitus, a rate of 8.8 per 10,000 population and 35.8 in the group aged 45 and over (PAHO, 1998). Diabetes in Chile showed a prevalence rate of 3.9 % in Valparaiso, showing no significant differences by sex or SES. As is expectable, higher prevalence rates were found in the group aged 45 and over (Jadue et al., 1999). Similarly, in 2003 the NHS reported a prevalence rate of 4.2%, with 4.8% for men and 3.8% for women, with virtually no urban-rural differences, however higher prevalence rates were exhibited by the low SES and less educated group. Prevalence is 0.1% among the population younger than 44 years of age, rising to 9.4% among the group aged 45-64, and reaching 15.2% in the group older than 64. As with hypertension, only a small proportion of the diabetic population is controlled and shows normal levels of blood sugar (glycemia), which is illustrated in figure 7.
93
Figure 7: Knowledge, treatment and control of diabetes among the adult population in Chile (2003)
100%
88,50% 91,20%
90% 80%
74,50%
86,10%
70%
76,50%
72,90%
60% 50% 40% 30%
19,70%
21,30%
20% 18,40%
10% 0%
Knowledge
Treatment
Country
Men
Control Women
Extracted from: Ministry of Health of Chile (MINSAL). The National Health Survey 2003
The metabolic syndrome, a complex variable that indicates high risk for the development of diabetes, showed a 23% overall prevalence rate, with almost no differences between men and women. As diabetes, it increases progressively with age in both sexes, reaching 48% among people older than 65 years of age. Its prevalence shows a distribution among SES and educational level similar to diabetes, however, after adjusting for age and sex there were no significant difference in the risk (odds ratio) between the different groups.
•
High cholesterol Studies carried out before the PAHO-CARMEN survey in Valparaiso reported
that cholesterol levels increased with age and income (Albala et al., 2002), however, this survey showed no differences by SES or sex, with an overall prevalence rate of high cholesterol level (> 200 mg/dL) of 39% (Jadue et al., 1999). The NHS (2003) reported an overall prevalence of 35.4%, with only slight differences between men and women, however there is a trend to exhibit adverse cholesterol levels among men with high SES group. When cholesterol levels were analyzed by educational level, it was observed that both men and women with poor 94
education and men with high educational level showed an adverse cholesterol profile compared to the group classified with medium educational level. A slight but not statistically significant difference was found between urbanrural prevalence, being higher among urban population (35.9% versus 31.3%). The national average cholesterol level increases over the recommended 200 mg/dL in the population older than 44 years of age.
4.3
Determinants of CVD risk factors in Chile Much was addressed in chapter one and especially in section 1.7 with regard to
CVD risk factors determinants. The review of the relevant literature in the field allowed to conclude that most of the risk is environmentally determined, being mainly the consequence of macroeconomic changes and the globalization and urbanization processes. The improvements in economic circumstances in Chile that lead to important demographic changes, as well as the growing urbanization process experienced by the country in the last decade ( described in appendix A) gives enough room to think that the Chilean environment might be a risk-inducing one. The studies carried out by Uauy et al. (2001) might be considered as a demonstration of the environmental determination of CVD risk factors in Chile. They revealed that indigenous Mapuche that live in rural areas, preserving ethnical and cultural distinctive characteristics, exhibit lower prevalence rates of obesity, diabetes and glucose intolerance than Mapuche population living un urban areas. Especially noticeable was that the 4.1% prevalence of diabetes in rural Mapuche was more than doubled by urban Mapuche, reaching 9.8%. The existing tobacco control provisions might constitute another example of high environmental exposure to risk.
Smoking is banned only on transports, and
although some forms of advertising are restricted (Shafey et al., 2003), comprehensive advertising and promotion bans are necessary to reduce demand (The World Bank, 1999); limited or partial bans have little or no effect (Myers & Wilkenfeld, 2001). Shafey et al. (2003) described in detail the existing infrastructure for tobacco control in 196 countries around the world, including Chile. The status of tobacco control provisions described for the country are described in table 3.
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Table 3: Infrastructure for tobacco control in Chile Not Banned Restricted Regulated Unknown
Tobacco Bans and restrictions
X
Advertising in certain media
Advertising health warnings/ messages
X
Advertising to certain audiences Advertising in certain locations
X
Advertisement content or design Sponsorship or promotion for certain audiences Sponsorship advertising of events
X
Tobacco requirements and regulations
Not Banned Restricted Regulated Unknown
X X
Age verification for sales
X
Manufacturing licensure
X
Package health warning/message
X
X
Label design on packaging
Band stretching
X
Sales to minors
X
Ingredient/constituent information on package label
Sales by minors
X
X X
Amount of tar
X
Place of sales
X
Amount of nicotine
X
Vending machines
X
Amount of other ingredients/constituents Product constituents as confidential information Product constituents as public information
X
X
Free products X
Single cigarrte sales Misleading information on packaging Smoking in government buildings (incl. work sites) Smoking in private work sites
X
Smoking in educational facilities
X
X
X
X
Constituent disclosure by brand
X
Constituent disclosure in the aggregate
X
X
Smoking in health care facilities
Other Provisions
X
Smoking on buses
X
National tobacco control committee Tobacco control education/ promotion Anti-smuggling provisions Litigation enabling provisions
X
Smoking on trains Smoking in taxis
X
Smoking on ferries
X
Smoking on domestic air flights Smoking on international air flights Smoking in restaurants
X
Yes
No
Unknown
X X X X
X X
Smoking in night clubs and bars
X
Smoking in other public spaces
X
Source: Shafey, O., Dolwick, S., Guindon, G.E.(2003). Tobacco control country profiles. American Cancer Society, Atlanta, GA
As is possible to notice from the table, tobacco regulations in Chile are poor, especially regarding advertising and restrictions for sales to minors. Of the 3,150 school students sampled in Santiago (where 40% of the Chilean population lives) in 2000 for the Global Youth Tobacco Survey (GYTS), 60.2% of those who smoked bought cigarettes in a store, and 88.1% of them were not refused purchase because of their age. The study also revealed that 88.2% of the students saw pro-cigarettes ads on billboards in the past 30 days, and 80.7% saw this kind of ads in newspapers or magazines within the same period. Anti-smoking media messages were seen by 76.2% of the students, however, only 23.2% of them have been taught in class during the past 96
year about the dangers of smoking (Caris, 2001). As was addressed in section 2.4.2, environmental change through policy interventions for regulation, taxation and banning have greater impact on tobacco use than interventions targeting individuals. The level of exposure of different population groups to adverse environmental conditions depends, however, on the prevailing, economic, cultural, political and social context, as was discussed in section 1.4.3. Even though the relative role of the social context is not yet well understood and needs to be further researched (Aboderin et al., 2001), its analysis might give a clue with regard to the determinants of CVD inequalities (Beaglehole et al., 2001). Under the different perspectives that social epidemiology utilizes to gain clarity on causes of social inequalities in health, psychosocial stress and low social support, economic and political determinants of health and integrative perspectives of social and biological aspects seek to develop new insights into the determinants of populations’ distribution of disease (Krieger, 2001). Recent research suggests that income inequality per se (i.e., the existence of inequality in the society or group to which a person belongs), regardless of the absolute individual income, is related to an individual’s health status (Subramanian et al., 2003; Lynch et al., 2000). Issues like the degree of influence of country level and community level inequality over health are not yet clear, as well as the interpretation of the links between income inequality and health. These interpretations are related to individual perceptions of inequality (psychosocial stress), and to structural causes of inequalities (economic and political determinants). The former explains this association through the psychosocial stress generated by the perceptions of place in the social hierarchy, based on the relative position according to income.
Stress increases biological susceptibility to disease via psycho-neuro-
endocrine, as well as induces behaviors such as overeating, smoke and social isolation, which in turn will be reflected in less social capital and cohesion within the community at societal level. The interpretation of the latter says that health inequalities are sourced in the material world, being the result of historical, cultural and political economic processes that influence the private resources available to individuals and shape the nature of public infrastructure such as education, health services, environmental control and availability of food among others (Lynch et al., 2000).
Regardless of which
interpretation reflects reality more accurately, it remains clear that psychosocial stress levels and cultural and political processes might potentially influence an individual’s health status (integrative perspective). Diex-Roux (2000) studied the influence of 97
income inequality particularly on CVD risk factors in U.S., because of their strong social position patterning, and found positive associations with obesity, physical inactivity and high blood pressure at low levels of individual-level income. Because Chile is progressively following the developed countries’ trend of distribution of CVD risk factors among the different social strata, with obesity and hypertension clustering among the less privileged segments of the Chilean society, especially women, and tobacco consumption rates rising mostly among women and youth of low SES (detailed in section 4.2.1), it is worthy to analyze the above mentioned factors: income inequality, psychosocial stress and cultural, economic and political processes.
4.3.1 Income inequality, psychosocial stress and the economic and political processes in Chile The course of the economic improvement that Chile experienced in the last decades, where neoliberal economic models were implemented during the 80s and 90s under the military government (1973-1990) following the advice of the Chicago school, increased the existent economic inequalities (Subramanian et al., 2003), which still persist and nowadays are reflected in considerable income inequalities and inequity between social groups (detailed in appendix A). On the other hand, the health care system reforms carried out within the same period, where a private sector was developed, conditioned also inequalities regarding financial contribution to the health system and access to health care (detailed in appendix B). Despite the efforts made by the democratic governments after 1990 to improve equity in the health sector, in Chile there are still considerable geographical differences with respect to mortality and other health outcomes, environmental conditions, and access and utilization of health care services (Arteaga et al., 2002). Differences between genders are consistent as well with regard to income, access to health services and financing of health insurance. Women’s salaries are 30% lower in all socioeconomic strata, they use health services 1.5 times more often, and in the private health sector, women pay higher insurance premiums than men (Vega et al., 2003) Chile is one of the 10 countries in the world with the most unequal distribution of income (Araya et al., 2003), and one of the most unfair health systems (Manuel, 2002), which has had repercussions on self-rated health status (Subramanian et al., 98
2003) and therefore on health-care seeking behavior, increasing the burden on health services (MINSAL, 2002). Recent studies carried out in Chile reveals high levels of psychosocial stress, hostility and depression, among different groups of the population. The NHQLS (2000) shows that 34% of the population feels stress and 10% frequently feel hostile impulses; only 57% have social networks for emotional and economic support and 46% belongs to social organizations, which is low compared with developed countries like USA, where 70% of the population belongs to such organizations. The average degree of satisfaction with life is in the limit of the qualification ‘good’. The country has low levels of interpersonal trust (22%) compared with developed nations, where between 60% and 80% of the population trust others (MINSAL, 2002).
4.3.2 Psychosocial stress, depression and its relationship with CVD risk factors in Chile. Previously on this thesis was discussed the relationship between CVD and stress and depression, and although psychosocial stress and depression are not currently considered as cardiovascular disease risk factors, recent research has progressively revealed a strong association between stress, depression and the incidence of stroke and CHD (described in section 2.6.2). The prevalence of mental health problems in Chile has increased substantially in recent years (PAHO, 1998). The figures from the NHS (2003) revealed that 17.5% of the population had depressive symptoms within the last year, being more prevalent in the age group 25-65 among women of medium-low SES (26.8%) and among residents of urban areas when compared to rural. There were no significant differences by educational level. Only 39.2% of the population with depressive symptoms consulted a physician, but great differences in the consultation rate among socioeconomic groups were observed; 74.3% of people of high SES consulted versus 34%-36% in the other strata. Medication, drugs and alcohol were used by 41.8% of the people in this group, being more frequent the consumption among men, with no differences by SES, educational level and between urban and rural. While 71.7% of the population without depressive symptoms perceives their quality of life as good, only 38.7% of depressive people do give the same qualification. 99
Poor housing quality, a recent income drop, and low level of education were associated with a high prevalence of common mental disorders such as depression among the most socially disadvantaged groups (Araya et al., 2003). Araya et al. (2002) carried out the first study that relates depression and CVD in Chile, in a small group of patients (42) with acute myocardial infarction. They found among these patients a significantly greater prevalence of major depression in the six months previous to the coronary event than among the general population older than 40 years of age (28.6% versus 15.4%). Despite the small sample size of the Chilean study (the only found in Medline, Pubmed and Elsevier databases that studies this association in the country), this association should be taken into account and further studied in the country, as well as the social factors that lie behind the distribution of income, stress and depression among gender and socioeconomic groups.
4.4 Conclusions The recent economic development experienced in Chile has conditioned great changes in the population epidemiologic profile, with a marked decrease in prevalence rates of diseases characteristic of underdevelopment and an increase in the prevalence of the so called “diseases of affluence”, with CVDs being the main cause of death and disability in the country. The globalization and urbanization processes typical of more affluent societies have established population lifestyles and environmental conditions that difficult healthy choices, especially with regard to tobacco consumption. The recent decline in CVD mortality rates due to medical improvements in therapies, together with the increased life expectancy in the country will determine greater disease prevalence rates, especially among the elderly, and longer periods of exposure to adverse behavioral and environmental conditions will worsens the situation, increasing the demand of health care services. Because the Chilean Health System is structured in such a way that fosters unequal access to health care, the increased demand might increase the existing inequalities in the distribution of CVD risk factors among the different segments of the population. As it has occurred in developed societies, the CVD epidemic in Chile tends to cluster among the socially deprived groups. Hypertension prevalence rates are higher 100
among the less educated segments of the population, and within the same group, prevalence rates for obesity are also higher, especially among women. With regard to behavioral risk factors, physical inactivity shows a marked socioeconomic and educational gradient, being also more prevalent among women, and smoking is progressively increasing among youth and women of low SES. Because behavioral risk factors are growing among the most disadvantaged Chileans, biological risk factors will grow among them in the same proportion. Their limited access to health care will therefore determine a situation where the burden of CVD will be progressively concentrated among the socially disadvantaged groups of the society, and especially women. Because of the already exposed arguments with respect to the Chilean Health care System preventive measures are urgent, and these should be oriented to prevent its incidence rather than control its prevalence. Preventive measures utilizing populationbased strategies might control CVD risk factors’ incidence if targets the determinants of the problem, as was already explained previously on this thesis. Because most of the risk in Chile is environmentally and socially determined, preventive policies should focus on improving environmental conditions that fosters unhealthy behaviors, and the social factors that increase the exposure of certain segments of the population to adverse environmental conditions. Although there are no certainties with regard to the paths that relate societal factors with the distribution of disease among the different groups of the population, it is clear that stress levels and depressive symptoms are related to CVD, and that income inequality is associated with health status and might also be with CVD risk factors distribution among the population. Despite the lack of studies on these subjects in Chile, because of the high levels of stress and depressive symptoms among the population, and the great existing income inequalities in the country and within communities, those aspects should at least be considered for the design of comprehensive policies aiming to improve the Chileans’ health status. Evidence-based health policies that integrate mental health and CVD incidence prevention, and especially social policies that consider health in the policy-making process would yield good results. To control CVD risk factors incidence in Chile, healthy public policies are essential to modify the existing environmental conditions and the social factors that determine the levels of exposure to an adverse environment, however, is necessary first to place health higher in the political agenda, because in many developing countries it 101
appears that economic factors are currently modeling the policy making process, and Chile might not be the exception. Because Chile is a developing country, depends on developed countries’ economic decisions and the support of the international community for the achievement of this task.
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Chapter 5
Strategies for CVD prevention and control in Chile
5.1
Preface One of the main health objectives defined by the Chilean government and
Ministry of Health for the 2000-2010 decade is to reduce death and disability due to CVD. The specific impact objectives are: (MINSAL, 2002) •
To decrease CVD mortality in 18%
•
To decrease mortality due to coronary ischemic disease in 30%
•
To decrease mortality due to cerebrovascular disease in 27%
To achieve these goals it is necessary to control biologic and behavioral CVD risk factors’ prevalence and incidence. For these purposes primary and secondary prevention approaches are utilized as strategies.
Primary prevention considers a
population-based intervention to target behavioral risk factors, the National Health Promotion Plan (NHPP), and an individual-based intervention for biologic risk factors’ early detection, the “ESPA” (‘Examen de Salud Preventivo del Adulto’, words in Spanish for adult’s preventive health exam). The secondary prevention strategy is made of a CVD management program to provide treatment for biologic risk factors and to prevent recurrences of cardiovascular non-fatal events, the Cardiovascular Health Program (CHP) or ‘Programa de Salud Cardiovascular’, implemented at primary care level and structured under the advice of WHO/PAHO and the existing CARMEN network. The WHO/PAHO Inter Health and CARMEN programs are also carrying out demonstration activities in several regions of the country to contribute to the development of strategies for prevention and control of NCDs in Chile. This chapter will describe each one of the interventions utilized, as well as the work of the WHO/PAHO programs in the country, reported outcomes and constraints for its implementation. The adequacy of the strategies and potential impact on the control of CVD risk factors’ incidence and prevalence will be assessed based on the findings of previous chapters. Afterwards, conclusions will be drawn.
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5.4
Population-based approach to primary prevention: The National Health Promotion Plan In response to the epidemiologic transition observed in Chile, the Ministry of
Health redefined the health priorities for the country in 1997. Since most of the health priorities defined were related with NCDs’ (Escobar& Legetic, 2001), the importance of preventive actions aiming to modify population’s lifestyles and related environmental conditions was highlighted. In accordance with the latter, in 1998 was created the Department of Health Promotion, which initiated the formulation and implementation of the NHPP. The plan established the health determinants to be targeted and the strategies for action (Salinas & Vio, 2002). These are described in table 4.
Table 4: National priorities and strategies for health promotion 2000-2010
Health priorities
Health determinants
Cardiovascular disease
Nutrition
Mental health
Physical Activity
Accidents
Tobacco
Cancer
Strategies National level: • Regulation • Communication • Education • Participation • Reorentation of health services
Local level: • Healthy spaces • Schools Environmental protective factors • Work places • Communities Psychosocial protective factors
Areas: • Tobacco • Obesity • Physical inactivity
Source: Ministerio de Salud (1999) Plan Nacional de Promoción de Salud. Santiago. Chile.
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In 1999 was constituted the National Council for Health Promotion, VIDA CHILE (CHILE LIFE), an intersectoral advisory agency presided by the Minister of health, which includes 25 national institutions. VIDA CHILE works in the formulation of healthy public policy, coordinates intersectoral work, and provides advice to ministers and regional governments with regard to health promotion-related issues. This council was created in virtually every region in the country. Another expression of the development of health promotion in Chile was the First National Health Promotion Congress, held in Santiago in 1999. A public commitment was subscribed in that occasion, the “Huechuraba Charter for Health Promotion”. Lecturers, members of the parliament, social leaders and civil, academic and governmental authorities participated in this event where 1200 people were congregated (Acta de Huechuraba, 1999). The political and technical bases of the NHPP considers a conceptual and legal framework; a decentralized and intersectoral management model; planning and intervention methodologies; an evaluation model, and financial mechanisms. The conceptual framework incorporated an operational definition based upon the international consensus in health promotion (Ottawa Charter and the next declarations): “strategy that involves individuals, families, communities and society in a process of change oriented to the modification of the determinants of health and to the improvement of quality of life”. The general objectives of the NHPP are the following: (Salinas, 2000) •
Promote healthy lifestyles and environments.
•
Increase knowledge and individual /community abilities to care for health.
•
Strengthen the regulatory role of the State on the determinants of health. The formulation and implementation of the plan was carried out in a
participatory and decentralized manner, with coordinated work between the local and national levels. Utilizing information collected from several national data sources, health promotion national goals were initially formulated for the year 2000 and posteriorly on extended to 2010 (Salinas & Vio, 2002). These are described in table 5.
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Table 5: Health Promotion National Goals for 2010 Priority areas Obesity
Physical inactivity Tobacco consumption
Goals
2000 (%)
2010 (%)
- Decrease the prevalence in pre-school children on 3% - Decrease the prevalence in first grade school children on 4% - Decrease the prevalence of obesity among pregnant women on 4% Decrease the prevalence in the population older than 15 years of age on 7%
10
7
16
12
32
28
91
84
- Decrease the prevalence in 8th grade school children on 7% - Decrease the prevalence among women in fertile age on 5% - Decrease the prevalence in the general population on 10%
27
20
45
40
40
30
Increase on 6% the participation of the population in social organizations
4
10
--
- 100% of the cities - 50% of schools - Percentages are established for each region
Social participation
- Recover public places for healthy life
Healthy places - Certify health promoting schools - Certify healthy work places
---
Source: Ministerio de Salud (1999) Plan Nacional de Promoción de Salud. Santiago. Chile
The main strategies utilized in each area to achieve the above-mentioned goals are the following: •
Obesity Aiming to change nutrition patterns since childhood, mass media campaigns and
educational programs have been implemented. In partnership with the educational sector, joint activities to promote healthy nutrition and physical activity among preschool children are being carried out, as well as coordinated work with the Ministry of Education to install an integrated model of nutrition, physical activity, tobacco and environment in schools. The existing Food School Program, or ‘Programa de Alimentación Escolar’ (PAE), and the National Complementary Food Program, or ‘Programa Nacional de Alimentación Complementaria’(PNAC) were reformulated since they were initially designed to address undernutrition problems (Salinas & Vio, 2002). According to Uauy et al. (2001), these programs probably contributed to the rising in the prevalence rate of obesity observed on children.
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At primary care level, educational interventions aiming to prevent obesity among specific groups such as children and pregnant women were designed. In the field of public policy, efforts have been made to increase the production, commercialization and consumption of vegetables, legumes, fruits and fish, as well as low-fat milk products and vegetal oils. (Salinas & Vio, 2002).
•
Physical inactivity In the frame of the WHO/PAHO “year of physical activity” in 2002, mass media
campaigns were carried out and guidelines with recommendations for an active life for the general population were developed. Several VIDA CHILE institutions and Municipalities have worked on initiatives to increase leisure time physical activity through educational activities and the creation of VIDA CHILE squares to offer public spaces to foster active recreational activities. There are concerted efforts to promote urban development policies that include parks and green areas, community equipment and sports facilities in order to use public spaces for recreation and active life (Salinas & Vio, 2002). Other initiatives on policy development include an educational reform emanated from the Ministry of Education that increases the number of hours devoted to physical activity in the curricula of preschool, school and high school students, and the creation of the Sports National Institute or ‘Instituto Nacional del Deporte’ (law Nº 19,712 from February 2001) to foster environmental conditions that promote an active life and reinforce the responsibility of the State on physical activity-related issues. In 2002 law Nº 19,787, which included economic incentives to promote physical activity such as subsidies and tax exemption to donations, modified the existing law. The Ministry of Health subscribed in 2001 an agreement with the Sports National Institute to create physical activity programs for pregnant women and for patients with chronic diseases at primary care level and for private and public companies’ workers (Salinas & Vio, 2003).
•
Tobacco consumption To control and prevent tobacco consumption several mass media and
educational campaigns seek to change the social perception of smoking in the population. These include the international contest “Quit and Win” every two years since 1998; the celebration of the global non-smoking day, and the school contest 107
“when I grow up will not smoke because…”. The tobacco-free environment program developed by the Ministry of Health has been implemented in private and public institutions, work places, hospitals and primary care facilities among others. Interventions to prevent tobacco consumption among high-risk groups and to help those who want to quit through counseling, individual treatment or group workshops are carried out in some primary health care facilities. Salinas & Vio (2002) report that legislative measures to ban tobacco advertisement and reduce demand are being worked out. The NHPP has been well evaluated with regard to organization, however several constraints such as weak intersectoral leadership and slowness in the management of local agreements have been reported (Salinas, 2000). The predominant biomedical and sectoral cultures; the existence of fragmented public programs and the scarce channels for cooperation and participation; the low coverage of the programs; and the lack of monetary resources are the main obstacles encountered. According to Salinas & Vio (2003), the fact that health promotion was turned in to state policy in Chile does not guarantee success and indicators’ improvement, being necessary further work on the formulation of healthy public policy in the long term. This area was regarded as the more complex and less developed by the Chilean NHPP (Salinas & Vio 2002).
5.5
Individual-based approach to primary prevention and secondary prevention: ESPA and Cardiovascular Health Program ESPA was first implemented in 1995 and then reformulated in 1999 to be in
accordance with the country health priorities. The program includes protocols for early detection of the most prevalent NCD-related behavioral and morbid conditions among adults older than 40 years of age, and for intervention on the detected behavioral risk factors. Among those conditions are the conventional CVD behavioral and biologic risk factors, plus mental health disorders and altered patterns of alcohol consumption among others. The examination protocol should be performed by either a health professional or a trained non-professional health worker, depending on the circumstance, to virtually any person that asks for a preventive exam in public facilities, and is mandatory for people that enters to work on the public administration. ESPA aims to prevent or 108
postpone CVD though a protocol of activities that include counseling on tobacco consumption, nutrition and physical activity to promote behavior change among people with detected unhealthy lifestyles; a surveillance system of the risk factors detected and, if necessary, derivation to the CHP if an individual presents one or more of the following risk factors: tobacco consumption, hypertension, diabetes and blood cholesterol disorders (MINSAL, 1999). Physical inactivity was not included in the surveillance because of methodological constraints for an objective evaluation, however, it is considered a basic element for the non-pharmacological management of CVD biologic risk factors (MINSAL, 2002*).
According to Escobar and Legetic
(2001), one of the main problems encountered for early detection of CVD risk factors at national level was the low coverage reached by ESPA. In 2002 the CHP was born from the reorientation of the existing hypertension and diabetes programs. Its distinctive characteristic is that the CHP aims to reduce an individual’s absolute CV risk, and do not target isolated risk factors. The general objective of the CHP is to prevent morbidity and mortality among individuals with high cardiovascular risk. Specific objectives are: •
To reduce the cardiovascular risk profile of those who attend the program.
•
To quit tobacco consumption among those who smoke.
•
To achieve optimum blood pressure levels among attendees.
•
To improve the metabolic control of diabetic individuals.
•
To reduce blood cholesterol levels among patients with cholesterol disorders.
•
To achieve a significant weight loss among obese and overweighed individuals.
•
To improve the physical capacity of those who attend the program. The selection of the protocol for intervention depends on the individual level of
risk, determined by the number, type and intensity of present risk factors. Three categories are defined according to the risk of a coronary event in the next 10 years: maximum, high and moderate. This classification is based on the Framingham’s score for prediction of coronary risk (Anderson et al., 1991, in MINSAL, 2002*), and seeks to identify high-risk individuals in order to carry out intense therapeutic interventions. The Framingham score is not recommended for individuals without risk factors or only with one, because the risk of an event in the next ten years rarely justifies an intense
109
intervention.
The actions to follow for the selection of high risk individuals is
illustrated in figure 8 (MINSAL, 2002*). Figure 8: Coordinated action between ESPA and CHP for the selection of high risk individuals
ESPA
One or more CV risk factors? (smoking, diabetes, hypertension, blood cholesterol
Yes
No
(with CV
(low CV risk)
Control in 3 years
Refer to Cardiovascular Health Classification according to CV risk
Mod
High
Max
Extracted from MINSAL (2002*)
The protocols for intervention are described for each level of risk, and include counseling for smoking cessation and non-pharmacological and pharmacological measures detailed for each risk factor present. The intervention is delivered to patients by a multi-professional team, which is also in charge of further controls. The selection of pharmacological treatment is influenced by socioeconomic factors that determine availability, patient’s CV risk profile, patient’s individual response to drugs, appearance of adverse effects and interaction with other drugs taken by the patient (MINSAL, 2002*).
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5.4
The WHO/PAHO CARMEN and Inter Health programs in Chile In 1996 Chile joined the CARMEN program (described in chapter 3) in response
to changes in the population epidemiologic profile. In 1997 a baseline survey was the start point for CARMEN activities in the health service of the demonstration area of Valparaiso (5th Region). In 2001 other five health services from the 8th Region and one from the metropolitan Santiago joined this initiative (MINSAL web page). The actions of CARMEN are oriented toward prevention of CVD risk factors among high risk individuals since the NHPP is in charge of CVD prevention among the general population. A specific protocol was elaborated based upon the program lines of action with two levels of intervention. The first level has a wide coverage and intervention delivered at ‘low intensity’, while the second, with a ‘high intensity’ intervention is restricted to a specific demonstrative project. The low intensity intervention consist in the application of ESPA to 100% of the population adscript to the demonstration areas’ primary care facilities, and the high intensity intervention corresponds to the design and implementation of an operational intervention project in accordance with local health priorities and the need to improve effectiveness of actions and efficiency in the utilization of the available human resources.
The activities
recently carried out by CARMEN include elaboration of guidelines to standardize procedures, increase professional capacity for monitoring national, regional and local situations with regard to NCDS, and health teams training for detection and management of NCDs in partnership with scientific societies and Universities. One of the main problems encountered in the first phase of the implementation of CARMEN was the low priority given to NCDs prevention, which did not have significant representation in the health budget (Escobar and Legetic, 2001). This situation probably changed in recent years because chronic disease prevention and healthy lifestyles are within the health objectives set for the 2000-2010 decade. The Inter Health program (described in chapter 3) “¡Mirame! para ser un adulto sano en el año 2000” (look at me! To be a healthy adult in the year 2000), dependent of the Center of Studies “Karelia 2000” of the Catholic University of Chile, started in 1992. The ‘Mirame’ program targeted school children in order to improve their “social abilities to resist negative environmental pressure and reinforce positive attitudes” through health education about risk factors and healthy lifestyles. Students’ parents and family members were also involved in the activities, which included as well teachers 111
and health personnel training to promote community actions (CDC, 1997).
The
effectiveness, feasibility and process evaluations that were carried out in 1996, comparing exposed and non-exposed groups to the intervention was positive. After an economic analysis of this intervention, Berrios et al. (2004) concluded that it is a costeffective strategy for Chile (Berrios et al., 2004).
5.6
Assessment of the strategies utilized in Chile for prevention and control of CVD risk factors The strategies utilized in Chile for primary and secondary prevention of CVD
were designed under the advice of WHO/PAHO, following the line of the North Karelia project in Finland. Much was addressed in chapter 2 with regard to the unique success of this program and the existing controversies around multiple risk factors interventions, as well as the issues that should be taken into account to effectively reduce incidence and control prevalence. If the strategies selected for CVD risk factors prevention and control in Chile are analyzed in the light of those arguments, it is possible to put in serious doubt the achievement of the NHPP goals (described in section 5.2), those stated for the CHP (described in section 5.3), and consequently the achievement of the specific impact objectives that aim to reduce death and disability due to CVD by 2010 (described in section 5.1). On the other hand, it is also possible to think that those objectives will be achieved, but the existing disparities in the distribution of CVD risk factors among the different segments of the population might increase in the future because the reductions in CVD mortality, and prevalence and incidence of CVD risk factors will favor the privileged segments of the Chilean society to a greater extent. The argument behind those statements is that the strategies used by the NHPP to change behavior are likely to have a greater impact on the more educated and affluent groups, and the unequal access to health care, and the inequalities in the allocation of resources between the different primary care centers throughout the country (Arteaga et al., 2002) might affect the quantity and quality of the health care delivered to the less educated and less affluent groups, whom also have the greater prevalence of CVD risk factors in the country. These aspects will be further explained in the following sections.
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5.6.1 Risk reduction and behavior change with the National Health Promotion Plan Much has been stressed throughout this thesis with regard to the little utility of health education among healthy people to achieve behavioral change, especially among those in the low socioeconomic strata because individual decisions in all levels of society are affected by social and economic factors, as was addressed in section 2.7 quoting Wilkinson & Marmot (1998). Health education as information is not enough to change behavior, especially tobacco use because of its addictive nature. The wide range of factors that influence individual behavior were detailed in section 2.2.3, and among those, the available networks for social support were mentioned. Because in Chile there are low levels of affiliation to social organizations and high levels of stress among the population (detailed in section 4.5), depressive symptoms are highly prevalent and affects women of low SES to a greater extent, and those symptoms were related to poor housing quality and recent income drop (Araya et al., 2003), it is possible to hypothesize that health education messages will not foster behavior change among a great proportion of the population, and especially among women of low SES, a group with a growing rate of tobacco consumption and a high prevalence of obesity. Health education interventions that target children in the frame of the NHPP, as well as health education contents delivered by the “Mirame” program might have a greater repercussion on health behavior than those educational interventions targeting adults (Berrios et al., 2004), however, the experiences that children of low SES traverse from childhood to adolescence and adulthood, the family structure and their parent’s own health behavior might have a greater influence on their individual behavior in the different stages of life than health education messages (explained in section 1.4.2). In section 2.2.3 was also addressed that individual preferences are influenced by personal levels of information and advertising and marketing among other factors. Tobacco advertising in Chile it is not banned but restricted. A high percentage of the students sampled for the GYTS reported exposure to tobacco advertising recently; also advertising of fast food chains is frequent, and mass media campaigns for health promotion in Chile have been sporadic because of lack of resources (Salinas & Vio, 2002). Therefore, frequent advertising and marketing of tobacco and fast food might influence Chilean’s individual choices to a greater extent than health promotion messages does. 113
Because most of the risk in Chile is environmentally determined, priority should be given to strategies aiming to provide a healthy environment and facilitate healthy choices, and to the social factors that determine the degree of exposure of population groups to environmental conditions.
Although the NHPP aims to increase social
support, a determinant of the degree of exposure to adverse environmental factors, seems contradictive to focus on a distal determinant first without tackling the proximal determinant in first place. The NHPP aims to increase the number of tobacco-free places (work sites, schools, hospitals, etc), however bans and taxes have been repeatedly regarded as the most efficient ways to reduce demand. Less affordable cigarette prices is the most effective method of curbing the prevalence and consumption of tobacco products (Guindon et al., 2002), especially among the group at higher risk: women and youth of low SES. It has been estimated that a 10% increase in the price of cigarettes in Chile would reduce demand in about 8%. Regrettably, policy interventions aiming to modify environmental conditions have been less developed by the NHPP (Salinas & Vio, 2002). Much has been achieved by the NHPP through policy interventions with regard to availability of public spaces for leisure time physical activity and to practice sports (Salinas & Vio, 2003), however, the fact that most Chileans work 48 hours per week (will be reduced to 45 on 2005) and that one of the main reasons argued for not practicing sports was lack of time, an increase in the levels of physical activity among blue-collar workers is doubtful. Two areas in need of regulation through policy that deserve priority over others in Chile are reduction of the salt content of processed food to reduce hypertension incidence and prevalence, and tobacco control. Because hypertension is the most prevalent biologic risk factor in Chile, also associated to higher prevalence of obesity and high cholesterol levels, even small reductions in population blood pressure levels would have a great impact in terms of CVD morbidity, mortality and global CVD risk levels in the country. For obvious reasons, no further explanations are required to justify tobacco control measures in Chile. This two strategies, however, require a high degree of intersectoral collaboration between the health sector and the food and tobacco industries, and because economic interests are involved, a strong political commitment and advocacy are necessary from representatives of the health area.
Regrettably,
advocacy and political commitment to the cause is difficult to get at least in the short 114
term or under the current government, which probably because of the existing biomedical culture is mainly focused on developing health care policies rather than healthy policies, and also because as many other developing countries, Chile favors economic issues over health in the policy making process. This became evident when one of the main national newspapers informed that the FCTC, subscribed by Chile on September 25 of 2003 was sent to the Congress by the Minister of Health almost a year later, on October 11 of 2004, and under pressure exerted by members of the congress on favor of tobacco control. This measure will reduce demand and therefore government revenues despite the increase in taxes. The legislators in favor of more regulations informed that the Ministry of Economy sent a document to the Ministry of Health requesting that “…any study requires to know the costs of the project and the fiscal lost revenues…” (Diario El Mercurio de Chile, 10/11/2004).
5.6.2 Treatment provision to control prevalence of CVD risk factors and reduce recurrences of cardiovascular events in Chile. Unequal access to health care in Chile is documented not only with regard to inequity between socioeconomic groups, genders and age, but also between regions of the country (Arteaga et al., 2002*). Although this single factor greatly contributes to the clustering of CVD morbidity among the socially disadvantages segments of the Chilean society, there are others (described in section 2.5) that might be contributing to the latter and should be assessed in order to identify the factors that foster an unequal distribution of CVD risk factors in the country. In Chile only a small proportion of the hypertensive and diabetic individuals do receive treatment, and among those, an even smaller group of people are controlled (figures were presented in section 4.4.1.2), evidencing problems with patient’s adherence to therapies, one of the main determinants of treatment effectiveness and therefore success of secondary prevention programs.
The levels of adherence to
treatment, which involves not only consumption of drugs but also to follow the agreed recommendations of a health care provider with regard to lifestyle modification, are influenced by several factors that can be broadly related to health systems and to patients.
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One of the main problems encountered for adherence to therapies at health systems level is availability and affordability of drugs, which depends on the existing drug policy, medication distribution systems and reimbursement of medication costs by private health insurers. In health care systems where costs of medication are not regulated, medication in the public area it is not enough to cover the needs, and private insurers’ costs containment strategies include patients’ share of medication costs, will show great differences among social classes with regard to prescription of treatment as well as adherence to therapies. The Chilean drug market is mainly affected by the market share of generic drugs and the existence of the Ministry of Health's Central Supply Clearinghouse; however, because there is no price control, only market forces and not negotiations between pharmaceuticals and the health sector influence pricing of medication. Although generics represented 38% of global sales in 2000, corresponded to only 10% when the monetary value is considered. Sales made on private pharmacies accounted for 89% of the total spending on medication, and only 11% corresponded to sales to the public sector. This difference occurs because the public sector utilizes mostly generics (PAHO, 2002*).
With regard to medication coverage, ISAPREs do not cover ambulatory
medication (only during hospitalization), and in the public sector, one criteria for the selection of drugs in the CHP was socioeconomic factors (MINSAL, 2002) that condition availability because the capability of the system to afford drugs is limited, which indicates that lots of people do not receive the adequate medication. It is likely, although not quantified, that those people do not afford their medication out of pocket because of lack of money or because they do not perceive themselves at risk and will privilege other investments for their monetary resources rather than medication. Perception of risk is considered as a patient-related factor that influences adherence to treatment and utilization of preventive services for early detection of risk factors. As was stressed in section 5.3, ESPA has low coverage at national level, which might be influenced by adults’ perception of risk. In the private sector the use of preventive services is also low, and because of the high mobility between ISAPREs, its use is not encouraged (issue explained in appendix B). The fact that in Chile women have greater prevalence of risk factors compared to men might also indicate low perception of risk among them. Probably if an anthropologic study were carried out in Chile to clear cultural perceptions of CVD illness and death, these would be congruent with the ‘lay theory of coronary candidacy’. 116
Other factors mentioned that are related to health systems and influence patient’s adherence and might contribute to the clustering of CVD risk factors among the less educated and less affluent people are the quality and quantity of services offered by primary care health centers, which is usually related to the payment system. Low quality and quantity include issues like lack of knowledge and training for providers on how to manage chronic diseases and to improve adherence, short consultations, a weak system capacity to educate patients and provide follow-up, and if the system do reimburse providers for patient counseling and education. In this regard, because within the Chilean health reform main objectives are to improve quality and opportunity of the services provided, several aspects that contribute to improve adherence at primary care level have been considered and are and will be developed, which in turn might help to reduce inequity in the distribution of CVD risk factors and the associated burden of disease. These include users’ evaluations of performance, the creation of the patient’s rights charter, professional economic incentives based on evaluations of performance, capacity building and a multiprofessional approach to health problems among others (PAHO, 2002*). Municipal primary health care centers in Chile since 1992 are financed by FONASA using a capitation-based payment mechanism. Residents of a given area register with their municipality, and FONASA allocates funds in proportion to enrollment, with adjustments for location and poverty.
This prospective payment
system fosters preventive activities because the risk is only on providers side, however, quality may be sacrificed in order to contain costs (Wouters, 1998). On the other hand, despite this financial measures that aim to increase equity, the municipal governments of the communes with higher average household incomes tends to contribute with more funds per beneficiary to their respective primary care health centers, which greatly contributes to the current unequal status in resource allocation. According to Arteaga et al. (2002), the financial contributions from the national government are well targeted, but they can only partially compensate for the more limited resources available in poorer communes, which also hold the less educated and less affluent groups of the Chilean population with the higher CVD risk factors prevalence rates. Because of the exposed arguments, it is possible to conclude that on one hand the Chilean health system reform will improve patients’ adherence and access to primary care, contributing to reduce the gap with regard to distribution of CVD risk factors between socioeconomic strata in the country. On the other hand, the unequal 117
contribution of funds for primary care health centers between the rich and the poor municipalities, the existing drug policy, the lack of funding to afford drugs in the public system and cost containments strategies in the private system contribute to increase the CVD risk factors’ gap between socioeconomic groups. Probably a re-distribution of the health care budget on favor of primary care would increase the system capability to afford drugs and compensate poor municipalities’ lack of funding. In 2000 only 16.2% of the health care expenditure in Chile was devoted to primary care, the rest went to secondary and tertiary care (PAHO, 2002*). At patients level would be useful to take into account cultural constructs of CVD illness and death and the insights of the ‘lay theory of coronary candidacy’ for high risk patients’ health education and counseling. Despite the lack of local studies in this regard, to increase CVDs’ perception of risk among those evaluated by ESPA and attendees of the CHP might increase adherence to therapies among certain groups. However it is doubtful that these messages might reach people of low SES because their attitudes toward health decisions that will affect them in the future, which is the case of CVD prevention, are driven by uncertainty and the need to solve immediate problems. The opinion of experts (stressed in section 2.4.1) is that although health education messages would yield better results among high risk patients, they need to be constantly reinforced to maintain behavior change and therefore adherence to therapy.
5.6
Conclusions In the frame of the Chilean Health Reform sixteen health priorities were
established, giving especial importance to NCDs. Objectives were set for the decade 2000-2010, which include the control of behavioral risk factors and reduction of CVD mortality and morbidity in Chile. For the accomplishment of the established objectives it is necessary to reduce CVD risk factors’ incidence and control its prevalence. The Chilean health sector utilizes strategies that aim to modify behavioral risk factors at individual level through the NHPP, and to early detect and treat biologic risk factors to decrease mortality and morbidity due to CVD though ESPA and the CHP respectively. Two WHO/PAHO networks, CARMEN program and the Inter Health program “Mirame! Para ser un adulto sano en el año 2000”, also aims to reduce the burden of NCDs in Chile. 118
CARMEN works in several demonstration areas in the country to improve the delivery of primary and secondary health care interventions to reduce NCDs among high-risk people, and “Mirame” seeks to promote healthy behavior among children. The analysis of these strategies, based on the arguments exposed in previous chapters, raises the following question: are these strategies going to reduce CVD incidence and prevalence in the group of Chileans with the worst indicators? In light of the arguments exposed in this chapter the answer is no. It is well known in public health that to effectively control a health problem it is necessary to target its main determinants. In chapter four was concluded that most of the risk in Chile is environmentally determined, and the degree of exposure to adverse environmental conditions is determined as well by social conditions. Policy interventions aiming to modify the current environmental status have been less developed by the NHPP, and although some effort is made to modify social conditions, it seems contradictory to tackle the distal determinant of the high incidence of behavioral risk factors without modifying the proximal determinant in first place. Some success has been achieved with regard to environmental change that promotes physical activity, however, to develop healthy policies in areas that deserve priority, such as tobacco control and salt content of processed food, strong political commitment and advocacy is necessary. The issues reported by the national newspaper “El Mercurio” with regard to the delay in sending the FCTC to the National Congress reveals lack of political commitment and advocacy toward these causes. Because indeed health is one of the main concerns of the current government, it is likely that the strong biomedical focus toward health in the country favors prioritization of health care policies over the healthy ones; also economic issues play a major role in the policy making process, as it occurs in most developing and developed countries of the world.
The role of
WHO/PAHO in setting priorities for the policy-making process and the achievement of international support would be useful and even more valuable for the health of Chileans than their current focus on preventive efforts directed to high risk individuals with strategies that have been repeatedly questioned by experts in the subject of CVD prevention and control, as was addressed in chapter 3. In second place, research has proven that health education as information directed to the healthy population does not achieve significant changes in health behavior, especially among low SES people. Health education taking cultural perspectives toward CVD and the ‘lay theory of coronary candidacy’ might be useful to 119
provide education and counseling to patients attending the CHP and would increase risk perception among vulnerable groups and consequently improve the use of ESPA, however this does not guarantee the attention of low SES groups to the message of prevention. Other aspects to consider that support the answer given to the question posed above are the health system-related factors that influence adherence to therapy among high risk individuals. The existing unequal status in the country with regard to access to health care, the differences between municipal contribution of funds for primary care health centers throughout the country, the existing drug policy, the lack of funding to afford drugs in the public system and the cost containment strategies in the private system threats to contribute to the maintenance or increase of the current unequal distribution of CVD risk factors between the different socioeconomic segments of the Chilean population, despite the government’s intended efforts to reverse this and other similar unequal health situations with the reform of the health system (detailed in appendix B). A re-distribution of the health care budget in favor of primary health care and maintenance of the current trend of progressive increase in the percentage of the GDP devoted to health might improve the provision and access to health care for high risk groups. The latter, however, does not guarantee a better distribution of the CVD burden of disease, only better health care conditions. It is necessary a comprehensive approach that also takes into account an anthropological perspective toward health education aiming to increase people’s perception of risk, and to target adverse environmental conditions and the determinants of exposure to those conditions through policy interventions.
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Conclusions and discussion
Conclusions Cardiovascular diseases are a major health problem worldwide and the main cause of death and disability in developed countries and in some developing nations. Currently, CVD constitutes a major public health problem in Chile. In 2002, 33.1% of deaths corresponded to this cause. Because of the important burden that cardiovascular disease represent for the country, the formulation of CVD policy and CVD-preventive policies were analyzed in this thesis in order to answer the following research question: How CVD policy and CVD-risk preventive policies are formulated in Chile? To answer the main research question posed above; the following specific research questions were posed: 1.
What is the scope of the CVD problem in Chile?
2.
How is the problem of CVD addressed in Chile?
3.
What is the status of CVD-risk preventive policies in Chile?
4.
Is the problem of CVD in Chile being managed according to WHO’s advice? The main determinants of the problem in the country are environmental
conditions that depend on urbanization, economic development and globalization, which have influenced health-related conditions and behaviors that consequently have changed the epidemiological profile of the population, moving the country toward late stages of the epidemiologic transition, where the CVD-related burden of disease is concentrated among low SES groups. Life-course and perhaps pre-natal exposure to adverse social and environmental conditions, as well as country and communes income inequality also play a role in the marked inverse social gradient currently exhibited by the Chilean CVD morbidity and mortality indicators. Recent publications reported that the decline in CVD mortality rates in developed countries was mostly attributed to treatment provision, which might be indicative that worldwide there is still a long way to run with regard to healthy public policy development. A similar situation was also reported in Chile, where a 28% decrease in the risk of CVD death was observed, and although the specific causes of this
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decline are not yet clear, were mostly attributed to medical progress in therapies for cerebrovascular disease and coronary heart disease. The fact that mortality rates due to diabetes and hypertension in the country have increased might indicate that therapies have improved at the second and mostly at the third levels of attention, where specialized care for cerebrovascular disease and coronary heart disease is provided to patients in high-technology equipped facilities, and not at the primary level of attention where patients with diabetes and hypertension receive their treatment. Another reason that might explain this is the low proportion of controlled individuals among the diabetic and hypertensive population and the wide amount of individuals who do not know of their condition. Without any doubt, the improvements in CVD mortality rates in the country are a positive issue, however because these might be due to treatment provided in the third level of attention probably to individuals traversing their late adulthood, the cost per DALY saved shall be very high. This implies either a misuse of public health care resources or more probably, unequal access to life-saving health care. These issues are currently being addressed by the Chilean Health Reform, which intents to reduce inequities in health care and strengthen the primary level of attention. In the re-definition of health priorities for the country, NCDs have an important place, and CVD mortality reduction is within the health objectives for the decade 2000-2010. The strategies selected for CVD prevention and control in Chile agree with WHO/PAHO recommendations; however it is likely that its implementation might worse the current unequal distribution of CVD risk factors not only among socioeconomic groups but also between genders in the long term, with a distribution pattern similar to the currently exhibited by developed and some developing countries like China and India firmly installed. To elucidate on the possible consequences of the latter is difficult, although they shall include issues like an increased demand for secondary and tertiary care that shall exceed the existing capacity and might threat further development of primary care; a decrease in the absolute number of CVD-related deaths among the poor with the current distribution of CVD deaths rates in the society remaining unchanged, which implies an increase in CVD-related disability rates among the socio-economically deprived groups due to the growing proportion of non-fatal events and increased life expectancy in the country; and finally, a derived increase in the dependency ratio. The latter in turn might negatively affect, to an extent difficult to assess objectively, the democratic governments’ efforts to improve the living conditions of the poor and less educated segments of the Chilean society. Because recent research 122
findings associate income inequality with increased exposure to CVD, in the absence of social policies that seek for a more equal distribution of income in Chile, currently considered one of the 10 countries in the world with the most unequal distribution of income, there might be a serious threat of a vicious circle with regard to CVD incidence, prevalence and the strategies used for prevention and control in the future. Improvements in the drug policy, a re-distribution of the health care budget, and actions aiming to reduce inequalities between municipalities might contribute to achieve good results with the interventions that target high-risk individuals. A culturally sensitive approach toward health education would be useful to increase the perception of risk among high-risk individuals and the general population. To focus the efforts of the NHPP on the development of national policies to modify legislation for tobacco control and the salt content of processed food would significantly impact CVD indicators in Chile, but for those efforts to be fruitful some issues deserve special attention and needs to be further discussed.
Discussion Many studies highlight the importance of genetic factors in the genesis and progression of CVD, and although its importance is undeniable, a recent study carried out by Yusuf et al. (2004) in 52 countries revealed that worldwide traditional risk factors (abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, low consumption of fruits and vegetables, alcohol, and physical inactivity) account for most of the risk of myocardial infarction, the main cause of CVD-attributable mortality in Chile.
Based on those results Yusuf et al. (2004)
suggested that “approaches to prevention can be based on similar principles worldwide and have the potential to prevent most premature cases of myocardial infarction”. This study gives room to draw some conclusions in light of the arguments analyzed in this thesis: the first is that despite ethnic differences that influence genetic susceptibility to CVD, worldwide incidence and prevalence can be decreased through modification of behavioral risk factors; the second issue is that because most of this risk is due to worldwide lifestyle changes, the main determinant of the problem is without any doubt the globalization phenomena.
Globalization, initially understood as an economic
phenomenon associated with extreme global inequities, has moved populations from 123
rural to urban areas, changed the environment and affected populations’ social, cultural and political aspects (Kickbush & de Leeuw, 1999). The strategies more commonly used in recent decades in developed and developing countries to reduce the burden of CVD aim to change behavior among the general population through health educational messages that inform about the dangers of unhealthy lifestyles, treatment provision and counseling for behavior modification to high-risk individuals, plus environmental change through policy, mostly using legislation as the main policy instrument to reduce tobacco consumption, change composition of some nutritional products and assure availability of safe public spaces to practice sports or for leisure time physical activity. Treatment provision is proven to be an effective strategy, however is quite expensive and depends on many factors such as access to health care, access to medication, frequent controls by a health provider, and cultural factors that affect population’s health seeking behavior and adherence to treatment. Because of the latter, this strategy indirectly favors health inequalities and the clustering of CVD morbidity and mortality among the less educated and less affluent segments of the population. Many authors claim that the effectiveness of the other strategies has been difficult to assess because they have been implemented in most cases in the context of multiple risk factors intervention trials that difficult to establish cause-effect relationships. The well known environmental intervention that modified the composition of cooking oil through legislation in Mauritius highlighted the importance of environmental interventions, because this single intervention showed remarkable results in reduction of cholesterol levels. The effectiveness of health education messages delivered as information over lifestyle and reduction of behavioral risk factors prevalence has been largely questioned, especially for socio-economically-disadvantaged groups because other factors rather than knowledge influence their health-related decisions. Social and economic issues such as low social support, unemployment and stress influence health behavior to a greater extent than healthy lifestyle advice. Based on the currently available evidence, treatment provision and interventions that aim to change environmental conditions through legislation are effective strategies to reduce CVD incidence and prevalence. For an effective provision of treatment, policy development on health systems reorganization is necessary, however because this strategy is quite expensive and tends to favors inequity, the development of policies that 124
seeks to improve globalization-dependent adverse environmental conditions through legislation should deserve priority. Regrettably, without an integrated action of the international community, and especially of WHO as the specialized health agency of the United Nations, environmental change is difficult, especially for developing countries. The influences of globalization on social and political issues consequently affects the health policy-making process, which no longer depends on individual governments
decisions
but
created
a
worldwide
situation
of
“increased
interdependence” (Lee, in Kickbush & de Leeuw, 1999). Despite countries’ sovereignty over health care policies, their sovereignty over policies related to health determinants is progressively being eroded by the marketing of tobacco and other non-healthy goods (e.g. fast food chains), the growth of a global health industry (e.g. pharmaceuticals and insurance), and the health impact of the global financial system, among others. “This erosion is not just directed at developing countries as a form of post-colonial interference but also affects the developed world” (Kickbush & de Leeuw, 1999). “Sovereignty exertion” of global networks to conduct healthy public policy at global level, such as the FCTC, provides a frame for action at local level. Chapter four conclusions highlight the importance of considering health in the policy making process to target both, the environmental and the social factors that lie behind the incidence and prevalence of CVD and also other NCDs in Chile. This is not an easy task, and several factors may act as constraints to place health issues higher in the political agenda and promote policy change. Usually health issues are seen as ‘low politics’ (McKee et al., 2000) and do not draw government’s attention as economy does. The government is one of the most important actors in the agenda setting, generally with control over legislation and the policy process; therefore to draw government’s attention on a particular health issue and highlight its importance over other matters is crucial. The role of the Minister of Health in this regard is relevant, his skills to argue for new directions on health policy as well as his professional background and the one of those who provides technical advice. Medical, dental, nursing and pharmaceutical professionals are heads of sector within the ministry, and some times there may be some dissonance between political and professional goals, especially if the Minister is a medical doctor.
When medical
professional values predominate there is a tendency to equate health with health care or medicine. Other relevant actors in the health policy making process, especially for 125
developing counties like Chile are WHO and other international agencies such as the World Bank. While WHO, that advocated for social justice have seen its power limited, the World Bank has acquired some leadership in the health field and provides inputs to health policy under a market driven perspective that advocates for packages of costeffective health interventions (Walt, 1994). Based on the exposed arguments, legislation for tobacco control in Chile depends on the Government’s and the Ministry of Health’s actions because the international support is guaranteed by the FCTC, however since one of the main lenders for the health reform is the World Bank, the Ministry of Health and the Government’s focus shall agree with the Bank’s priorities with regard to cost-effectiveness of interventions. The reduction of the salt content of processed food was regarded as costeffective for U.S. by Hunink et al. (1997), however because its cost-effectiveness for Chile is uncertain probably this strategy would not have priority in the health agenda nor be considered in the policy-making process.
The World Bank (1999) highly
recommends tax increase as a cost-effective way to reduce demand, although states that “for governments considering intervention, an important further consideration is the cost-effectiveness of tobacco control measures relative to other health interventions”. Because for Chile economic studies that compare tobacco control measures with other health interventions are not yet available, probably the Ministry of Health will not urge the congress to discuss the FCTC. Unless interest groups that acted as advocates to send the FCTC to the congress exercise pressure again, it is likely that tobacco control measures will not be implemented in the near future despite the country subscription to the FCTC in 2003. Other issues that might act as constraints for CVD-preventive policies to be placed higher in the health agenda and later on reach the political agenda are the existing beliefs that behavioral risk factors and even health care-seeking behavior are fully under individual’s control. Also the extent to which NCDs and especially CVDs are influenced by societal factors might not be known or recognized neither by policymakers nor even by health professionals or groups that might advocate for this cause. McKee at al. (2000) provides a framework to analyze policy responses to health challenges, which considers five necessary prerequisites: visibility of the problem, professional capacity to make the problem visible, sense of ownership over the problem, intersectoral action and effective government.
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The problem of CVD in Chile is, based on the findings of this thesis, only partially visible. Although quantitative data are accurate, qualitative data on attitudes and perceptions is largely lacking, as well as information that stresses the importance of the societal determinants of the problem.
Recent research (Araya et al., 2003;
Subramanian et al., 2003) provides valuable information on social issues and health, and might be considered as a starting point. Based on the fact that to build capacity is one of the goals of the health reform, the growing number of universities that offer epidemiology and public health courses, and the creation of the medical specialization area of family and community medicine not a long a go, should be possible to state that in Chile there are professionals and will be more in the future with enough capacity to analyze the existing data. Nevertheless, because the predominance of a sectoral and biomedical culture in the country was regarded by Salinas & Vio (2003) as one of the main obstacles encountered for the implementation of health promotion initiatives in the country, should be worthy to explore professional’s beliefs and attitudes toward CVD, especially with respect to the relevance they give to social and environmental issues as causes of disease. To assess how strong is the presence of non-medical professionals in the Ministry of Health, as well as the extent to which social sciences professionals are consulted for health decision making at national and regional levels might be a useful indicator of the existing focus toward data analysis. Currently in Chile there are no campaigns or actions that might lead to think that some organization or group particularly owns the problem of healthy public policy or CVD preventive-policies, although no further information was found in this regard. The Chilean Society of Cardiology, or ‘Sociedad Chilena de Cardiologia’ may be considered by the health community as “owners” of the problem, however the information offered in their web page for common people contains mostly health information on behavioral risk factors and their avoidance, no environmental issues were mentioned; and the professionals’ section is focused on CVD risk factors’ medical treatment (Soc. Chilena de Cardiologia).
Probably the group of members of the
congress that pressured the Minister of Health to send the FCTC owns the cause of tobacco control, however no public information on this regard was found. Intersectoral action in Chile has been qualified as weak for the implementation of CARMEN (CDC, 1997), as well as for the implementation of the NHPP (Salinas, 2000). In this regard Salinas (2000) stressed that among the main weaknesses observed 127
were “the lesser intersectoral leadership, slowness in the management of local agreements and lack of influence on the regulation of health determinants”. After the return to democracy in 1990, governments in Chile have incrementally performed several policy changes that through the years are being more notorious, so Chilean democratic governments may be qualified as effective to develop health-related legislation and social policies because of their commitment with poverty alleviation. However, the fact that governments’ main focus is on economic growth, improvement of education and health care coverage, raises some doubts in this respect. A strong commitment to healthy public policy is therefore necessary from the groups involved to make visible a concept of health and development different than the traditionally claimed by economists, which understands development as “a problem of economic welfare first, with social welfare a distant second. ‘Investment’ is the priority: that is investment mainly in infrastructure and industry. ‘Consumption’ is to be deferred for as long as possible and health is seen as consumption” (Gerein, in Walt, 1994). For environmental and social policies related to CVD to reach the policy agenda in Chile, is necessary in first place to promote and develop local research in the field under a social perspective, since currently is mostly oriented toward the biomedical area, and the solutions posed for CVD prevention and control mostly suggests to blueprint developed countries’ experiences (Bunout & Escobar, 2000; Nissinen et al, 2001). For research to contribute in the policy-making process, the dialogue between researchers and its users in the policy process is essential, however, interpretations of data are influenced by personal and professional values as well as the social context within research findings are to be applied (Elliot & Popay, 2000). Therefore, researchers can not adopt a passive role, their attitudes and skills for disseminating the information are essential for research to have an impact. Since values are difficult (or impossible?) to change, the target should be to challenge and change health beliefs (Black, 2001). Information disseminated as arguments, with researchers taking the role of advocates may yield good results, especially for environmental change (Walt, 1994). Funds for research in Chile are mostly granted by the Government, through the National Science and Technology Council or ‘Fondo Nacional de Desarrollo Cientifico y Tecnologico’ (FONDECYT), which provides incentives for health research that has targeted basic sciences and clinical areas more than public health. To promote essential research on the country's priority health problems, the Ministry of Health has developed
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a national research policy directed to health policies (PAHO, 2002). Innovative and well-developed proposals for research on healthy public policies might be welcomed. The role of mass media in disseminating the information gathered by research is important and also might offer good opportunities for public health partnerships to influence public agendas for social and policy change, although because of its commercial nature, a sustained commitment to CVD prevention is in doubt (Finnegan el al., 1999). In Chile mass media has contributed to the visibility of the CVD problem through reports on obesity and hypertension rates, however, the fact that many reports focused on the success of gastric surgery as a solution to obesity evidences the predominant medical focus toward CVD and the possible solutions to the problem. Mass media campaigns and health education messages with a more social and culturally-sensitive approach toward CVD, using the ‘lay theory of the coronary candidacy’ until local research results were available, might contribute to modify perceptions of risk, health beliefs and attitudes among policy-makers and the general public in the long term. To bring the issue of reduction in the salt content on processed food to the political agenda probably will take some time in Chile. On the other hand, tobacco control is a quite visible problem, and the FCTC provides a policy frame for action at local level. Apparently the only necessary actions should be oriented to further develop the already existent sense of ownership among members of the congress and to foster intersectoral work between the health and the financial sector in the country. A possible window of opportunity might open every four years, when elections take place because presidential and congress candidates make their ‘electoral commitments’; however, to keep the problem visible by those with a sense of ownership; and to gain clarity on the financial and health impact of tobacco control measures in order to propose alternative solutions for local adaptation of the FCTC in Chile might guarantee some success.
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Appendix A
Chilean demographic and economic indicators A.1
Chile: Country profile Located in the southern corner of Latin America, the Republic of Chile (official
name) has a surface of 744,097 km2, and a total population of 15,116,435 according to its last census (2002), of which 7,447,695 were men and 7,668,740 were women (INE, 2002). Its capital city is Santiago de Chile, being Spanish the official language of the country. Within PAHO sub regions, Chile is considered part of the Southern Cone. Chile is a unitary State with a democratic government since 1990. The country is divided into 13 political-administrative regions. Almost half of the population is concentrated on two regions, Valparaiso and metropolitan Santiago, which represents only 4% of the national territory. The total urban population corresponds to 86.3%. Eight indigenous groups, comprising 10% of the total population, are identified in Chile: Aymará, Atacameño, Quichua, Mapuche, Rapa Nui , Colla, Kaueskar, and Yámana. The Chilean demographic profile is in transition, with birth and mortality rates having declined in recent decades. The average annual population growth was 1.6% for 1990-2000, being reduced to 1.2% in 2002. In 1998, children under age 15 accounted for 28.8% of the population, the 15-64 years age group for 64.2%, and persons aged 65 and older for 7%. The dependency ratio was 54% in 2002 (PAHO, 2002).
A.2
Economic and social context Classified as an intermediate-development nation, Chile experienced sustained
economic growth until 1998, with GDP growing by 7.7% per year. Inflation was 4.7% in 1998 and unemployment rates were moderate. The economically active population grew from 5,500,000 in 1996 to 5,738,470 in 1998. Due to the crisis of the international markets, growth turned negative in 1999, around -1.1%, and unemployment rose
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significantly. Nevertheless, the country economy has partially recovered and continues growing. According to the United Nations’ Human Development Index of the UNDP, Chile ranks in 43rd place among 173 nations (U.N., 2004) Social and economic indicators show clear economic improvements, which are expressed in poverty levels’ reductions from 39.3% in 1990 to 20.6% in 2000, and per capita GDP growth of 46.9% between 1991 and 1999, when it reached US$ 4,492. Social expenditure increased as a percentage of GDP up from 12.9% in 1990 to 13.2% in 1995 and 16.6% in 2002. However, despite economic improvements, inequities between social groups and regions in Chile are quite significant. At the end of 2000, 10% of the wealthiest households captured 40.3% of the income, while the poorest 10% obtained just 1.7% (PAHO, 2002). The income gap between the highest and lowest deciles has consistently increased over the last years, being a slow but persistent erosion of the share of the poorest deciles, whereas the share of the richest 10% has continued to climb. Unemployment was concentrated among the poorest quintile, women, and young population. In 2002 the population economically active was 40%, and of these, 94% were employed. There is a close relationship between education, occupation and income, with higher education related to higher income occupational categories (Vega et al., 2002). The Chilean educational system comprises a compulsory-attendance primary level of 8 years, and a secondary level of 4 years. On average, Chileans attended school for 9.9 years and exhibited a literacy rate of 96.1% in 2002 (PAHO, 2002).
A.3
Health Status Global health indicators in Chile show consistent improvements in the last
decades. Infant mortality decreased from 32 per 1,000 live births in 1980 to 10.1 per 1,000 live births in 1999, general mortality declined from 6.6 per 1,000 inhabitants in 1980 to 5.3 in 1999, and life expectancy has increased from 67 years in 1980 to 75.2 in 1995-2000. Regrettably, not all socioeconomic groups have benefited equally from these improvements, existing notorious differences between rich and poor communities. For example, life expectancy at county level reveals that male life expectancy at birth ranges over a span of 19.6 years, from 66.1 to 85.7 years according to the 131
socioeconomic condition of the county. For females, this indicator ranges over a span of 11.4 years, from 73.3 to 84.7 years. Infant mortality rates change according to the educational level of the parents, being five times higher in infants born from mothers with less than eight years of education compared with those born from mothers with 12 or more years. The leading causes of mortality in Chile are diseases of the circulatory system, which accounted for 28% of all deaths in 1999; in second place and first among women were malignant neoplasm. Mortality from infectious diseases and perinatal complications have declined over time as well as the rates for metabolic, endocrine and nutritional disorders, mainly due to a decrease in diabetes mortality. The most often reported non-communicable chronic diseases are cardiovascular diseases, especially hypertension; rheumatic diseases; diabetes mellitus, chronic bronchitis; mental health disorders; peptic ulcer and epilepsy (Vega et al., 2002). Available but incomplete epidemiological data suggests that the regions that hold the largest concentrations of indigenous populations have less favorable health indicators than the rest of the country. Infant mortality rates in the period 1988–1992 varied among different indigenous groups, being 40 per 1,000 live births among the Aymará; 57 among the Atacameños; 32 among the Rapa Nui; and 34 among the Mapuche. Health conditions among the indigenous population appear to have deteriorated more in urban areas than in rural ones (PAHO, 1998). In 1998, 99% of the urban population had access to potable water through public systems, 90% had access to sewerage systems, and 4% to mainly septic tanks and soak ways. One percent of the urban population (115,000 people) had no water service, and 7% (853,000 people) had no adequate sewage disposal system (PAHO, 2002).
A.4
Demographic and epidemiologic transition in Chile The above-mentioned improvements that occurred in the health status of the
Chilean population in the last decades proveoked great changes in the Chilean demographic and epidemiologic profile. In 1960, 39.6% of the Chilean population had less than 14 years old, birth rate was 36.3 per 1,000, general mortality rate was 12.3 per 1,000 and infant mortality rate was 120 per 1,000, with infectious and newborn's diseases representing 44% of deaths. By contrast, in 2001, 28% of the population was 132
less than 14 years old, birth rate decreased to 18.3 per 1,000, and general and infant mortality rates diminished respectively to 5.4 and 8.9 per 1,000, with 68% of deaths due to chronic diseases. These figures evidence that Chile is currently in a late stage of the demographic and epidemiological transition, similar to the exhibited by developed countries, with an aging population due to decreases in birth rates and increases in life expectancy, with chronic non-communicable diseases as the main causes of death (Szot, 2003). The epidemiologic transition in Chile has had a rapid progression, from a transition stage in the 1970s to a post-transition or late stage by the end of the 80s. The main mechanism involved in this transition are the increase of risk factors for chronic diseases characteristic of the urbanization process, that has affected the incidence of chronic diseases, the fertility decline, which has changes the age structure of the population, and the improvement in case-fatality rates.
The economic growth
experienced in the decade of the 1990s and its consequent modernization improved access o health care and education, coverage of potable water and sanitation and therefore a decrease in infectious diseases, malnutrition and infant mortality rates was observed, however, produced negative effects on lifestyle, such as a decrease in physical activity and changes in feeding patterns toward a western diet and its predominance of fast food consumption, as it has occurred in many developed societies, although in Chile the rate of change has been faster than in industrialized nations. In two decades the country transited from a transitional stage with high undernutrition and low obesity rates to a post-transition stage with high obesity prevalence rates in all ages and virtual eradication of undernutrition. An increase in alcohol and drug abuse and a sustained high prevalence of smoking has also been observed, as well as air pollution, an important public health problem, especially in Santiago (Albala et al., 2002). While Chile, Uruguay and Argentina are in a late stage of the transition, other Latin American countries such as Honduras, Guatemala, and Bolivia are in an early stage, with most Latin American countries being in intermediate stages (Szot, 2003). The epidemiologic transition in Chile, as it has occurred in many other nations, has determined a health situation where some problems related to under development, such as some particular communicable diseases, coexist with chronic diseases, accidents and mental health problems associated with unhealthy lifestyles, pollution problems and a perception of social vulnerability on the population (Salinas, 2000).
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Appendix B The Chilean health system B.1
Health system organization Health is considered a basic human right by the Constitution of 1980, being the
State’s duty to ensure that all citizens are able to exercise their right to protect their health and to live in an unpolluted environment. The Constitution recognizes a person’s right to choose whether to receive care in the public or the private health care system. The health sector is a mixed system, with a private and a public component. The public component covers around 60% of the population, basically the urban and rural poor, the lower middle-class and the retirees. Around 35% of the population, mostly the upper-middle class receives care from the private sector. The public system or National Health Services System (SNSS) consists of the Ministry of Health (MINSAL) and its sub-agencies, the 29 Regional Health Services (SS); the National Health Fund (FONASA); the Public Health Institute (ISP); the Central Supply Clearinghouse (CENABAST); the ISAPRE Authority, and the network of primary health care facilities under municipal administration. There is also an Environmental Health Service in the Santiago metropolitan region. FONASA is the financing body of the public sector, which collects, administers and distributes financial resources. The Public Health institute is in charge of all issues related to drugs and medicines and supervises public laboratories, being the national reference center for public health issues. CENABAST controls the purchase and delivery of all drugs, supplies and medical equipment for the SNSS. The ISAPRE Authority regulates the private insurer institutions (ISAPREs). The Ministry of Health is the lead agency in the sector. It formulates and establishes health policies and issues general standards, as well as plans, supervises, monitors, and evaluates compliance with them. The Health Services, FONASA, the ISAPRE Authority, the Public Health Institute, and the Central Supply Clearinghouse (CENABAST) report to the Ministry.
In each region, the Ministry of Health is
represented by a regional secretariat. The 29 health services are in charge of health promotion and protection plans, and deliver health care services to patients through a
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network of hospitals and health posts. Although they have administrative autonomy, have to follow the rules and instructions of the MINSAL. Most of primary health care is provided through the Municipal Primary Health Care System; however, the MINSAL supervises, through the Regional Health Services, the delivery of primary care and primary health care facilities’ compliance with the MINSAL technical norms. The private system includes basically the Health Provision Institutions or ‘Instituciones de Salud Previsional’ (ISAPREs) and other agencies such as Army Health Services. ISAPREs collect and administer the mandatory health contribution from the people that choose to be insured by the private sector instead of FONASA, offering health plans on an individual basis to its members and families. Additionally to the mandatory contribution, members can pay an additional contribution to have access to additional benefits. These institutions provide services through their own outpatient primary care services or, mainly, through contracted private or public primary care and hospital facilities, with the level of freedom of choice for the affiliated varying according to the contracted plan. ISAPREs have the legal obligation to cover in all plans preventive medicine exams, sickness pay insurance and protection for pregnant women and children aged less than 6 years. Of the approximately 35.3% of the population that receives care in the private sector, 23.7% are covered by ISAPREs, 2.7% by the Armed Forces health care system, 0.9% by other systems, and 8.0 % cover their own health care expenses. A parallel private system for occupational health, which consist of three not-for-profit organizations (Mutuales), insure and provide health services to more than 2.5 million workers (PAHO, 1998). Health care is regulated by rules that form part of the Ministry of Health's programs. The programs define coverage, frequency of contacts between users and services providers, and the responsibilities of the different levels in the system. The Health Services Directorates are responsible for regulating public and private health care establishments located in the territory of the respective Health Service. The drug market is governed by a series of regulations on standards for products and distribution and sales chains, being affected by factors such as the significant market share of generic drugs, the large presence of national laboratories, and the existence of the Ministry of Health's Central Supply Clearinghouse. There are no price controls on medications. Generic drugs account for 38% of the total pharmaceutical market.
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The Public Health Institute has responsibility for controlling the quality of foods, but the Ministry of Health through the regional health services authorizes the marketing of foods, monitors food-handling practices, and inspects the sanitary conditions in food establishments. A network of public health laboratories carries out analysis of food samples. A new regulation governing food safety has been promulgated. There is also a control and hygiene program with national coverage and coordination, which is supported by the national network of bromatological laboratories (PAHO, 2002). Regarding human resources, the country had 17,467 physicians in 1998 (18 physicians per 10,000 population). It is estimated that just 8,000 of the country's 18,000 nurses worked in the public sector. In 2000, the public health sector employed 90,000 people, which indicates that administrative and service staff accounted for one-third of the total (PAHO, 2002).
B.2
Health care financing All employees and retirees make a contribution to health of 7% of their taxable
revenues, up to a top limit, being their choice to pay this either to FONASA or to an ISAPRE. For self-employed citizens, this contribution is optional. The resources of FONASA, which is in charge of financing the public sector health services, come mostly from general taxes, the mandatory contribution and copayments. This agency finances the SNSS and the Municipal services. SNSS health facilities receive diagnosis-based-payments from FONASA for the most frequent pathologies and a prospective-payment-for-service for other diagnoses.
Municipal
facilities funding is based on a per-capita system that takes into account the registered population, its socio-economic characteristics (rurality and poverty), and the amount of services effectively delivered. The population under FONASA’s institutional modality (basically the poor who make no mandatory contribution) cannot choose their provider and receive care only from public facilities. People who make their mandatory contribution to FONASA can use either the institutional modality or the free-choice modality. Co-payments can be 0%, 10% or 20%, depending on the income level. Under the free-choice modality, users can choose private providers, with the co-payment depending on the registered level of
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the provider. There are three levels, and providers register themselves into the group of their choice. The funds of the ISAPREs come from the mandatory contribution, additional voluntary contributions to improve coverage and voluntary contributions of the selfemployed, plus a 2% contribution paid by employers for some low-income employees and co-payments (Manuel, 2002). Table 6 illustrates the most relevant Chilean health account indicators. Table 6: Chilean health account indicators
Indicator Per capita GDP in international dollars, 2001
Value 11,265
Total health expenditure Total expenditure on health as % of GDP, 2001 Per capita total expenditure on health at average exchange rate (US$), 2001 Per capita total expenditure on health in international dollars, 2001
7.0 303 792
Public health expenditure General Government expenditure on health as % of total expenditure on health, 2001 General Government expenditure on health as % of total general government expenditure, 2001 Per capita government expenditure on health at average exchange rate (US$), 2001 Per capita government expenditure on health in international dollars, 2001
44.0 12.7 133 348
Sources of public health expenditure Social security expenditure on health as % of general government expenditure on health, 2001 External resources for health as % of total expenditure on health, 2001
71.8 0.1
Private health expenditure Private expenditure on health as % of total expenditure on health, 2001
56.0
Sources of private health expenditure Prepaid plans as % of private expenditure on health, 2001 Out-of-pocket expenditure on health as % of private expenditure on health, 2001
40.3 59.60
Extracted from: http://www.who.int/countries/chl/en/ (site visited on September 2002)
B.3
Chilean health reforms The Chilean health care system has been subject of several reforms in the past
decades. The unified public health care system of 1952, which provided coverage for the entire population, started to change substantially since 1980, starting these changes
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under the military government (1973-1990).
The reforms consisted mainly in the
development of a private sector and decentralization of the system, which involved both a deconcentration process and the devolution of primary health care to municipalities. The democratic governments after 1990 have preserved the core organization, but introduced reforms aiming to reinforce the regulatory role of the state on the private sector and improve quality of care, because the decline in public health expenditure during the previous decades lead to a deterioration of public infrastructure, and the management of the deconcentrated organizations involved inefficient allocation of public resources due to a centralized system of payment and fixed structure of personnel (salaries were fixed by law for each service). This payment system lacked incentives for quality and cost-containment, and favored curative over preventive care, because most health promotion and prevention activities were not reimbursed. At primary health care facilities, the latter provoked a great financial problem since the fixed budget for each center underestimated the costs of the services, which also were insufficiently adjusted for inflation. This provoked deterioration in the quality and quantity of the services provided by these centers, which deliver care mostly for the poor and rural areas. Coordination between the health services’ institutions and primary health care centers was also poor. In the private sector the main problems were weak regulation concerning ISAPREs ability to discriminate risks. Despite better regulations, in recent years about 3.2% of the patients covered by these private institutions are 60 years of age or older, as compared with 12% of the patients seen at public facilities, and annually, around 24% of patients covered by ISAPREs receive services in public facilities because they cannot afford co-payments for certain interventions. Although public health expenditure has considerably increased over the years with funds provided by the state, grants and loans from foreign democracies, the World Bank and the Inter-American Development Bank (IDB), the main problem of the Chilean health system is fairness. Chilean health indicators are among the best in Latin America and close to those of industrialized countries, and according to the World Health Report 2000, which analyzed the performance of 191 countries’ health systems, Chile is ranked 33rd for the overall health system performance, 23rd for the level of health, and 1st for the equity in distribution of health conditions; however, ranked 168th for fairness concerning financial contribution to the health system. Because people can choose whether to pay their contribution to the public or the private system, the high 138
income strata do not contribute to the public sector except through general taxes, thus, health care of the poor is ensured by the contributions of the middle and lower classes that remain in the public sector. Efficiency of both, public and private sector is another problem. ISAPREs competition and the mobility allowed to the affiliated result in a system of short term contracts, which leads to under-provision and coverage of preventive medicine since private institutions do not benefit from preventive strategies in the long term. Although ISAPREs are obliged to provide regular check-ups, they do not encourage their use. In the public sector efficiency problems are related with information gaps regarding people’s ability to afford co-payments, and low production of health services despite the increase in public expenditure. Health services and municipal authorities lack autonomy for the most efficient management of resources, particularly human (Manuel, 2002). In recent years, the country has undergone a health reform process.
This
includes health objectives definition for the 2000-2010 decade (MINSAL, 2002), definition of a new National Health Authority and its corresponding Regional Health Authorities, development of an integral health package, and the reengineering of the provision and financing of health services (Vega et al., 2002). The purpose of the reform is to guarantee the right to health for all Chileans without discrimination; improve their levels of health; and reduce inequities owing to the socioeconomic status and geographical location. The basic proposal establishes a guaranteed plan that is binding on the public insurer (FONASA) and the private insurers (ISAPREs) and assures effective and timely treatment of the most frequent, serious, and costly diseases. Priority is placed on primary care, and the family and community health teams will be strengthened. In structural terms, the reform is intended to create a solidarity fund, financed by government contributions and three-sevenths of the mandatory health care quotas, which will finance a guaranteed plan for the members of FONASA and the ISAPREs (PAHO, 2002).
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