September 2011 Number 171 www.worldbank.org/enbreve A regular series of notes highlighting recent lessons emerging from the operational and analytical program of the World Bank‘s Latin America and Caribbean Region (LAC). Non-Communicable Diseases in Jamaica: 65101 Moving from Prescription to Prevention by Shiyan Chao, Carmen Carpio and Willy de Geyndt Non communicable diseases (NCDs) are the leading cause of death throughout the Americas, but the epidemic has hit the Caribbean region particularly hard. NCDs represent not only the major causes of death (heart disease, cancer, stroke, and diabetes) but are responsible for the greatest share of the burden of disease in the Caribbean region (65 percent)2. Jamaica is not an exception. NCDs have spread progressively among the entire population in the last decade and are the leading cause of mortality and morbidity, accounting for the largest number of hospital discharges. Reducing the burden of NCDs in Jamaica is a national policy. The Government of Jamaica has recognized the importance of preventing and controlling NCDs and created the National Health Fund (NHF) to reduce the cost of treating them by providing free or subsidized medicines to patients with NCD conditions and finance some prevention Programs. The World Bank undertook a study to learn from Jamaica’s experience in tackling major NCDs and related risk factors, provide policy options for Jamaica to improve the NCD Program, and share with other Caribbean countries lessons learned from this experience. The study answered three questions: (i) whether Jamaica’s NHF and its drug subsidy Program have reduced out of pocket spending on NCD treatment; (ii) whether access to treatment of NCDs has improved in the country; and (iii) what is the economic burden on patients with NCDs and their families. Main Findings Treatment for NCDs is more affordable The NHF Drug Subsidy Program has achieved its primary goal of making NCD drugs more affordable. The results from the analysis of the Household Surveys before and after the establishment of the NHF indicate that patients with NCDs under the Fund paid less out of pocket for their pharmaceuticals than patients with NCDs without coverage. Individuals suffering from NCDs reduced   1 Based on the forthcoming study, “Non-Communicable Diseases in Jamaica: Moving from Prescription to Prevention�, June 2011, Report No. 62065-JM 2 PAHO/CARICOM 2006 1 their medicine and prescription drug expenditure on average by roughly 10 percent in 2006 and 2007 after the NHF drug purchase subsidy Program was introduced, relative to 2000 and 2001. Figure 1 summarizes the healthcare expenditure pattern for the poorest 20 percent population group with NCDs (quintile 1) and the richest population group suffering from these same diseases (quintile 5), respectively, and it shows that the distribution of NHF benefits is unequal among socioeconomic groups. The economically better off population group appears to benefit more from the Government subsidy of pharmaceuticals and is more likely to enroll in the NHF Program. The richest group spent seven times more than the poorest group, suggesting the need for the Program to more effectively target the poor and extend their enrollment. Figure 1. Individual Annual Medical Expenditures Individual annual 1 medical expenditures before and after NHF Program among NCD population (in 1000 2008 constant JMD) Program among population with NCDs before and after the NHF (in 2008 constant JM$, thousands) Utilization of healthcare has increased People with NCDs in general increased their Richest 20% utilization of health services. Health service expenditure Medical service Poorest 20% visits among patients with NCDs showed 100% of Population an upward trend as opposed to a fairly flat curve among non-patients with NCDs. Medicine and Richest 20% expenditure prescription Patients with NCDs on average had more drug Poorest 20% 100% of Population healthcare visits than other patients, and $0 $10 $20 $30 $40 $50 $60 $70 $80 this gap increased six times in a period of 17 years, from 3.8 percent in 1990 to 18 2006 and 2007 2000 and 2001 percent in 2007 (Figure 2). Although the Source: Study estimates based on JSLC 2000-2007 implementation of the NHF Program may Note: Expenditures data combined and annualized for period before NHF (2000 and Source: Studies estimates based on JSLC 2000-2007 2001) and after NHF (2006 and 2007) to expand study sample size. not explain this profound change in care seeking behavior, patients with NCDs are obviously utilizing healthcare services Figure 2. Adjusted Health Service Visits for individuals with and without NCDs (%) more. 80% The population with NCDs visiting health 75% 70% services increased by approximately 65% 5-6 percent, from 70 percent in 2001 to % visit 60% 76 percent in 2006, after the establishment 55% of the Program (Table 1). The average 50% number of visits per patient slightly 45% decreased from 1.6 to 1.3 in the same period. 40% However, the proportion of visits to public 19 0 19 1 19 2 19 3 19 4 19 5 19 6 19 7 19 8 20 9 20 0 20 1 20 2 20 3 20 4 20 5 20 6 07 facilities, including public health centers and 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 19 year non chronic chronic hospitals, as well as pharmaceutical drug purchases, did not significantly change. Source: Estimates based on JSLC 1990-2007 Note: Adjusted for major household socioeconomic characteristics. Table 1. Individual Health Service Utilization before and after the NHF Program among population with NCDs 2000 and 2001 2006 and 2007   Population with NCDs Poorest 20% Richest 20% Population with NCDs Poorest 20% Richest 20% Health Service Visits (%) 70 71 69 76 73 77 Number of Visits 1.6 1.7 1.5 1.3 1.3 1.2 Public Facility Visits (%) 45 69 31 44 64 28 Medication Purchases (%) 79 66 85 78 72 81 Source: Estimates based on JSLC 2000, 2001, 2006 and 2007 2 NCDs impose heavy burden on patients and their families NCDs not only adversely impact quality of life through morbidity or mortality, but also impose an economic burden on households and on society as a whole. The direct economic burden at individual level is the sum of out of pocket spending by patients with NCDs on outpatient and inpatient care, and medication. The indirect economic burden of NCDs comes from loss of income due to work absenteeism associated with illness. The study estimated the direct and indirect economic burden of NCDs on individuals and their   families. An individual suffering from NCDs spends approximately one third of household per capita multilevel, and multisector strategy. Reversing expenditure on healthcare services and purchase the NCD epidemic in Jamaica requires a of pharmaceutical drugs. National aggregate out of National Strategy that combines three levels of pocket health expenditure amounted to JM$ 33,813 prevention. The focus so far has been on clinical million (US$452 million), or 3.08 percent of Jamaica’s interventions, by prescribing and subsidizing GDP. The 2006 and 2007 annual average total pharmaceutical drugs, and less on population- economic burden of NCDs, including indirect income based primary and secondary prevention. The loss, was estimated to be JM$ 47,882 million (US$ National Strategy will need to put population- 641 million). The poorest, the elderly, and persons based prevention at center stage and define with hypertension spent more on healthcare than achievable and measureable goals with specified other groups of the population, indicating important time frames. targets for Government intervention. 2) Improve the efficiency of the NHF by: (i) Policy Options assessing the effectiveness of the prevention programs financed by the NHF; (ii) striking the The preliminary analysis of Jamaica’s NCD policy appropriate balance between prevention and and Program indicates that the drug subsidy the drug subsidy programs; and (iii) improve Program supported by the NHF has helped targeting of the poor under the drug subsidy patients with NCDs reduce their spending on Program. Activities should focus on geographic treatment. However, there is little evidence areas where poverty, disease, and violence are indicating that the trend of burden of disease concentrated, areas where the poor population due to NCDs is declining, and the study suggests would benefit from NHF coverage. much more needs to be done to stop and reverse the increasing trend. Treating patients by 3) Improve the surveillance system to monitor prescribing drugs at a lower cost to the patient the risk factors and NCDs. The dearth of is a worthwhile objective, but evidence from reliable registration and reporting of cause- elsewhere suggests that preventing the disease specific mortality and morbidity makes targeting from occurring is more cost effective. difficult. Improved information on risk factors is a necessary first step to feed data into the NCD Jamaica may want to consider the following policy policy dialogue. Health information systems options and interventions for enhancing its NCD need to be developed to collect and report data Prevention and Control Program: on risk factors, mortality, morbidity, and the determinants of NCDs. 1) Agree on a comprehensive National Strategy to tackle NCDs. NCDs are due to behaviors and 4) Evaluate the effectiveness of strategies, social conditions that require a comprehensive, policies and interventions. Evaluation of the 3 effectiveness of existing strategies, policies and ongoing interventions will allow the Government to refine target groups and accelerate, adjust, or change interventions as a necessary process of learning from results on the ground. 5) Policies to tackle NCDs should include primary, secondary, and tertiary prevention. Primary prevention aims to prevent exposure to the risk factors that cause NCDs. These may include policies against smoking, and to promote   a healthy diet, encourage physical activity, and reduce harmful use of alcohol. Secondary improve health outcomes of patients with NCDs, prevention strategies aim at identifying and as well as potentially contain costs and increase mitigating risk factors before they result in disease, patient satisfaction. and these include interventions such as quit smoking clinics and weight reduction programs. 8) Adopt a multi-sector approach for NCD Tertiary prevention consists of measures aimed prevention and control by involving non- at softening the impact of long-term disease and health ministries, civil society organizations, disability by eliminating or reducing impairment, and the private sector. Jamaica has a wealth of disability and handicap; minimizing suffering; experience in controlling the HIV/AIDS epidemic and maximizing potential years or useful life3. and this knowledge can be applied to NCD Activities at the tertiary level should focus on the prevention and control. Civil Society Organizations avoidance of complications and preventing the (CSOs) and the private sector can play critical progress of the disease. The NHF Drug Subsidy roles in promoting a healthy lifestyle and society, Program falls into this category. and preventing unhealthy diets, encouraging physical activities, and discouraging smoking 6) Address the gender dimension when and excessive alcohol consumption. The business targeting. Women and men are exposed to risk community can contribute to both financing and factors to a different degree. Men are more likely implementing NCD prevention and control. to use tobacco and consume alcohol in excess, while women are more likely to be obese and About the Authors physically inactive. Health promotion and disease prevention programs should target gender- Shiyan Chao is a Senior Health Economist and Team specific risk factors using tested methodologies. Leader for the Economic Sector Work on NCDs in the Caribbean, Willy de Geyndt is a Public Health 7) Reorient the health services delivery system to Advisor, and Carmen Carpio is a Public Health adopt new care models. Disease Management Specialist. This “en breve� benefited from comments Programs and integrated care models hold from Joana Godinho, LAC Health Sector Manager, promise for more effective approaches to and David Seth Warren, Caribbean Sector Leader. 3 A Dictionary of Epidemiology. 4 ed. Oxford University Press, 2001 via http://www.cdc.gov Disclaimer: The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the Executive Directors of the International Bank for Reconstruction and Development / The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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