Moving Towards Optimized Noncommunicable Disease Management in the ASEAN Region: Recommendations from a Review and Multidisciplinary Expert Panel

Figures & data

Table 1 Burden of NCDs in Selected ASEAN Member States^a in 2017

	Death (n)	Disability^b (Years)
Cardiovascular diseases	4.2 million	6.6 million
Chronic respiratory diseases	1.5 million	13.7 million
Cancer	1.6 million	0.9 million
Diabetes and chronic kidney disease	0.8 million	12 million
Mental disorders	0.06 million^c	32 million

Notes: Data from Institute for Health Metrics and Evaluation, GBD Compare.^{4 a}Data are for the following selected ASEAN countries: Indonesia, Malaysia, Philippines, Singapore, Thailand, and Vietnam. ^bDisability is measured as disability-adjusted life years (DALYs). ^cDeath from mental disorders, suicide and self-harm (excluding mortality from comorbid NCDs in people with mental disorders).

Abbreviations: ASEAN, Association of Southeast Asian Nations; NCDs, noncommunicable diseases.

Table 2 Prevalence of Behavioral and Metabolic NCD Risk Factors in the ASEAN Member States

	Current Tobacco Smoking, Aged ≥15 Years	Insufficient Physical Activity, Aged ≥18 Years	Mean Population Salt/Sodium Intake, Aged ≥20 Years (g/day)	Total Alcohol/Capita Consumption, Aged ≥15 Years (Liters of Pure Alcohol)	Raised Blood Pressure, Aged ≥18 Years	Obesity (Aged ≥18 Years, Aged 10–19 Years)	Raised Blood Glucose, Aged ≥18 Years
Brunei Darussalam	17%	26%	11	0	18%	15%,12%	9%
Cambodia	15%	10%	11	7	23%	4%, 3%	6%
Indonesia	39%	22%	9	1	22%	7%, 5%	7%
Lao PDR	27%	15%	11	10	19%	5%, 4%	6%
Malaysia	22%	38%	9	1	21%	15%, 11%	10%
Myanmar	20%	10%	11	5	23%	6%, 3%	7%
Philippines	24%	38%	11	7	19%	6%, 3%	6%
Singapore	16%	38%	13	2	17%	7%, 6%	9%
Thailand	21%	25%	13	8	25%	11%, 10%	10%
Vietnam	23%	25%	12	8	22%	2%, 2%	5%

Note: Data from the World Health Organization.⁸

Abbreviations: ASEAN, Association of Southeast Asian Nations; BMI, body mass index; NCD, noncommunicable diseases.

Figure 1 Structure of health expenditure in selected ASEAN member states in 2017.

Note: Data from the World Health Organization.¹⁷
Abbreviation: ASEAN, Association of Southeast Asian Nations.

Table 3 Healthcare Spending and Availability of Resources for NCD Management in the ASEAN Member States

	Current World Bank Income Group	Government Health Expenditure as %GDP	Total Health Expenditure per Capita (%Government, %OOP)	Existence of an Operational Integrated NCD National Policy/Strategy/Action Plan	Existence of national NCD Guidelines at Primary Care	NCD Medicines Reported as “Generally Available”^a	NCD Technologies Reported as “Generally Available”^b	Density of Medical Doctors per 10,000 Population^c	Density of Nursing Personnel per 10,000 Population^c
Brunei Darussalam	High income	2.3%	US $671 (95%, 5%)	Yes	No	10 of 10	6 of 6	16.1	59.0
Cambodia	Lower-middle income	1.4%	US $82 (24%, 60%)	No	No	3 of 10	1 of 6	1.9	6.9
Indonesia	Lower-middle income	1.4%	US $115 (48%, 35%)	Yes	Yes	10 of 10	5 of 6	4.3	24.2
Lao PDR	Lower-middle income	0.9%	US $62 (35%, 46%)	Yes	Yes	8 of 10	6 of 6	3.7	9.5
Malaysia	Upper-middle income	2.0%	US $384 (51%, 38%)	No	Yes	10 of 10	6 of 6	15.4	34.7
Myanmar	Lower-middle income	0.7%	US $58 (15%, 76%)	Yes	Yes	7 of 10	4 of 6	6.8	10.0
Philippines	Lower-middle income	1.4%	US $133 (32%, 53%)	Yes	No	4 of 10	4 of 6	6.0	49.4
Singapore	High income	2.1%	US $2,619 (48%, 32%)	No	Yes	10 of 10	6 of 6	22.9	62.4
Thailand	Upper-middle income	2.9%	US $247 (76%, 11%)	Yes	Yes	8 of 10	6 of 6	8.1	27.6
Vietnam	Lower-middle income	2.7%	US $130 (49%, 45%)	Yes	Yes	2 of 10	3 of 6	8.3	14.5

Notes: Data from the World Health Organization.^{8,16–18 a}List of essential NCD medicines include at least aspirin, a statin, an angiotensin-converting enzyme inhibitor, a thiazide diuretic, a long-acting calcium channel blocker, metformin, insulin, a bronchodilator and a steroid inhalant.¹⁹ bList of essential NCD technologies include at least a blood pressure measurement device, a weighing scale, blood sugar and blood cholesterol measurement devices with strips and urine strips for albumin assay.¹⁹ cThe data are as per the latest statistics from the WHO Global Health Workforce Statistics (December 2018 update).¹⁸

Abbreviations: ASEAN, Association of Southeast Asian Nations; GDP, gross domestic product; NCD, noncommunicable diseases; OOP, out-of-pocket expenditure, WHO, World Health Organization.

Table 4 Proposed Recommendations for Addressing Gaps in Policies for Optimizing NCD Management in the ASEAN Member States

	Recommended Actions	Potential Stakeholders	Performance Indicators
1. Implement national NCD screening programs by providing adequate resources (healthcare facilities and trained health workers)	Conduct annual/biannual screening—a minimum of BMI, BP, blood sugar, blood lipid measurements as defined by existing clinical practice guidelines in the country Train community volunteers as auxiliary healthcare workers	Government, healthcare volunteers, nonprofit organizations, HCPs and community	Proportion of eligible population screened per year
2. Improve access to NCD medication	Regulate to ensure general availability of NCD medicines and basic technologies at public and private primary care centers through UHC or health insurance Increase availability of cost-effective NCD interventions and quality low-cost generics in the basic primary healthcare package Explore evidence-based and viable health-financing mechanisms and innovative economic tools	Government, payers, pharmaceutical organizations, pharmacies, technology companies, HCPs and society	Access and availability of essential NCD medications including quality low-cost generics and technologies in private and public healthcare facilities Population covered by UHC or other forms of health insurance
3. Introduce health promotion programs in schools, universities, workplaces and public/private spaces	Organize NCD risk factor awareness programs Introduce school and work-based meal programs with healthy and balanced diet	Government, education institutions, nonprofit organizations, nutrition experts and society	Incidence of diabetes, hypertension and obesity in the population
4. Pass and implement legislation to reduce NCD risk factors (tobacco use, excessive alcohol use and salt intake)	Increase taxes on tobacco and alcohol Implement salt tax on food processing industry Ban use of trans-fat in processed food	Government, civil society, nonprofit organizations, tobacco industry, food industry, private sector and academia	Trend in number of smokers Trend in average alcohol consumption Salt intake <5 g/day (measured by dietary record or urinary sodium excretion) in the adult population
5. Provide an encouraging physical and social environment for people to practice healthy habits and incentivize healthy lifestyle	Create smoke-free areas in cities Improve pedestrian and bicycle network infrastructure across city Increase green, open and safe spaces in cities Reduce air pollution Provide incentive-linked health insurance schemes	Government, healthcare organizations, professional organizations, educational systems, health insurance companies, nonprofit organizations, media outlets, technology companies, food industry, health and fitness industry, transportation sector, real estate companies and society	Percent of population with ≥2.5 hours of moderate aerobic physical activity per week Incidence of obesity in the population
6. Integrate mental health in the management of chronic conditions in primary care settings	Integrate mental health care into national health policy using simple, cost-effective screening tools for depression, anxiety or stress Prioritize screening of mental disorders in NCD patients with poorly controlled risk factors (such as high blood sugar, BP and BMI) or with poor adherence, with appropriate referral for treatment in both primary and specialist care services	Government, professional organizations, psychiatrists, healthcare volunteers, psychiatrists, GPs, nurses and healthcare workers	Percent of ASEAN countries with an operational integrated national health plan with mental health risk assessment Percent of patients with uncontrolled chronic conditions screened for mental disorders Number of people screened for mental health problems at primary care facilities

Abbreviations: ASEAN, Association of Southeast Asian Nations; BMI, body mass index; BP, blood pressure; CVD, cardiovascular diseases; GPs, general physicians; HCPs, healthcare professionals; NCDs, noncommunicable diseases; UHC, universal health coverage

Table 5 Proposed Recommendations for Addressing Gaps in Clinical and Public Health Practice for Optimizing NCD Management in the ASEAN Member States

Recommendations	Recommended Actions	Potential Stakeholders	Performance Indicators
1. Set up local public and private primary care networks	Set up primary care networks with shared target goals, referral services and treatment guidelines	Government and private sector, professional organizations and HCPs	Number of operational primary care networks deployed in the region
2. Improve treatment adherence using evidence-based and innovative solutions	Develop evidence-based digital platforms to facilitate patient self-care, patient communication and patient education Promote SDM through patient decision-making tools and SDM training workshops for HCPs	Professional organizations, HCPs, nurses, pharmacists, technology companies, pharmaceutical sector, individuals and caregiver	Treatment adherence rate for NCDs
3. Actively promote interprofessional collaboration for holistic management of NCDs	Facilitate effective multidisciplinary treatment of NCDs through joint education/training sessions, shared document processing platforms, clinical decision support and defined referral pathways Engage family members/caregivers as peer support workers	Government, private sector, academia, HCPs, nurses, allied health professionals, patient and family	Hospitalization rates due to NCDs Biochemical risk factors (high blood sugar, high BMI, high BP, and high blood lipids) Number of venues available for patients and their family’s co-participation
4. Strengthen the role of pharmacists and other allied health professionals in NCD prevention and care	Build capability of pharmacists and other allied health professionals through accredited trainings to screen, counsel and monitor NCD outcomes Develop specialist referral pathways for pharmacists	Government and private sector, professional organizations, HCPs, nurses, pharmacists, pharmaceutical sector, technology companies, individuals and caregivers	Percent of patients counselled on their medications by pharmacists and other allied health professionals Number of trained pharmacists who can prescribe medicines Number of pharmacies with point-of-care NCD screening capabilities
5. Reform health professions education (HPE) curricula to enhance clinical practice for improved mental health management	Reorient training curricula towards identification and management of common mental health problems for physicians, nurses and pharmacists Train health workers to screen for and identify mental health problems among constituents in schools and colleges	Government and private sector, academia, education board, schools and community	Number of physicians, nurses and pharmacists trained with the revised curricula Number of trained personnel in schools and colleges equipped to screen for mental health problems
6. Enhance monitoring of NCD risk factors using evidence-based technology	Develop a robust national implementation framework for evidence-based technology for health care Promote disease surveillance through use of smartphone-based apps and home-based medical devices for measuring BP, blood sugar and BMI Generate and disseminate evidence on the efficacy and effectiveness of technological solutions in improving clinical outcomes	Government, technology companies, pharmaceutical sector, health insurance companies and data scientists	Rate of premature mortality and hospitalizations due to NCDs among the population using technology-based interventions Percent of people with NCDs using evidence-based technology for health care

Abbreviations: ASEAN, Association of Southeast Asian Nations; BMI, body mass index; BP, blood pressure; HCPs, healthcare professionals; HPE, health professions curricula; NCD, noncommunicable disease; SDM, shared decision-making.

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