In the previous session, we have examined the so-called high risk strategy to address non-communicable disease, and I have spoken about what is called the PEN package to address various non-communicable disease risk factors at individual level in the primary health care setting. Now, I would like to emphasize a little bit more on one risk factor which is hypertension. If you look at this slide here, you will see the burden that is the total number of deaths due to different conditions. And you can see in this slides that the first cause of death is high blood pressure. In blue, it's low-income countries, in red is middle-income countries, and in yellow, it's high-income countries. And what you see is that in all countries, all types of countries high blood pressure is by far the leading cause of death. With this so high frequency of high blood pressure in all countries, this deserves special attention to address this issue if we want to reduce non-communicable disease by 25 percent in 2025. In this slide here, I have tabulated different conditions and the different characteristics associated with screening and treatment. Let me go through these different factors whether it's frequent in the population or not, whether it's easy to measure or not, whether the measurement is expensive or not, whether there is an effective treatment available, whether this treatment has side effects or not, whether the treatment can cost less than five dollars a month, whether the treatment could be given along a guideline that will be no longer than one single page that can be read by anyone, whether the diagnoses can be done by a non-doctor, whether the treatment can be started by a non-doctor, and whether the follow up of that condition can be done by somebody else than a doctor. Now when you look at the different conditions of non-communicable disease in this table, high blood pressure, high cholesterol, diabetes type 2, diabetes type 1, treatment for myocardial infarction, rheumatic heart disease, and other NCDs. You can see that only high blood pressure is green, that means good, favorable, easy, simple, not expensive or other conditions have one or more issues that make them not so easy to be managed at primary health care level. Now, a lot of people would say treatment for non-communicable disease is expensive and that's a major barrier to long-term treatment since non-communicable disease mainly high blood pressure, diabetes, dyslipidemia generally need to be treated for life. That means for 10, 20, 30 years of time. Now you can see here from this table that is a public table that treatment for several of these NCDs includes even high blood pressure can be purchased for less than two or three dollars per month. Two or three dollars per month is not cheap in low-income countries but is not very expensive, and in particular it's not more expensive than treatment for HIV. So, by having good procurement of this medication through appropriate channels, it is possible to have treatment, long-term treatment for non-communicable condition at least for selected of them at a fairly low cost. I show here an evaluation that was done by WHO and other organizations about what would be the cost of treating all people at high cardiovascular disease risk in a country. And one you can see is that this addressing priority non-communicable diseases in a country can cost as little as one dollar per capita in low-income countries. Again, one dollar is not that low but it is absolutely addressable by most of the countries. In that slide which is a very classical slide, we see that if we really want that some screening and treatment strategy is taken up by countries, we need to think about different dimension in terms of systems. One is to provide NCD services, extended services. And I make the case that starting with blood pressure would already be a big progress, big step forward. Then we have to reduce the cost, the cost of sharing expenses by patients. And I would argue medication should be free for people if you want people to take medications on the long term in low-income countries and cover the uninsured, and that comes back to the same issue when it comes to non-communicable disease medication that needs to be taken on the long-term, needs to be provided free of charge or at a very low cost but certainly rather without expenses at the level of the patients, because taking long-term treatment for people is a major cause for impoverishment. Now, service delivery model: what to do at what level? Again, there are many things that are included on NCDs, there are many conditions that are complicated to treat and that need to be taken care at second or tertiary level, that means at hospital level. But again, I want to make the case that high blood pressure is simple as a simple treatment can be managed by almost anyone non-medical and can be addressed and managed at very low primary health care level inclusive at village level. And that's a reason blood pressure is added in that slide in yellow at the lowest health care level. We have to figure out that there are hundreds of millions of people worldwide who have that condition and there is no other choice that these people must need to be seen and managed at the lowest primary health care level. They're cannot be seen at hospital level because they were overburdened hospital services then they need to be seen at primary health care level. And in this last slide, I want just to emphasize a few issues that are related to providing health care especially for high blood pressure at the lowest possible primary health care level. One is to set national targets that need to be a political agreement on what has to be done. Then as I said earlier, health care has to be given at the lowest possible level. That means in a dispensary in a very remote village by any kind of health person. Persons do not need to travel to a hospital to get treatment otherwise treatment will never be taken for long. Then we have to focus on easy wins. An easy wins is, as I showed earlier in the previous table, high blood pressure is an easy win. Emphasis need to be on total risk approach. This is simple to say is not always easy to do because to assess total risk, we need to assess a few other things. So this has to be discussed in different context as that might not be that simple to practice. Then we need to have guidelines and protocols. For high blood pressure guidelines can have one pitch, and I emphasize on this because that comes to my next point. Treatment of NCD needs to be shifted or shared with other health professionals than doctors. In many places, there are no doctors in villages. We have nurses or perhaps even other person than nurses, community workers, or any other allied health professionals. And these people must be able to treat hypertension in these remote villages that what is called task sharing or task shifting. Then the treatment has to be person-centered. It needs not to be hypertension clinic or HIV clinic or whatever. We need to see the patients as a whole and bridge gaps. Measure high blood pressure in an HIV clinic, measure high blood pressure in a TB clinic, and so long. Quality of service is essential because we have to empower patients for long term services. Health informations need to be collected. For blood pressure, we need to measure blood pressure over time to see how it goes. Universal access to health care is important. As I said, treatment needs to be free. And generally, a program need to be accepted by health professional in the country. So finally in conclusion, I just want to emphasize that screening and management of selected condition especially high blood pressure is essential in non-communicable disease if we want to achieve a reduction of 25 percent of NCD by 2025. Focus should be on condition that contribute most to the total burden and high blood pressure clearly is one. They are tools for management of non-communicable diseases, I spoke earlier of the Pan package. And I insist again that high blood pressure is the perfect low-hanging fruit, something that can be fairly easily assessed. And if assessed and if managed properly would be by itself a big contributor of health benefit to achieve the goal of 25 percent reduction of NCDs by 2025.
