Challenge
Uruguay’s aging demographic structure was associated with a shifting epidemiological profile and a rising prevalence of NCDs. In 2003, six out of ten deaths were linked to cardiovascular diseases and various forms of cancer related to old age. Likewise, chronic illnesses accounted for an estimated 75 percent of all lost disability-adjusted life years. The burden of chronic NCDs was distributed inequitably, with the poor enduring more suffering than the rich. The increase in NCDs and the growing financial cost associated with their treatment posed a serious concern about the financial sustainability of the health system, with total health expenditure corresponding to 9 percent of GDP. Therefore, an emphasis on NCD and associated risk factor prevention and surveillance was critical to contain rising health care costs and improve the financial efficiency of the health system.
Approach
The NCD Prevention Project supported the Uruguayan government’s effort to re-focus the prevailing health care model towards NCD and risk factor prevention. The Project worked simultaneously on the supply and the demand side, achieving both a change in the model of attention toward NCDs while containing fiscal pressures. Supply-side measures included: (i) the design of relevant policy tools (regulation, stewardship, and surveillance); (ii) the strengthening of NCD screening and control-related infrastructure, management and public health system human resource capacity; and (iii) establishment of, and training for, NCD prevention programs. Demand side measures centered on promotion and communication activities. NCD risk factor prevention was also promoted through Previniendo, an innovative program that linked financing to outcomes related to prevention activities for targeted NCDs with high prevalence (hypertension, diabetes, obesity/overweight, and colon cancer).
Results
The NCD Prevention Project has helped support improvements in several key outcomes:
- Mortality linked to circulatory system diseases in the population aged 70 years and above fell from 75.18 percent in 2006 to 60.3 percent in 2014
- The cases diagnosed and under follow-up by primary care teams for the following NCDs increased between 2006 and 2014, reaching
- 62.6%, up from 54.7% for hypertension,
- 77.6%, up from 63.9% for diabetes, and
- 34.3%, up from 13% for obesity/overweight
- The population in the highest risk age bracket (45–64 years) covered by the National Integrated Health System and screened for NCD risk factors rose from 0% in 2006 to 36.7% in 2015.
- One hundred and twenty two public and private primary health care establishments were certified and accredited on NCDs medical care ambulatory procedures, increasing the quality of primary health services.
- Uruguay’s Ministry of Public Health (MSP for its acronym in Spanish) was strengthened in the following areas: (i) surveillance capacity to monitor NCDs and related risks factors; (ii) promotion policies fostering healthy lifestyles; and (iii) regulation
Bank Group Contribution
The World Bank’s 2005 Health Sector Review in Uruguay and the 2007 Healthy Development Report, provided the analytical foundation for the Project of US$ 25 million. The Project also benefited from a Policy and Human Resources Development Grant (TF 52535) of US$ 447k from Japan which financed technical assistance and preparatory studies.
Partners
The MSP and the State Health Services Administration (ASSE for its acronym in Spanish), the main public provider in Uruguay, implemented project activities. A distinctive feature of the project was its implementation using the state internal administrative structure with overall support and coordination from a Project Unit within the MSP. This type of arrangement facilitated the institutionalization of the activities supported by the project, although it led to a longer execution period.
Moving Forward
Uruguay’s commitment towards the NCDs agenda suggest that support to the Project’s development objectives will continue beyond the life of the Project. The MSP’s NCD focus continues to be a priority due to the country’s aging and high NCD incidence and the impact this has on the health sector. As the health information system is strengthened, both through data system improvements and more comprehensive data on the country’s health profile, the emphasis on NCD risk factor prevention is gradually being mainstreamed.
Beneficiaries
The primary project beneficiaries were individuals suffering from selected NCDs and those exposed to related risk factors, in particular low-income groups with a higher incidence of NCDs. Specifically, this included individuals diagnosed and under follow-up treatment for hypertension, diabetes obesity/overweight and colon cancer, women at risk of breast cancer and newborn and child with disabilities. The entire Uruguayan population benefitted from improved health promotion and regulatory measures.