Pekka Puska Professor, Member of Parliament Past Director General, National Institute for Health and Welfare (THL), Finland Past President, International Association of National Public Health Institutes (IANPHI) ACHIEVEMENTS AND CHALLENGES IN NCD PREVENTION IN FINLAND Northern Dimension Partnership in Public Health meeting Helsinki 11.10.2018
HISTORY IN FINLAND Hardships of war and postwar years Relative increase in standard of living Great increase in CVD Attention to extremely high CVD mortality Determined action: North Karelia Project 2
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NORTH KARELIA PROJECT PRINCIPLES Due to the chronic nature of CVD, the potential for the control of the problem lies in primary prevention The risk factors were chosen on the basis of best available knowledge: - previous studies - collective international recommendations - epidemiological situation in North Karelia Chosen risk factors: - smoking - elevated serum cholesterol (diet) - elevated blood pressure (diet & treatment Community based approach to change lifestyles 4
EVALUATION / MONITORING North Karelia all Finland Monitoring systems health behaviour risk factors nutrition diseases, mortality Monitoring developed to a national NCD monitoring system by THL 5
RESULTS Lifestyles and public health can change! 6
USE OF BUTTER ON BREAD (MEN 30-59) SERUM CHOLESTEROL (MEN30-59) mmol/l Laboratory bias corrected 7
SALT INTAKE IN FINLAND 1977-2007 FINNDIET STUDY (MEN 30-59) SYSTOLIC BLOOD PRESSURE 8
Now official aim: Smokefree Finland 9
CHANGE IN AGE-ADJUSTED MORTALITY RATES FINLAND, MALES AGED 35 64 (PER 100 000 POPULATION) Coronary heart disease start of the North Karelia Project extension of the Project nationally North Karelia -85% Rate per 100 000 1969-1971 2006 Change from 1969-1971 to 2006 All causes 1328 583-56% All cardiovascular 680 172-75% Coronary heart disease 489 103-79% All Finland -80% All cancers 262 124-53% Gain of some 10 healthy years in Finnish population 10
years years Healthy and sick years of life expectancy of 65 year old Finns in 1980 and in 2000 20 15 10 5 0 Managing basic functions Subjective health men women men women 1980 2000 1980 2000 Sick/disability Healthy/no disability 20 15 10 5 0 1980 2000 1980 2000 SIHVONEN YM. 2003 11
RESULTS: SUMMARY Big change in lifestyles and biological risk factors Big reduction in premature NCD mortality and incidence Increased subjective health Healthy ageing x x x NCD changes explained to great extent by risk factor changes 12
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MAJOR ELEMENTS OF FINNISH MAJOR ELEMENTS OF NATIONAL ACTION 1. FINNISH NATIONAL ACTION 2. Research & international research collaboration Health services (especially primary health care) North Karelia Project, other demonstration programmes Health Promotion Programmes (coalitions, NGO s, collaboration with media etc.) Schools, educational institutions Industry, business collaboration Policy decisions, intersectional collaboration, legislation Monitoring system: health behaviours, risk factors, nutrition, diseases, mortality International collaboration 14
INTERSECTORAL WORK FOR NCD PREVENTION - HEALTH IN ALL POLICIES People s lifestyles are influenced by decisions in different sectors of society (much of them beyond the health sector) Health in general and NCD prevention in particular should be taken into account in decisions made by different sectors (health impact assessment) Ultimately success calls for a social change process, combining government policies, expert guidance, broad health promotion and mobilization of people 15
8 th Global WHO Conference on health promotion - Health in all policies From Ottawa to Helsinki (June 2013) HELSINKI STATEMENT 16
EXAMPLES OF INTERSECTORAL WORK (1/3) Development of Finnish Rapeseed oil Change in fat content of Finnish cow milk g/kg 45 45 44 Fen: y = -0.16x + 362 44 43 43 Fen 42 Gen 42 Gen: y = -0.16x + 358 41 1970 1975 1980 1985 1990 1995 2000 2005 2010 Year 17
EXAMPLES OF INTERSECTORAL WORK (2/3) Biscuit example: Leading Finnish biscuit manufacturer (LU Finland Ltd) has removed some 80.000 kg of SAFA by changing the fats used All trans fats removed and major transfer to rapeseed oil Meat product example: HK (Leading Finnish meat company) since 2007 annually: 40.000 kg less salt 100.000 kg less saturated fat in their products Sal t concent r at i on ( % ) 2. 4 2. 2 2. 0 1. 8 1. 6 Sal t l evel i n Fi nni sh sausages 1975 1980 1985 1990 1995 YEAR 18
EXAMPLES OF INTERSECTORAL WORK (3/3) Berry project in North Karelia To promote berry farming, product development and consumption Dairy farmers could switch over to berry farming Financing from Ministries of Agriculture and Commerce Finnish Heart Symbol 19
REDIRECTION OF HEALTH SERVICES Reorientation and strengthening of health systems Primary health care: Now more than ever (WHR 2008) Special emphasis for NCDs Chronic care model Preventive practices 20
REFORM OF SOCIAL AND HEALTH CARE IN FINLAND (SOTE) Background: Changing needs Changing possibilities Ageing of population Increasing costs Objectives: Larger population base Integration (primary sector care, social services) Wider choice of services Equal acces to services Control of increasing costs Greater emphasis on primary care and prevention 21
SOLUTION Regions (maakunnat) to be responsible Integration Additional contribution of private services to public primary care Strenghtened ICT systems Digitalization Strengthened prevention & health promotion (regions, municipalities, NGO s incentives) The reform will create 18 autonomous regions with elected councils 22
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CORNERSTONES OF NCD PREVENTION AND CONTROL (WHO GLOBAL STRATEGY) Attention to behavioral risk factors Tobacco use Unhealthy diet Physical inactivity Harmful use of alcohol Monitoring and surveillance of Risk factors and diseases Preventive actions Redirection of health services Prevention Chronic care model 24
GLOBAL TARGETS (WHO NCD ACTION PLAN) 1. 25 % reduction of avoidable mortality 2. 10 % reduction in harmful use of alcohol 3. 10 % reduction in insufficient physical activity 4. 30 % reduction in mean population salt intake 5. 30 % reduction in tobacco use 6. 25 % reduction in raised blood pressure 7. Halt the raise in diabetes and obesity 8. At least 50 % of eligible (=high risk) people receive drug treatment and councelling to prevent heart attack and stroke 9. In 80 % availability of affordable basic technologies and essential medicines for NCD 25
INTEGRATED PREVENTION COMMON RISK FACTORS TOBACCO USE CVD UNHEALTHY DIET DIABETES PHYSICAL INACTIVITY ALCOHOL CANCER COPD MUSCULOSCELETAL ORAL HEALTH 26
SOUND COMBINATION OF POPULATION STRATEGY WITH HIGH RISK STRATEGY 1. Population strategy: - Greatest public health gains - Cost effective - Results also in other health benefits 2. High risk strategy: - Great benefits to the persons concerned - Effective use of health services 27
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PUBLIC RESPONSIBILITY POLICY INTERVENTIONS 29
DURING THE LAST FEW YEARS A GREAT NUMBER OF STRATEGIES AND PLANS FOR EVIDENCE-BASED, EFFECTIVE PREVENTION OF NCD S AND HEART HEALTH PROMOTION HAVE BEEN PRODUCED Many important priorities have been identified 30
FROM PRIORITIES TO IMPLEMENTATION IDENTIFYING PRIORITIES IMPLEMENTING THEM Implementation gap 31
From strategies to effective action IDENTIFYING PRIORITIES Less is more IMPLEMENTING THEM Policy support Institutional base Media support Resources Monitoring 32
MAIN CAUSES OF MORTALITY 33
COMPREHENSIVE ACTION AND PARTNERSHIP FOR NATIONAL NCD PREVENTION Governments, policies (national, local) Health services Civil society (NGOs) Private sector Media International collaboration (esp. WHO) 34
MOBILIZATION OF PEOPLE IS THE KEY CHANGES IN PEOPLE S LIFESTYLES POLICY DECISIONS SOCIAL CHANGE PROCESS! 35
SUCCESFUL PREVENTION OF NCD S IS NOT ONE TIME DECISION It is an incremental process, applying - Health promotion - Series of policy decisions Policies (laws) influence people and people influence policy (example: tobacco control process) Monitoring of changes crucial, for both the policy makers and the public Strong public health institutional base + strong NGO s Leadership focal point(s) - collaboration 36
Sustained changes in population health can only take place with permanent changes in people s lifestyles and environments, and represent a long term social change process! 37
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Thank you 39