Dr. Tawfik A. Khoja1 Dr. Tawfik A. M. Khoja MBBS, DPHC, FRCGP, FFPH,FRCP (UK) Director General - GCC Riyadh 11/1/1430H - 8/1/2009

Dr. Tawfik A. Khoja2 ” أَفَمَن يَمْشِي مُكِبًّا عَلَى وَجْهِهِ أَهْدَى أَمَّن يَمْشِي سَوِيًّا عَلَى صِرَاطٍ مُّسْتَقِيمٍ ” “ Is then one who Walks headlong, with his face Grovelling, better guided, Or one who walks Evenly on a Straight Way ? ” سورة الملك ( آية 22) Holy Quran

Dr. Tawfik A. Khoja3 SINCE the GCC States constitute one regional community in its Islamic religion, Arabic language, population, similarity in geography, and values history, traditions, economic sources, social and cultural circumstances. THEREFORE they had to unify their efforts in different fields of life to face the quick changes, and the overall development requirements.

Dr. Tawfik A. Khoja4

5 The Health Minister's Council for Cooperation Council States, was established in 1397 H (1976G. ) for coordination between the GCC States in the fields of health to join the common world efforts symbolizing one goal for better achievement of health and expectation for health. MISSION in the Gulf States based on these principles:- Common development & coordination between the Members States in the preventive, curative and rehabilitation fields.Common development & coordination between the Members States in the preventive, curative and rehabilitation fields.

Dr. Tawfik A. Khoja6 Identify the concepts and directions of the different health and scientific issues.Identify the concepts and directions of the different health and scientific issues. Unify and arranging the priorities as well as adopting the common executive programs in Gulf States.Unify and arranging the priorities as well as adopting the common executive programs in Gulf States. Assessment of the existing systems and strategies in the health fields and supporting the successful experiences in the Gulf States to exchange such achievements in other Member State.Assessment of the existing systems and strategies in the health fields and supporting the successful experiences in the Gulf States to exchange such achievements in other Member State.

Dr. Tawfik A. Khoja7 Since Alma Ata in 1978 Dramatic changes have occurred: *In the pattern of diseases. *In demographic profiles. In socioeconomic environment. Growing demand on health services. Rising costs. Public needs for better quality services. Which present new challenges to PHC. These changes are seen globally: For example: Increase in the prevalence of preventable risks In crease in the prevalence of chronic non- communicable disease.

Introduction The GCC is witnessing the last few years huge changes in the health needs of its population. MANY countries are suffering from the effects of the double burden due to infectious and non- communicable diseases (NCD). NCDs forms the main causes of premature deaths and disability where it forms around 60% of the overall mortality and 47% of the global burden of diseases. These two rates are expected to jump into 73% and 62% respectively by the year Dr. Tawfik A. M. Khoja8

The epidemiologic transition in the GCC : The quick ageing of the population the steadily increasing urbanization with consequent social and economic impact. Important behavioral factors related to the dietary pattern, physical inactivity leading to overweight and obesity and thus increasing rates of cardiovascular diseases, diabetes, hypertension, some types of cancer.. etc. The effects of this epidemiologic transition is far more than expected by the health policy makers. Dr. Tawfik A. M. Khoja9

10 The burden of NCD : Has major adverse effects on the quality of life of affected individuals; Causes premature death; Creates large adverse – and under appreciated – economic effects on families, communities and societies in general.

Dr. Tawfik A. Khoja11 CVD and diabetes are emerging as the single leading cause of mortality in the Gulf. The enormous burden caused, in terms of suffering and health costs is escalating. NCDs present mainly at the primary health care (PHC) level and will therefore need to be handled principally in these settings. Yet, most primary health care has developed in response to acute problems and the urgent needs of patients. Health care workers need the skills and practical tools to manage these chronic conditions and to ensure that patients receive comprehensive, coordinated care.

Dr. Tawfik A. Khoja12 Health care systems must guard against the fragmentation of services. Care for NCDs needs integration to ensure shared information across setting and providers, this means setting priorities for screening, early detection prioritising surveillance, and management to be applied and followed among Gulf area, through community - based programme as well as health team training on: Evidence-based, clinical management of chronic conditions. Organizational factors that support the provision of care for patients with chronic conditions. A proven methodology for accelerating health care improvement in PHC.

EMRO &NCD RISK FACTORS Diabetes in 10 Hypertension1 in 4 Smoking1 in 3 Obesity 1 in 2 Dyslipidaemia1 in 2 Physical Inactivity 8 in 10 13Dr. Tawfik A. M. Khoja

14 Prevalence of Physical Inactivity GCC mean of Physical inactivity is 71.4%

Dr. Tawfik A. M. Khoja15

Dr. Tawfik A. M. Khoja16 Global effect of Over weight & Obesity on developing NCDs In WHO analysis:  58% of Diabetes Mellitus  21% Ischemic heart diseases  4-42% of certain cancer Were attributable to BMI above 21 kg/m 2

Dr. Tawfik A. Khoja17

د. توفيق بن أحمد خوجة 18

Dr. Tawfik A. M. Khoja19 Current Situation in the GCC States The GCC countries lie in the center of these epidemiologic transitions. Statistical studies affirms that more than (40-50%) of the Gulf community are suffering high rates of overweight (which increases with age) in addition to the high prevalence of risk factors; namely high lipids and cholesterol in blood – smoking and others. The studies emphasized as well the aggravation of this health phenomenon and its consequent economic burden.

Dr. Tawfik A. Khoja20 Chronic conditions Among person aged 15 years and over, the percentage reported of have ever had specific chronic conditions confirmed by a doctor, by sex, GCC Family Health Survey

Dr. Tawfik A. Khoja21 Many studies affirmed the high prevalence of the risk factors in the Gulf region for the age group 25-65, as follows: Risk factors in the GCC States - Smoking % - Hypertension % - Fats and lipids % - Physical Inactivity % -Diabetes % - Overweight and obesity 40-70%

Dr. Tawfik A. M. Khoja22

Dr. Tawfik A. M. Khoja % (age >15) Bacchus & Madkour % Fatani % AbuZaid % (age >14 years) Hazmi % (age >30 years) Nuaim % (age >30 years) Nozha % (age >30 years) MOH 2010??? Diabetes - an escalating problem in the Kingdom of Saudi Arabia

UAE 32.0% (DM 22.0% + IGT 10.0%) Bahrain DM 30% (age >40 years)… Mahroos Saudi Arabia 40% (DM % + IGT %) (age >30 years) Oman 19.0% (DM 10.0% + IGT9.0%) Kuwait 22.0% (DM 20.0% + IGT 12.0%) Qatar 30.0% (DM 10.0% + IGT 20.0%) Diabetes in the Gulf Region 24Dr. Tawfik A. Khoja

25

Dr. Tawfik A. Khoja26 Control of Cardiovascular Diseases. Control of Diabetes. Cancer Control and Registration. Health Education and Information. School Health. Mental Health. Strengthening the Role of PHC in Prevention and Control. Hence, it became mandatory for the Health Ministers’ Council for the Cooperation council States to confront this problem, through a number of strategic directions: I- Establishing Specialized Consultative National Committees

Dr. Tawfik A. Khoja27 II- Strategic Resolutions by the Health Ministers’ Council for Cooperation Council States

Dr. Tawfik A. Khoja28

Dr. Tawfik A. Khoja29 Resolution # 3/50 (Kuwait, Shawwal 13-15, 1421H /Jan. 8-10, 2001). It decided the following: a: a: 1-Establish diabetes epidemiological screening program, collect information and prepare diabetes health indicators in the Gulf States. 1-Establish diabetes epidemiological screening program, collect information and prepare diabetes health indicators in the Gulf States. 2- Coordinate, follow-up and communicate in the field of dissemination of information and develop preventive, educational, and treatment programs to control this disease, and help individuals to lead a healthy life. 2- Coordinate, follow-up and communicate in the field of dissemination of information and develop preventive, educational, and treatment programs to control this disease, and help individuals to lead a healthy life. 3-Supervise the training programs and train workers in the field of healthcare for Diabetes mellitus. 3-Supervise the training programs and train workers in the field of healthcare for Diabetes mellitus.

Dr. Tawfik A. Khoja30 b. Adopt new methods in the health care service of diabetes,i.e. specialized primary healthcare clinics for diabetic patients, adoption of shared care for chronic diseases, and reinforce the referral system within the different levels of health care services. b. Adopt new methods in the health care service of diabetes,i.e. specialized primary healthcare clinics for diabetic patients, adoption of shared care for chronic diseases, and reinforce the referral system within the different levels of health care services. c.Adopt national diabetes registration system to register all the diabetes cases in each country of the Gulf States. It should possess very clear views and methodology to achieve each goal. c.Adopt national diabetes registration system to register all the diabetes cases in each country of the Gulf States. It should possess very clear views and methodology to achieve each goal.

Dr. Tawfik A. Khoja31 1- Approve the "Gulf Plan of Action" (2001 — 2002) which has been suggested by the referenced taskforce team, as a guiding plan for the rest of the Gulf countries. 1- Approve the "Gulf Plan of Action" (2001 — 2002) which has been suggested by the referenced taskforce team, as a guiding plan for the rest of the Gulf countries. 2-Take the initiative of forming the "National Committee for the Control of Diabetes" in member countries where these committees have not been formed yet. 2-Take the initiative of forming the "National Committee for the Control of Diabetes" in member countries where these committees have not been formed yet. 3- Incorporate diabetes control programs in the other programs that are related to chronic noncommunicable diseases i.e. high blood pressure (hypertension), obesity, etc… within the healthcare joint systems for chronic diseases, and the specialized clinics in the primary health care sector. 3- Incorporate diabetes control programs in the other programs that are related to chronic noncommunicable diseases i.e. high blood pressure (hypertension), obesity, etc… within the healthcare joint systems for chronic diseases, and the specialized clinics in the primary health care sector. Resolution # 2/51 (Geneva, Safar 1422H /May 2001) It affirmed the following:

Dr. Tawfik A. Khoja Member countries should submit their suggestions for the activation of the “Gulf Diabetes Control Plan”. These suggestions should indicate a phased goals plan, and a specific timetable, taking into consideration that special emphasis should be made on preventive measures in controlling diabetes. 1 - Member countries should submit their suggestions for the activation of the “Gulf Diabetes Control Plan”. These suggestions should indicate a phased goals plan, and a specific timetable, taking into consideration that special emphasis should be made on preventive measures in controlling diabetes. 2- Instruct the “Health Education and Information Committee” of the executive board, to prepare a special program to enhance positive healthy life style approach and encourage the change of individual attitudes and behavior to go alongside with this concept. 2- Instruct the “Health Education and Information Committee” of the executive board, to prepare a special program to enhance positive healthy life style approach and encourage the change of individual attitudes and behavior to go alongside with this concept. Resolution # 8/52 (Riyadh, Shawwal, 1422H / 8-9 Jan. 2002) It adopted the following:

Dr. Tawfik A. Khoja33 Resolution # 5, conference 58 HMC (Muscat, 5-6/1/1426 H – 14-15/2/2005) Which affirmed the following: A- Giving effect to the “global strategy on diet, physical activity and health” within the related programs and departments in the Ministries of Health.

Dr. Tawfik A. Khoja34 Resolution # 4 Conference 60 (Feb., 2006) A)Adopting new approaches to evaluate medical services for the care of patients of such diseases and giving effect to and developing the role of health centers in this respect (prevention, cure, and rehabilitation). B) Giving effect to the concept of health promotion within the Healthy Lifestyle, prevention and control of chronic and non-Infectious diseases. - Reaffirming the previous endorsed resolutions of the Council concerning the importance of supporting and promoting the role of control of non-communicable diseases and positioning the extended medical care as one of the priorities in the strategies of the ministries of health, with emphasis on:

Dr. Tawfik A. Khoja35

Resolution # 2 the 61st conference of the Health Ministers (held in Geneva on 26//4/1427 H / 24/5/2006), which assigned the specialized Gulf committee to undertake the process of development and update of the programme through the following: Developments of the Gulf Program for Diabetes Control 36Dr. Tawfik A. M. Khoja 1- Review of the Gulf plan for Diabetes Control in the light of the recent scientific updates, and after evaluation of the achievements made in various stages, and hence setting an executive workplan including preventive and promotive aspects.

2- Studying the current situation of the diabetes problem in the Council States and the objectives realized in the Gulf programme for Diabetes Control, reduction of diabetes incidence and its complications along 10 years. 37Dr. Tawfik A. M. Khoja

The Director General of the Executive Board submitted a proposed working paper to update and develop the Gulf plan for Diabetes Control. The working paper included a number of very important items: 38Dr. Tawfik A. M. Khoja 1) Evaluation of what has been achieved in the Gulf plan (infrastructure – training, learning and development of health caders - prevention programmes – scientific research). 2) Determinants of the Gulf plan which is considered so far a general framework for a comprehensive plan, especially after defining weaknesses and shortcomings.

3)Methods of realizing the strategic objectives of the Gulf plan guided with the leading international experiences. 4)Proposed developmental steps – emphasis on the community dimension – preventive aspect - scientific research. 5) Guarantees of success and continuity – at all levels in (MOH – related authorities – political level and decision making). 39Dr. Tawfik A. M. Khoja

Resolution # (1) 63rd conference (Geneva, 29/4/1428 H – 16/5/2007) which is considered an applied approach to the directives of the Ministers of Health in their 62nd conference in Kuwait which was named (The conference of diabetes control) and included a number of key directions, on top of which come the following: 40Dr. Tawfik A. M. Khoja 1-Signing the “ ” and its endorsement as a commitment to improve public health and confront the diabetes epidemic. 1-Signing the “joint statement for the Health Ministers’ of the Cooperation Council States about Diabetes” and its endorsement as a commitment to improve public health and confront the diabetes epidemic.

41Dr. Tawfik A. M. Khoja

2- Endorsement of the updating Integrated Executive Gulf plan (2008/2018) set by the specialized technical committees, which included the vision, mission and strategic objectives – mechanisms of implementation as well as indicators of follow up and improvement. 3- Selection of a work team at the highest technical and leading level from the ministry of health to undertake the process of follow up of implementation of the plan and developing it according to the needs and the stages of progress. 42Dr. Tawfik A. M. Khoja

4-Calling upon the Council States to establish a supreme national council for control of diabetes, on the basis that control of diabetes is a case of nation and the responsibility of all community classes. 5-Each member state shall propose the “national executive plan for control of diabetes “based on the general framework for the Gulf executive plan ( ). 6-Approval on establishing a “Gulf Central Supervisory Team”. The team is assigned to set protocol for a Gulf study with unified methodology to deal with epidemiology, burden of disease and economics of diabetes. 43Dr. Tawfik A. M. Khoja

It is worthy to mention that the “joint statement for diabetes” document had been circulated to all related bodies, organizations, scientific institutes local, regional and international. The joint statement had a very resonant impact in all those institutions. The most prominent is the message received from the Secretary General / Arab League office (188/5 dated 19/6/2007) in which HE the Secretary General expressed his appreciation and acknowledgement of this important strategy and he proposed establishing an umbrella for protection of diabetic patients at the Arab level. In addition, HE called upon considering this declaration a statement among the formal documents and it had been registered under the number (400) and a copy of this document was put on the website of the Arab League and it had been circulated to the Arab Countries. 44Dr. Tawfik A. M. Khoja

45Dr. Tawfik A. M. Khoja

The Assistant Secretary General – Chairman of social affairs – General Secretary for the Arab League has been addressed to take the executive actions to include this Gulf document as well as the Gulf Executive plan for Diabetes Control (2008/2018) on the agenda of such meeting. And, to give effect to resolution # (1) for the 63rd conference, and put it into action. 46Dr. Tawfik A. M. Khoja

Dr. Tawfik A. Khoja47

Based on the request of the Director General of the Executive Board, the meeting for the Specialized Technical Committee was held alongside the Diabetes Economics Conference “Diabetes Economics – Vital Investment”). The main question was what next? and what are the next steps to combat diabetes. It was agreed on dividing the Gulf plan into 5 stages, where each stage is evaluated, reviewed and the progress assessed as well as shortcomings. Thereafter, a plan for the next stage is set. 48Dr. Tawfik A. M. Khoja The proposed Interim Operational Plan ( )

-it represent the (first ) executive stage of the endorsed Gulf Executive plan. -It involves the minimum amount of strategies to be implemented. - Mechanisms and requirements for starting implementation of the plan were selected. 49Dr. Tawfik A. M. Khoja It was agreed to put an interim operational plan (2008/2009) as follows:

I-Appreciation of the initiative of presenting the joint statement for the Health Ministers’ in the Cooperation Council States about Diabetes, and the endorsed Gulf Executive plan for diabetes control to the next Arab Health Ministers. This is starting from the joint Arab Cooperation principle which was crowned by the proposal of HE the Secretary General of the Arab League concerning “Establishing an umbrella of protection for diabetic patients at the Arab level. 50Dr. Tawfik A. M. Khoja What has been achieved during 2007 ( the year of control of diabetes) has been presented and reviewed by the Health Ministers’ Council in the 64th conference (held in Riyadh, Muharam 1429 H – February 2008) where resolution # (3-A) was issued. The resolution defined the path of the new Gulf programme through the following:

II- Work towards putting resolution # 4 / 62 and 1 / 63 into action and the Council States shall provide the Executive Board with a periodic interim follow up report every 6 months, and specifically the following: 51Dr. Tawfik A. M. Khoja 1- Giving effect to the items in the “ joint statement of the Health Ministers about Diabetes” into work executive programmes. 2-Giving effect to the Integrated updated executive Gulf plan (2008/2018) according to the approved mechanisms and indicators.

III- Approval on starting giving effect to and implementing the interim operational aplan ( ) proposed by the technical sub- committee, which is considered the first statge of the endorsed executive plan for control of diabetes. IV- Finalizing the unified Gulf research project on diabetes according to the following: 52Dr. Tawfik A. M. Khoja A- Endorsing establishment of the Central Gulf Supervisory Team. B- Finalizing preparation of the estimated budget for the unified Gulf research on diabetes.

د. توفيق بن أحمد خوجة 53

proper (effective) promotion, prevention and treatment not to be seen as a cost but as an investment in ’health capital’ Professor David Cutler, Harvard University Dr. Tawfik A. M. Khoja54

د. توفيق بن أحمد خوجة FROM ILLNESS TO WELLNESS LOOKING AHEAD- PRIORITY CHOICES LOOKING AHEAD- PRIORITY CHOICES

Dr. Tawfik A. Khoja56 In the 64th conference held in Riyadh throughout the period (Muharram 1429 H / February 2008) the Health Ministers affirmed the importance of putting the criteria and standards of healthy diet as an entrance in the Control of NCDs programme, and resolution # (6-C) was issued which included the following: 1- The Council affirms the importance of the issue of healthy diet, physical activity in the prevention of NCDs and the serious role played by the unhealthy components and fast food industries in the increased rates of risk factors leading to such group of diseases which extended its effect to children and youngsters.

Dr. Tawfik A. Khoja57 2- Urging the Council states to establish public health committees in coordination with concerned ministries; industry, commerce, agriculture and other concerned bodies such as standardization and specifications organization, municipalities, and food industries as well as consumer protection societies to work towards setting national strategic plans for healthy diet, guided with the international strategy for diet, physical activity and health.

Dr. Tawfik A. Khoja58 3- Intensifying constructive cooperation with related authorities especially ministries of information, education, industry, agriculture and endowment towards setting a national alliance for health education to confront these deleterious community phenomena. 4- Giving effect to the “International Strategy on Diet, Physical Activity and Health” and working towards putting it into action through various programmes and health departments in cooperation with governmental and non- governmental authorities in a comprehensive national framework.

59Dr. Tawfik A. M. Khoja Current Situation Follow up of Implementation of the Gulf Plan for Diabetes Control

60Dr. Tawfik A. M. Khoja

61Dr. Tawfik A. M. Khoja

Dr. Tawfik A. Khoja62 Strategic Directions The HMC has to adopt Networking with EMAN and carrying out the STEPwise approach. Networking with EMAN and carrying out the STEPwise approach. Making full use of the Gulf plan for health education of Non-communicable Making full use of the Gulf plan for health education of Non-communicablediseases. Giving effect to the “Global Giving effect to the “Global Strategy on Diet, Physical Activity and Health Implementation of the World Implementation of the World Health survey. Conduction of the Burden of Conduction of the Burden of Diseases Research. Issuance of the Book Entitled “Facts for Life”

Dr. Tawfik A. Khoja63 Health promoting schools (United Arab Emirates) Health Promotion Council in the Kingdom of Bahrain (National Plan for Control of Chronic Diseases). Specialized clinics Initiatives (Kingdom of Saudi Arabia) NIZWA project for Healthy Life Style (Sultanate of Oman) Facts for Life “ Book (Cooperation Council States). Examples of some leading gulf Achievements

Dr. Tawfik A. Khoja64 1- Unifying methods of treatment and follow up of chronic diseases in H C according to evidence-based scientific methods towards the optimal use of available resources to reduce morbidity and mortality as well as disability rates. Mechanisms of implementation of concept of specialized clinics initiative 2- Prevention of diseases, through: a)Minimizing the risk factors such as obesity, and others. b)Early detection of cases. c) Early detection of complications. d)Increasing of health education and awareness and development healthy attitudes.

Dr. Tawfik A. Khoja65

Dr. Tawfik A. Khoja66

Dr. Tawfik A. Khoja67

Dr. Tawfik A. Khoja68 Control of Non-communicable Diseases (DM) and its prevention is POSSIBLE The rapid changes that threaten health in the Arab world require a speedy response, it must be proactive first and beforehand. It is unlikely that epidemics of today are similar to those that happened in the past. This is due to the progress made in controlling infectious diseases. If full alertness should be given to new outbreaks such as Avian influenza, the concealed epidemics e.g. cardiac diseases, stroke, diabetes, cancer and others… will result in the future in the largest number of victims whether victims of death or disability.

Dr. Tawfik A. M. Khoja 69

Dr. Tawfik A. M. Khoja70

Dr. Tawfik A. Khoja71 Requirements for Development in the Current Stage 1- Support promotion and development of optimal methods of health programs for such group of diseases and implementing programs of prevention and control of infectious and noninfectious diseases within a comprehensive and integrated health system in the primary health care in various sectors of health service, (e.g: school health) based on the concept of double burden. 2- Giving effect to the “Global Strategy on Diet, physical Activity and Health through the various programmes and health departments and in collaboration with the related governmental and non-governmental agencies and bodies within a comprehensive national conceptual framework.

Dr. Tawfik A. Khoja72 3- Establishing a reliable and accurate data base about the patterns of prevalence rates of these diseases and their determinants as well as preparing a dynamic health information program for collection and analysis of data in addition to networking and evaluation. Work should be done to formulate document based health system and plans. 4- Investment in health system research and implementing community health research models which have to be realistic and comparable. 5- Unifying all related activities and programs in the fields of control of non communicable diseases in a unified national/Gulf / Arab frame for “Health Promotion” guided by the successful experiences such as:

Dr. Tawfik A. Khoja73 a) Experience of the Kingdom of Bahrain concerning the “Health Promotion Council and its role in the control of chronic diseases. b) Kuwait program about the (health promotion as a comprehensive umbrella for all programs of control of chronic diseases. c) Specialized clinics program in the health centers in the Kingdom of Saudi Arabia. d) Community intervention program for prevention of cardiac diseases in Lebanon. e) MONICA project for smoking and Myocardial infarction. f) Prevention of cardiovascular diseases project (U.K.) g) Prevention of Diabetes project (USA) h) North Carlina Project

Dr. Tawfik A. Khoja74 Primary prevention, based on comprehensive _population-based programmes, is the most cost- effective approach to contain this emerging epidemic. Therefore, action to reduce these major NCDs and mainly (DM) should focus on preventing and controlling the risk factors in an integrated manner. Intervention at all levels of society, from communities to governments, private organizations and nongovernmental groups, is essential for prevention since the risk groups are entrenched in the framework of society influenced by many areas of national policy.

COLLABORATION AMONG GCC COUNTREIS AND SHARING COMMUNITY- BASED PROGRAMMES & SUCCESSFUL INITIATIVES 75Dr. Tawfik A. Khoja

د. توفيق بن أحمد خوجة 76

Dr. Tawfik A. Khoja77 Thank you for your kind attention داعياً الله سبحانه لي ولكم بدوام الصحة والعافية والرضوان