1. Area informatics in community health policy & system development to cope with changing health needs in South East Asia Prof. Masami MATSUDA, Dr.H. Sc., Prof. of Public Health, Dep. of Health Nutrition, Tokyo Kasei-gakuin University PNC 2103,Kyoto Univ. Japan, Dec.11th, 2013

2. The recent development process of community health policy & health system change in Thailand show the position as the leading case of the area informatics in health field in South East Asia. From the viewpoints of health status & policy reports on global health such as in WHO (World Health Organization: United Nations’ Technical Agency in Health established in 1948), the current innovative programmer of TCNAP/RECAP on community health, nursing & information system in Thailand will be overviewed in the framework of international trend to understand the meaning of those activities in world health. The overview of framework in international health include such as 1.Primary Health Care in 1978 (Alma- Ata Declaration) & Primary Health Care 2008 (The World Health Report 2008, PHC: Now more and ever, 1)universal coverage, 2)primary care,3)public policy, and 4)leadership & government), 2.Health Promotion in 1986 (Ottawa Charter), 3.NCDs (the Political Declaration on Noncommunicable Diseases adopted by the UN General Assembly in 2011), 4.SDH (Rio Political Declaration at the World Conference on Social Determinants of Health in October 2011 in Rio de Janeiro, Brazil & Conceptual framework on Social determinants of health inequities,2010:CSDH),5.Global health risks,2009(WHO) & GBD (Global Burden of Disease) 2010 (Institute for Health Metrics and Evaluation).

3. The position of Data analysis and informatics in current innovative health activities in South East Asia is on the frontline in community health planning & policy implementation from the health statistics in national level. The content of health data in community include not only quantitative data but also qualitative data and how to marge those data is the critical issue in the actual field to cope with changing health needs such as aging, lifestyle diseases, NCDs. The factors which affect health policy change are the emerging four changes in population structure & social environments, such as rapidly aging society, epidemiological transition, risk behaviors & economic crises. The current health activities of TCNAP in Thailand are ample examples of the five sectors (1.Community empowerment, 2.Health literacy and health behavior, 3.Strengthening health systems, 4.Partnerships and intersectoral action, 5.Building capacity for health promotion) of the 7th Global Conference on Health Promotion, Kenya, 2009.

4. Change of Community & health issue in 40 years Disease structure (DM, hypertension, cancer) Lifestyle(obesity) Economic development (4C: Car, Cooler, Calar TV, Computer) Autonomy in local government Information revolution- personal computer Educational level Globalization Loan, increasing debt Aging Disabilities: ＩＣＦ （ International Classification of Functioning, Disability and Health ） May,2001 （ＷＨ Ｏ）,1980 ＷＨＯ（ＩＣＩ ＤＨ）, ICD(International Statistical Classification of Diseases) to Health & Indicators from death rate to DALY

5. PHC in 1978-2000 Health: infectious diseases (Diarrhea, TB, AIDS) Development: occupational training, water supply, etc. Information: IEC Participation: to Care provision such as VHV(health volunteer ) GIS: nothing Equipment in community: few telephone, no computer, Manpower: PHC worker but no RN/NP

6. Started the bachelor degree program Established the 1 year course for th 1 st - formal Program to train nurses at the Department of Public Health Nursing, Faculty of Public Health, Mahidol University Lacked of Community Nurse who could provide screening and treatment Demand ed on Neonatal NP 200219841980- 1981 1977 Development of Nursing Practitioner and Community Nurse in Thailand 1970 Faculty members and nursing staff = 4 NPs Produce d 12 groups (apprx.1 0-15 nurses/g r.) 1979 Produced and entitled the ‘Public Health Nurse Practitioner Program” Started the 6 M NP course under physician authorities at Ramathibo di School of Nursing, Mahidol University Not enough doctor specialists to meet the needs of the people and lacked of skill nurses to screen and provide basic Tx to eyes pts Established th 2rd- formal program 6 m. eye-NP program, by a physician from the Dept. of Ophthal. in collaboratio n with Dept. of Nursing, Faculty of Medicine, Ramathibodi Hosp., Mahidol Uni. Demanded on ER NP to be able to manage cases Produc ed ER-NP Established th 3rd- formal program 6 m for ER- NP for Faculty of Medicine, Ramathibo di Hosp, Mahidol Uni. Establish ed th 4rd- formal program 4 m for Neonatal -NP to work on growth, developm ent, overall health of newborns Produced Neonatal- NP 2007 MoPH released regulation s for NPs to provide treatment legally. 1990 Program of Nursing of Communi ty students started at FON/KKU NP’s performances were unacceptabili ty by the physicians. Stopped th 1 st - formal program training activitie s Apprx. 700 people produce d totally Thailand Economi c crisis/IM F Needed students to diagnosed and screening to work in rural but no competent teacher Th 3rd- formal progra m reduced to 4 m for ER- NP 4 m for ER-NP course The Thailand Nursing and Midwifery Council (TNMC) took the lead in respondin g to this need. First group of selected students by communit y learned at FON/KKU Be a NOC model. Other 26 NU institutes apply this idea. Needed more institutes to produce NP Nursing institues in Thailand provided 4 m. NP course and 2 Yrs. for Advance nursing practice (APN) -a master degree Able to produce NP 1000 prs/ yr and APN of community 250 prs/ yr Needed more CN belongin g to communi ty Able to produce the undergrade CN apporx. 20prs./yrs. To return to their communitie s Expanded to Local Admin. Org.+ private sector for funded selected students National Health Security office, Thailand signed MOU with TNMC to produce NP 10 yrs to response the needs at PC level 2004 To comply with the regulati ons of govern ment. Asean Econom ic Commu nity Demograp hic impact of the HIV/AIDS epidemic 20151997 2001 Sources of Fund 1988 Universal coverage scheme (2001-2007) 2005 2008- 2014 Primary Health Care (Until 2000) Primary Health Care (Until 2000) The National Health Care Reform and the Universal Health Care Coverage System was implemented, demanded NP in PCU = 15,000 prs. ?? Merging of Health Funds Sources: Khanitta Nuntaboot, 2007; Somchit Hanucharunkul,2007 Health Security (2007-2013) Health Security (2007-2013)

7. 2009 2001 ユニーバル・ヘ ルス（国民皆保 険）制度の開始 タイヘルス・ プロモーショ ン財団の設立 国民保健法 2007 2005 Healthy Thailand’ policy 2008 Health Risk /Health demands 参考 Khanitta Nuntaboot タイの保健システム発展の外的・内的要因 School Health Policy Public Health Ministry Policy Oral Health Promotion Saiyairak project Ministry of Social Development and Human Security Policy Millennium Development Goal Constitution of Kingdom of Thailand 2010 2012 Her Royal highness Princess Sirasm, Royal Consort of His Royal highness Crown Prince Mahavagiralongkorn 1999 1986 Bangkok charter for health promotion Economic crisis Thai Royal election/politic al party’s interest Demanded on decentralized 地方分権化 の開始（市 町の自治権 ） The Nairobi charter for health promotion The Ottawa charter for Health Promotion

8. 2009 2001 ユニー バル・ ヘルス （国民 皆保険 ）制度 の開始 タイヘ ルス・ プロモ ーショ ン財団 の設立 国民保健法国民保健法 2007 2005 健康タイ政策健康タイ政策 2008 参考 Khanitta Nuntaboot タイの保健システム発展の外的（図 上）・内的（図下）要因（ 1986-2013 ） 公衆衛生省政策の革新公衆衛生省政策の革新 公衆衛生省政策の革新公衆衛生省政策の革新 社会保障省の新政策社会保障省の新政策 憲法改正憲法改正 2010 2012 王立健康増進プロジェクト王立健康増進プロジェクト 1999 1986 バンコク 憲章 HP 経済危機 地方 分権 化の 開始 : 市町 の自 治権 ナイロビ 憲章 HP オタワ憲章・ヘ ルス・プロモー ション (HP) ミレニアム開 発目標

9. 学部の看護 教育開始 200219841980- 1981 1977 タイの Nursing Practitioner と地域看護師の発展過 程 1970 眼 科 NP 1979 保健師NP保健師NP NPの養成開始NPの養成開始 救 急 ER - NP の 養 成 新生児NPの養成新生児NPの養成 2007 公衆 衛生 省 NP の治 療を 許可 1990 NP の質 が問題化 N P の 養 成 70 0 名 で 停 止 IM F 経 済 危 機 ｺﾝｹﾝ 大で 地域 NP 養成 年間 1000 人の NP と 250 人の地 域 APN Advan ce nursin g practi ce 学部 の地 域看 護強 化 2004 HIV/ AIDS の広 がり 1997 2001 1988 Universal coverage scheme (2001-2007) 2005 2008- 2014 Primary Health Care (Until 2000) Primary Health Care (Until 2000) NP / PCU が 15,000 名必要 参照 : Khanitta Nuntaboot, 2007; Somchit Hanucharunkul,2007 Health Security (2007-2013) Health Security (2007-2013)

10. TCNAP in 2009-2012 Health: lifestyle diseases (DM,hypertension, cancer),Aging, disability Development: economic development (from bicycle to car in local area) etc. Information: information system Participation: in all revel of decision making (from data collection, analysis, policy) GIS: challenging Equipment in community: mobile telephone, computer, camera,PHC unit(curative care & preventive care) Manpower: RN,NP

11. Comparison of TCNAP with PHC PHC in 1978-2000 Health: infectious disease Development: occupational training, water supply, etc. Information: IEC Participation: to Care provision such as VHV(health volunteer ) GIS: nothing Equipment in community: few telephone, no computer Manpower: PHC worker but no RN/NP TCNAP in 2009-2012 Health: lifestyle diseases (DM,hypertension, cancer), Aging, disability Development: economic development (from bicycle to car in local area) etc. Information: information system Participation: in all revel of decision making (from data collection, analysis, policy) GIS: challenging Equipment in community: mobile telephone, computer, camera, PHC unit(curative care & preventive care) Manpower: RN,NP

12. Change the health & welfare system with rapidly aging society What is the factor to change the role of PHNs & health system ? 1.Population structure(Aging) 2.Disease structure (cause of death, communicable diseases, NCDs) 3.Risk factors(life style ) 4.Economic conditions

13. Community data base in health promotion policy making with Multi-sectoral Collaboration & Multi-stakeholders Partnership 量 Quantity Data (work place, public health insurance, community, school) 質 Quality Data 個 Individual Health Risks (smoking) Meaning of Life, Mental Health, Terminal Care (Clinical) 集団 / 地域 Population/ Community Utilize the Epidemiological Indicators in Community level (Death Rate, Prevalence Rate …) Integrate Individual & Community in Healthy Life Expectancy Community Assessment (People, PHNs, Nutritionists, MD) Social Capital

14. Leading causes of attributable global mortality and burden of disease, 2004 (WHO) % 1.High blood pressure 12.8 2.Tobacco use8.7 3.High blood glucose 5.8 4.Physical inactivity 5.5 5.Overweight and obesity 4.8 6.High cholesterol 4.5 7.Unsafe sex 4.0 8.Alcohol use3.8 9.Childhood underweight 3.8 10.Indoor smoke from solid fuels 3.3 59 million total global deaths in 2004 % 1.Childhood underweight 5.9 2.Unsafe sex4.6 3.Alcohol use4.5 4.Unsafe water, sanitation, hygiene 4.2 5.High blood pressure3.7 6.Tobacco use3.7 7.Suboptimal breastfeeding 2.9 8.High blood glucose 2.7 9.Indoor smoke from solid fuels 2.7 10.Overweight and obesity 2.3 1.5 billion total global DALYs in 2004 Attributable MortalityAttributable DALYs

16. GBD2010

17. Nature of Change Quantitative change (such as 10 % to 15% increase, 50 % to 35 % decrease) Qualitative change(epidemiological transition, health transition, population transition) Speed( low, high, very high) Aging (Slow Speed: Quantity, Quality: Europe) (High Speed: Japan, Asia, other countries) Age: 0,5,10,15,20,30,40,50,60,70 : 0,5,20,40

18. Globalization of unstable- welfare state such as Japan which is rapidly Aging society with family collapse There are four types of welfare states in sociology. Japanese health & welfare system is a mixture of four welfare states. 1.Libertarian type(Market system) : US, Canada, Australia In Japan; Fee- for Service in medical care mixed with social insurance 2.Beveridge-libertarian type (National minimum) : UK In Japan; Welfare system for child care, elderly care, disability care 3.Social insurance type : Germany, France, Italy In Japan; National Medical Care Insurance from 1965 National Care Insurance for aged from 2000 4.Scandinavian type (De-commercialization of labour with maternity leave, parental leave & educational leave) : Sweden, Denmark, Finland, Norway In Japan; ??? (Esping-Andersen, The three worlds of welfare capitalism, Polity press, 1990) (Kenichi Tominaga, Welfare state in social change, p156-157, Chuokouron-shinsha, 2001 in Japanese)

19. 1947; Social Right (Beveridge-libertarian ) in the new constitution of article 25 1950’; Priority is recovery of economy (Libertarian ) 1961 ; National health insurance and pension system (toward Beveridge-libertarian type) 1973 ; Starting point of welfare state (strengthen Beveridge-libertarian type) (Matsuda in Tokyo University) 1982 ; budget cut(Libertarian) (Matsuda in Graduate school of Tokyo Univ. & in Mahidol U.,Thailand) 1989-2000 ; Gold plan for the Aged and care insurance scheme for the Aged requiring nursing care (Scandinavian type or Social insurance type) (Matsuda in RITB & U.Shizuoka) 2001-2013; Libertarian with budget cut (Matsuda in U.Shizuoka, Care of my mother, in U. Kasei-gakuin) (K. Tominaga, Welfare state in social change, p182-196, Chuokouron-shinsha,2001 in Japanese) Socio-economic condition and population aging

20. Rapidly Aging Society-speed of Aging 2-4 times ( 7%→14% Japan 25 years 、 Europe, US 45 ～ 115 years 10%→20% Japan 21 years 、 Europe, US 43 ～ 86 years) 7% to 14%10% to 20% canada Japan USA Italy France

21. Rapidly Aging Society- Japan as a Model of Countries in Asia, Latin America & Eastern Europe in future Japan USA,EU Thailand,Korea,Singapore,China,Indonesia

22. How to cope with Rapidly Aging Society like Japan 1.Do not rely on the western model of aging society but try to create own activities based on each community settings. 2.Change the target of health & welfare services from the longevity of life to healthy life expectancy plus QOL(Quality of Life).(Development of New data system) 3.Putting together the experiences of PHC (TB control, MCH) into NCDs prevention with emphasis on health promotion with academic society: JAHWP.(Reform Health & Welfare System and Society)

23. 2009 Breast feeding policy Baby friendly hospital Mother-Child policy Child care center/ Kindergarten Teenage health promotion ( Pregnant, Youth council from school-to-University) Healthy working place Woman Health (Violence, CA screening) Health promotion The "3 Generations Weave Family Love” Center Elderly people club Accident and Emergency prevention National institute of Emergency medicine/Disaster management 2001 Cost USD 2 billion for health promotion activities a year Launching of the Universal Health Coverage Scheme Draws upon a 2 percent surcharge levied on alcohol and tobacco excise tax, approximately USD 50-60 million a year ThaiHealth funds programs health risks/issues such as alcohol, tobacco, accidents, exercise, as well as area or setting based programs, for example, school, work place, community, and programs that target specific population groups such as the youth, the elderly, Muslim community Open grants program invites proposals from all kinds of organizations/groups interested in launching HP initiatives Establishment of the ThaiHealth Promotion Foundation as a HP funding mechanism National Health Act 2007 2005 Healthy Thailand’ policy Embraces the principle of human rights and key principles of the Ottawa Charter in 2005. It is a result of five years of extensive public dialogues on important health issues that enhanced public awareness and nation wide networking on health promotion 2008 Health Risk /Health demands Largest aerobic display Against drunk driving and controls on tobacco Thailand is committed to reducing substance Policies influencing health promotion scheme in Thailand Thai Royal Government Policy Statement School Health Policy Public Health Ministry Policy Oral Health Promotion Saiyairak project Ministry of Social Development and Human Security Policy Millennium Development Goal Constitution of Kingdom of Thailand 2010 2012 Her Royal highness Princess Sirasm, Royal Consort of His Royal highness Crown Prince Mahavagiralongkorn 1999 1986 Increasing prevalence of chronic illness Changing demographics of aging adults Risk Behavior i.e. smoking Alc. Drinking, Changing diet habit and unsafe sex practices Bangkok charter for health promotion Economic crisis Thai Royal election/politic al party’s interest Demanded on decentralized Decentralization started Decentralization to LAO (Authorities and fund) Sub- district fund allocation Control social determinants to health Welfare to population The Nairobi charter for health promotion The Ottawa charter for Health Promotion Embraces the principle and direction of health promotion

24. GBD2010

28. Role of public health Policy, quality assurance, evaluation(ABM) traditional public health practitioners and institutions are reaching out (or could reach out) to the public through social media. "Public Health 2.0" is used to describe public health research that uses data gathered from social networking sites, search engine queries, cell phones, or other technologies.(Wiki)

29. Brief History; PHN Role(3) Contemporary roles – Community Developer – Facilitator of self-health promoter/self-help – Resource Manager – Policy Formulator Remarkable topics today : lifestyle disease, frail elderly – Community level activities – Health problems of the growing elderly population, so on – PHNs are using a variety of health promotion strategies The role of PHN has become bigger and bigger in Japan. Feb. 5 th 2009Katsumasa Ota

30. New role of head PHN in Shizuoka government for the policy in health promotion (Eguchi A.) Several key health promotion concepts were identified in various health promotion initiatives. The mindsets in PHNs’ activities became the driving force behind the initiatives. In the development of health promotion initiatives, PHNs work proactively in order to understand the opinions and concerns of both municipalities and residents through a variety of channels. By observing both the overall picture and disparities in health status in different areas, prefectural PHNs supported the “visualization” of processes involved in and results produced by initiatives undertaken by its municipalities, while also promoting the “visualization” of reliable health information. PHNs created an administrative system for ensuring the effectiveness of initiatives. Advancing community development through win-win partnership that exceeds the boundaries of health sector appears to be linked to positive participation in health promotion by both individuals and private corporations.

32. Box 1: Disability-adjusted life years (DALYs) DALYs are a common currency by which deaths at different ages and disability may be measured. One DALY can be thought of as one lost year of “healthy” life, and the burden of disease can be thought of as a measurement of the gap between current health status and an ideal situation where everyone lives into old age, free of disease and disability. DALYs for a disease or injury are calculated as the sum of the years of life lost due to premature mortality (YLL) in the population and the years lost due to disability (YLD) for incident cases of the disease or injury. YLL are calculated from the number of deaths at each age multiplied by a global standard life expectancy of the age at which death occurs. YLD for a particular cause in a particular time period are estimated as follows: YLD = number of incident cases in that period × average duration of the disease × disability weight The disability weight reflects the severity of the disease on a scale from 0 (perfect health) to 1 (death). The disability weights used for global burden of disease DALY estimates are listed elsewhere (6). In the standard DALYs in recent WHO reports, calculations of YLD used an additional 3% time discounting and non-uniform age weights that give less weight to years lived at young and older ages (7). Using discounting and age weights, a death in infancy corresponds to 33 DALYs, and deaths at ages 5–20 years to around 36 DALYs.

33. Development of Healthy Japan 21 st –National & Regional/Local Level (A.Eguchi)

34. Achievements of Healthy Japan 21 st (1 st Stage :2000-2012) 1.National Level: Decrease the Smoking Rate of Male from 50 % to 35 % (still high) 2.National Level: Decrease the Suicide Population from over 30000 per year to under of it in 2012 (-1997 over 20000, increased during 1998-2011 over 30000) 3.Local Level: Average Prefecture of Shizuoka in any health & welfare outcomes became No.1 in healthy life expectancy in 2012(Male 71.68 years, Female 75.32 years)

36. Example “Visualization of Health Indicators” Source: Shizuoka Municipal Health Index, 19, 2011Source: 2010 Report on Health Checkup and Guidance by Shizuoka Municipal, 2012 Heart disease SMR (2004-2008) Smokers (male) (2004-2008) Smokers (female) (2004-2008) Significantly lower Lower Higher Significantly higher ※ significant level P<0.05 Significantly lower Lower Higher Significantly higher ※ significant level P<0.05 Empower local city & town using area data on Smoking & heart disease -A Case of Shizuoka- (A.Eguchi)

37. JAHWP compare with TCNAP;Community Strengthening Actions RECAP TCNAP (1) HFA21Japan,9 HPP,130 Targets 7 HPP Healthy Public Policy (84 proposals) HFA21Japan,9 HPP,130 Targets 7 HPP Healthy Public Policy (84 proposals) Systems/Civil groups (SOJO method; Iwanaga) Systems/Civil groups (SOJO method; Iwanaga) Outcomes & Impacts of initiatives & actions Outcomes & Impacts of initiatives & actions Multi-stakeholders Partnership Multi-stakeholders Partnership 1.Alcohol Consumption 2. Smoking 3. Accident 4. Healthy Food (Shokuiku;eating education) 5. Physical Activity(100ys old Ikiiki; Horikawa) 6. Health Care (Economics, Politics) 7. Health Investment (Inequality & social divide) 8. Disaster management (Kobe,Fukushima) (Climate & Nuclear disasters)Etc. Multi-sectoral Collaboration 1. Disaster management 2. Learning & Education 3. Welfare 4. Health Care 5.Environment & natural resources management 6.Food security & organic agriculture 7.Governance in administration of local government Health : (1) Health care (2) Social Health Determinant Evaluation of HFA21Japan 8+ Impacts of Health Evaluation of HFA21Japan 8+ Impacts of Health Management of effective Initiatives & Actions 1. Technical Team 2. Management Team 3. Communication Team 4. Mayor/Administrator Team HP 10 Acts/law (Nishimoto) Case; 1.Shizuoka Prefecture (Eguchi,et al) 2.Hachioji city (Noyama) Shimane; GIS-Social capital (Shiwaku, Hamano)

41. PHN:Role in the past Health Systems in Transition Kozo Tatara, Etsuji Okamoto,WHO,2009 Health education For improvements in community involvement, it is essential to provide opportunities for residents to obtain information about health planning promoted in their community. This has yet to be fully implemented in Japan, although residents may have had such opportunities in the various actions for health education organized by public health nurses in their community. Reduction Long life expectancy in Japan is largely the result of a reduction in infant mortality and deaths from TB and cerebrovascular diseases. The recent decline in deaths from cerebrovascular diseases reflects the strong network of community activities, with an important role of public health nurses (Tatara et al., 1984).

42. Brief History; PHN Role(1) (truncated) The first PHN activities started in 1920. – Prevalence of Tuberculosis; prevalence rate 223.7 – Main role; prevention and visiting care for TB patients, school nursing, et. al The systemized education of PHN began – 1928 ; Japan Red-Cross – 1930 ; Japan Saint-luke’s Nursing School, so on. PHN Act was established in 1941. – To promote health condition of the candidate for soldiers by the governmental request. Feb. 5 th 2009Katsumasa Ota

43. Brief History; PHN Role(2) After WW-II –Japanese health condition in general; so terrible –The American General Head Quarter GHQ re- organized Japanese nursing system and unified the legislation of nurse, PHN and midwife into one ACT.. –The conventional role of the PHN: cutting off vicious circle of poverty and disease prevention of disease supporting the effort of self-improvement by residents, et. al. An episode of the PHN in those days –PHNs completed successfully to give the poliomyelitis vaccine to 13 million children within a month in 1955. –This resulted in big contribution for termination of poliomyelitis in Japan, afterwards. Feb. 5 th 2009Katsumasa Ota

44. Education System for Nurses Junior High High School 4-year Univ/Col BScN Program 3-year RN School Diploma Program MW RN 1-year PHN Course 1-year MW Course PHN MW 2-year LPN School LPN 2-year RN School (JH grads need min. 3-year clinical exp.) RNPHN Feb. 5 th 2009Katsumasa Ota

46. GBD2010