Kingdom of Morocco Ministry of Health International Seminar

Kingdom of Morocco Ministry of Health International Seminar on the Public Health Aspects of Noncommunicable Diseases Lausanne, 10 – 18 August 2010 Dr. Mustapha MAHFOUDI MPH

Kingdom of Morocco

Evolution of the total population by area (Population by million) Source : sensus (1960, 1971 and 1982) and projections

Evolution of life expectancy to birth by area Source : Direction de la Statistique

Population pyramid Moroccan Population by age and sex (In thousands) 2004 / 2022

Epidemiologic Transition Communicable diseases Noncommunicable diseases

Noncommunicable diseases 1. 2. 3. 4. 5. 6. Cardiovascular diseases: HTA and RAA. Diabetes. Cancer. Chronic respiratory infection. Mental diseases. Dental diseases.

Epidémiologic situation MS/2000 Pop + 20 years 1. Rheumatic heart disease first cause of morbidity, mortality and cardiovascular surgery (age from 15 to 24 years). 2. Hypertension 33, 6% of age 20 years and over, and 54% at the age 40 years and over (55% of grade 1). 3. Diabetes 6, 6% (age 20 years and over). 4. Obesity 13. 3% (age 20 years and over).

Epidemiologic situation 5. Cancer 30. 500 new cases of which more than the 2/3 are ascribable with the environment and the lifestyle particularly the nicotinic (2004). 6. Mental health (+15 years) § 26. 5% of the population suffers from a depressive disorder. • 09% of anxiety and 5. 6% of psychotic disorders. • Alcohol abuse: 2%, dependance: 1, 4%. • Substance abuse: 3%, dependance : 2, 8 %. 7. Dental diseases 72% among children aged 12. Parodontopathy 62, 5%.

Bronchopulmonaire Lung cancer Prostate Vessie Lymphome non. Hodgkinien Estomac Rectum & JRS* Larynx Peau Pancréas Côlon Nasopharynx Leucémie myéloïde Localisation primitive. Encéphale inconnue Foie Cavité buccale Tissu conjonctif Vésicule & voies biliaires Myélome multiple Autres localisations 19. 8% 16. 7% 8. 1% 5. 7% 4. 7% 3. 9% 3. 6% 3. 4% 2. 9% 2. 6% 2. 3% 1. 8% 1. 6% 9. 6% Sein Col utérin Thyroïde ovaire Corps utérin Estomac Rectum & JRS* Bronchopulmonaire Lymphome non. Hodgkinien Peau Encéphale Pancréas Cavité buccale Vésicule & voies biliaires Nasopharynx Leucémie myéloïde Côlon Tissu conjonctif Localisation primitive inconnue Autres localisations 33. 5% 13. 5% 4. 5% 3. 4% 3. 2% 2. 9% 2. 6% 2. 4% 1. 8% 1. 6% 1. 3% 0. 0% 11. 3% 10. 0% 20. 0% women Men cancer records / Rabat. 30. 0% 40. 0%

Comparison of results of Marta’s study (2006) and study on cardiovascular risk factors (2000) (cases aged 20 and over) Smoking Prevalence according to Study 2000 N=1802 Prevalence according to Study 2006 N=9197 Total Men 17, 2 18, 5 34, 5 36, 3 Women 0. 6 3, 4 Urban 17, 9 21, 5 Rural 16, 5 18, 9

Comparison of survey data from 2001 and 2006 among people 13 to 15 years in Morocco Indicator Investigation 2001 % Investigation 2006 % Proportion of students who ever tried smoking 13, 5 14, 5 Proportion who smoke cigarettes 4, 2 6, 4 Proportion of all those who use tobacco products 13, 9 15, 5 Proportion of those who use tobacco products other than cigarettes 11, 6 12

New paradigm – Before: Passive role of the patient. – Now: Central role and responsibility of the patient and his/her own care. To center the care on the patient and his family (concerted Approach).

Objectifs • Achieve universal access to diagnosis and treatment. • Protect poor and vulnerable populations from heart disease, stroke, hypertension, cancer, diabetes, asthma and chronic respiratory disease. • Reduce the burden associated with major NCDs. • Implement a set of essential NCD interventions to improve service delivery and reduce inequity. • Provide effective and affordable prevention and treatment through primary care. • Support community engagement.

Strategic axes KNOWLEDGE COMMUNITY SUPPORT ADVOCACY REGULATION AND FINANCING Total integrated care of quality, continuous and centered on the PATIENT CAPACITIES HEALTH SERVICE DELIVERY 15

Objectives To develop actions of advocacy and awareness targeting health professionals, the population and stakeholders. Axe 1 : ADVOCACY Activties All people (HP, teaching CHU, Managers, NGO representatives) are informed and sensitized on national chronic diseases strategic plan (Diabetes, Cardiovascular diseases, Mental health, dental health). Timing Advocacy targeting Ministers of education, Interior, Justice, Youth and Sport, Agriculture, … for the development of sectoral plans as regards chronic diseases (mental health, cancer, DH, CV, health at the work, etc). . 16

Axe 1 : ADVOCACY Objectives To promote Noncommunicable diseases prevention and control. Activties Timing Resp Promoting healthy lifestyle through organizing awareness campaign targeting the general population. Production and dissemination of TV capsules: HTA, RAA, Diabetes, oral Health and mental health. Promoting healthy lifestyle through organizing awareness campaigns in schools, summer camps and MCH units. (RAA, Tobacco, food, physical-activity, drug and dental health…). 17

Axe 2 : KNOWLEDGE Objectives Activties TO develop knowledge and evidence on NCD: reports, studies and investigations Study on the risk factors of the cardiovascular diseases. Timing Resp Study on the prevalence of the risks related to the use of drugs in Tanger and Casablanca. Studies on the risk factors of cancer (Cancer of the vacuum in North, etc). Studies, KAP diabetes & KAP dental health. Carry out a national survey to measure the importance of risk of professionals 'exposure. Establishment of hospital registers of cancer in the seven public structures of oncology. Support regional areas for the implementation of the regional action plans relating to the NCD. 18

Axe 2 : KNOWLEDGE Objectives Activties Standardize the preventives and curatives activities about noncommunicables diseases • 4 therapeutic reference frames are developed: diabetes I and II - HTA and RAA. Timing Resp • Validation of therapeutic protocol of oncology care. • Development of a therapeutic program of education with standards concerning diabetics and hypertensive. Improve information management about NCD. • Development an information system concerning drugs (Diabetes, HTA, Cancer, etc. ). (traceability) • Development an integrated information system concerning NCD. 19

Axe 3 : CAPACITIES Objectives Activties Improve of the health Development of the modules concerning NCD (diabetes, professionals managerial capacities HTA, RAA, schizophrenia, depression, oral and dental health). concerning NCD. Timing Resp 32 trainers are trained by discipline as regards management of NCD (Cancer, Diabète, HTA, RAA, Schizophrenia, Depression, Oral and dental health) 1440 PS/an. All the Physicians (SSB) and Lung specialists will be trained of methods of assistance to nicotinic weaning. Training the HP to the regulation (10 psychiatrists) and dispensation (30 MG and nurses) of methadone on the level of the units (Tangiers, Salé and Casablanca). 20

Axe 3 : CAPACITIES Objectives Activties Improve of the health professionals managerial capacities concerning NCD. 53 Psychiatrists and Physicians are in the course of training for obtaining a DIU on addictology and reduction demand (Medical college and Pharmacies of Casablanca). Timing Resp training of 100 Health Professionals ((M/C SIAAP, program managers) in public health program management in collaboration with INAS. Mainstreaming of oral and dental care in nurses training curricula of nurses training. Mainstreaming of psychiatrics (schizophrenia) in nurses training curricula of nurses training. 21

Axe 3 : CAPACITIES Objectives Activties Improve the technical plateau in PHC /ESSB to carry out preventive actions and control of the chronic diseases. Improve the technical plateau of health facilities for the metabolic follow-up of the diabetics and hypertensive. Timing Resp The metabolic follow-up concerning diabetics is ensured in all (81) provinces and prefectures level. The tracking and follow-up of hypertensive will be ensured at the level of all health centers (2500 AT 20 ECG). The offer of dental care is widened. The management of the dental care campaigns is decentralized at the level of the 16 Regions (2 equipments/regions). 22

Objectives Activities Axe 3 : CAPACITIES Improve the Pedopsychiatrics consultation in ambulatory and in care offer UHC level are established in Casablanca and Rabat. services concerning NCD Timing Resp Project of the capacity litter improvement by the creation of 7 integrated psychiatric services and hospital (Phase of study). Capacity litter will pass from 2204 to 2764 between 2010 and 2012. CL: 7. 3 with 9. 2 lits /100. 000 h. Admissions for 2010: 27. 300. TOM: 93. 4%. DMS: 22 J 23

Axe 3 : CAPACITIES Objectives Activities Timing Resp Build health workers capacities in screening and Improvement of care offer services management of collar and Breast cancer in five regions. concerning NCD. Improvement of care offer in oncology by: The construction of two Regional centers of Oncology in Tangier and Meknès. The rehabilitation of two centers of gynecological oncology (centers) in Casablanca and Rabat. The construction of 4 units of proximity in Errachidia, Khémisset, Ouarzazate and Béni Mellal. 24

Axe 4 : HEALTH SERVICE DELIVERY Objectives Activities Integrate the NCD The Hospital Without Tobacco Initiative is launched at package of activities the national level: 114 hospitals adhered to the IHST. in the primary health care Situation: 412 Physician and 104 nurses are trained, education (PHC) Timing Resp and 3980 students and 610 professors seen for nicotinic weaning on the level of the health systems (2009). The IHST is extended to all the administrative ESSB and structures: ministerial circular. 25

Objectives Axe 4 : HEALTH SERVICE DELIVERY Activties Integrate the NCD Recruitment of 100. 000 new diabetes by tracking package of activities 500. 000 people at the risk (each year). (passing from in the primary health 340. 000 to 440. 000 cases). care education (PHC) Recruitment of 30. 000 new hypertensive by tracking 100. 000 people at the risk (each year). Timing Resp Recruitment of 200. 000 new anginas by tracking 100. 000 people at the risk (each year) (passing from 1. 300. 000 to 1. 500. 000 of anginas). Screening of breast cancer among 960. 000 old women from 45 to 70 years Recruitment of 39. 000 women is 10% of the at risk population. 5 areas (Reduction, Casablanca, Fez, Marrakech, Meknes). Tracking of the cancer of the collar among 1. 700. 000 old women from 30 to 50 years: 5 areas. 26

Axe 5 : REGULATION AND FINANCING Objectives Activities Strengthen the legislative and lawful support for prevention and control of the NCD. Revision of the Dahir of 1959 (Mental health). Timing Resp Law 15. 91 on the tobacco is revised and adopted by the Parliament: Advocacy for the publication and enforcement of law 15. 91. Advocacy for the ratification of FCTC / WHO. Institutionalization of the Casablanca registry of cancers (circular). Advocacy targeting concerned sectors to work out a legal text of fight against the illegal practice of dental profession. 27

Axe 6 : COMMUNITY SUPPORT Objectives Activies Partnership and community support of prevention and control of the NCD. tripartite convention is signed between the Ministry for Health, ALSC and the FNUAP for the integration of collar cncer early detection of the cancer of the collar and breast in PHC. Timing Resp A partnership convention signed between the Ministry for health and the Sanofi Laboratory and CH of Casablanca relating to the assumption of responsibility of schizophrenic cases into ambulatory . Conventions concerning the diabetes established with the regional scales (Fès, Tahanaout). Convention between MOH and MEN for the generalization of the fluoridation program in school. Identification of NGOs working in the field / NCD. 28

REORGANIZATION AND REORIENTATION OF THE HEALTH CARE SERVICES / NCD level 1 Health Center level 2 CHP Level 3 CHR - CHU Prevention and promotion NCD Tracking NCD Regular follow-up Therapeutic education Reference Specialized consultation Tracking of the complications Therapeutic education Reference and against-reference PEC of the complications therapeutic Education Reference and Against-reference

CONCLUSION The integrated management of the NCD requires: • political commitment. • material and human resources suitable. • Organization of the specialized care (centers of reference). • Introduction of mechanisms of coordination between the various levels of care. • Development of an integrate surveillance system. • Development of a public/private partnership.

Thank You for your attention 31