doha, qatar, 15-16 jumadai 1430h / 10-11 may 2009g dr. tawfik a. m. khoja1

Doha, Qatar, 15-16 Jumada’I 1430H / 10-11 May 2009G

Dr. Tawfik A. M. Khoja 1

Dr. Tawfik A. Khoja 2

يي�مش�ي أ�ف�م�ن” أ�ف�م�ن” ك�ب�ا ي�مش� ك�ب�ام� ه� ع�ل�ىع�ل�ى م� ه� ه�و�ج ه� و�جد�ىأ�هد�ى م�ن أ�ه

م�نأ� أ�

يي�مش�ي ع�ل�ى ي�مش� ي�ا و� ع�ل�ى س� ي�ا و� اط� س� ر� اط�ص� ر� يم� ص� ت�ق� يم� م)س ت�ق� م)س””

“ Is then one who Walks headlong, with his face Grovelling, better

guided, Or one who walks Evenly on a Straight Way ? ”

آية ) الملك (22سورة

Holy Quran

Dr. Tawfik A. Khoja3

1. Barriers to integration, and problems facing implementation of NCD programmes in PHC.

2. Current Health care system (Radar syndrome) and explain the innovative care for NCD framework based upon a set of (6) guiding principles with clear differences between existing and reformed services characteristics.


3. some Gulf and regional successful solutions as follows:


a. Two important strategic resolutions from HMC/GCC states.

b. Mini Clinic initiative for chronic illnesses care in PHC

4. UK initiative for quality performance indicators in NCD management and control in general practice as an important international example for integration improvement.

5. Additional some helpful solution in building capacity of human resources, other new approaches and CME, beside the requirements for development in the current stage.

Cognitive Barriers:Cognitive Barriers: People often have little thought for the

future. Doctor-initiated, i.e. the demand should be

predictable Non-urgent. Easily delegated to other primary health

care team members. Focused on high-risk groups & focused on

individuals. Good records are essential; audit is usually

straightforward .Dr. Tawfik A. M. Khoja 7

Psychological Barriers:Psychological Barriers: All of us at times are prone to promote our own idea as keenly as we promote our own survival.

Political Barriers:Political Barriers: It is not unknown for governments to back out silently of preventive obligations as if influenced by pressure groups who would lose if prevention were successful.


Logistic Barriers:Logistic Barriers:

“Who has not had their blood pressure checked for 3 years?”

“Who has not turned up to their request to attend for screening”?

“Who has stopped sending in for their repeat prescriptions for anti-hypertensive”?

A health Center needs to be highly organized. Answer questions like:

Remote, rural, and inner cities areas poses major logistic problems.


Ethical BarriersEthical Barriers

Financial Barriers:Financial Barriers: A practice may have to pay for extra staff to run an effective screening programme.

Motivation Barriers:Motivation Barriers: Changing from a crisis-led work pattern to strategic prevention & Integration is one way that practice nurses can lead the way. There is some evidence that they are particularly successful at the meticulous, repetitive tasks on which all good prevention depends.


Problems Facing Implementation of NCD Programmes

Lack of risk factor surveillance.Non-harmonization of monitoring &

surveillance methodologies.Lack of reliable mortality data.Lack of training of professionals in NCDs

prevention & control.Deficiency of information on health care

services management for NCDs.Inadequate Health facilities infrastructural.


Current Health Care Current Health Care SystemSystem


Patient appears. Patient is treated

“find it & fix it” Patient is discharged. …… then disappears

from radar screen.

The Radar Syndrome

Primary care definedPrimary care defined

"Primary care is the provision of integrated, "Primary care is the provision of integrated, accessible health care services by clinicians accessible health care services by clinicians who are accountable for addressing a large who are accountable for addressing a large majority of personal health care needs, majority of personal health care needs, developing a sustained partnership with developing a sustained partnership with patients, and practicing in the context of family patients, and practicing in the context of family and community.“and community.“


SourceSource: : Institute of Medicine, Committee on Institute of Medicine, Committee on the Future of Primary Care. the Future of Primary Care. Primary Care: Primary Care: America's Health in a New Era. America's Health in a New Era. Washington, Washington, DC: National Academy Press, 1996.DC: National Academy Press, 1996.

Efficient Primary Health Care Must Include The Following “9 As”. It Must be:

AvailableAvailableAccessibleAccessibleAffordableAffordableAcceptableAcceptableAdaptableAdaptableApplicableApplicableAttainableAttainableAppropriateAppropriate

AssessableAssessable

Keeping PEOPLE Well

Getting PEOPLE Better

Helping PEOPLE Cope


INTEGRATIONINTEGRATION Integrated health promotion

and NCD’s prevention is a coordinated, systematic plan involving various Stakeholders using a combination of approaches to address health determinants and risk factors.



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 PHC team training on:• Evidence-based clinical guidelines 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.

18Dr. Tawfik A. M. Khoja


Strategic Resolutions by

the Health Ministers’

Council for Cooperation

Council States


CONTROL OF NON- COMMUNICABLE DISEASES IN THE GULF REGION

The Executive office circulated the recommendations issued by the various international organizations stressing the need for more support to the regional networks to combat non- communicable diseases and putting an emphasis on the following 4 points:

1. Health services development.

2. Defining risk factors and how to face them.

3. Surveillance of these diseases.

4. Continuous monitering , evaluation & research .

Resolution # 1 Conference 63rd (Geneva, 29/4/1428 Corresponding to 16/5/2007 G)



Resolution # 6-B Conference 64 (Riyadh, 2/2008 G)

Approval on the “Gulf charter for Health of the Heart, putting Heart first” project and its endorsement under the name “Riyadh Declaration”.

On the 64th conference resolutions # 6-B (Riyadh, 27-28 Muharram 1429H / 5-6 February 2008)


Work towards adopting the slogan (2008 for control of cardiovascular diseases) and putting it into effect.

• • Health promoting schools (United Arab Emirates)Health promoting schools (United Arab Emirates)

• • Health Promotion Council in the Kingdom of Bahrain Health Promotion Council in the Kingdom of Bahrain (National Plan for Control of Chronic Diseases).(National Plan for Control of Chronic Diseases).

• • Specialized clinics Initiatives (Kingdom of Saudi Specialized clinics Initiatives (Kingdom of Saudi Arabia).Arabia).

• • NIZWA project for Healthy Life Style (Sultanate of NIZWA project for Healthy Life Style (Sultanate of Oman).Oman).

• • Facts for Life “ Book (Cooperation Council States).Facts for Life “ Book (Cooperation Council States).


Examples of some leading gulf Achievements

THUS. WE. NEED

Continuous Quality Improvement Process

NCD’s Integration FOR ALL-NCD’s Integration FOR ALL-BEYOND THE YEAR 2009GBEYOND THE YEAR 2009G


بسم الله الرحمن الرحيم

Theme: “Learning together”1

Pearls and Pearls and PerilsPerils

InInMini-Clinic Mini-Clinic InitiativeInitiative

forfor

NCD’sNCD’s

The Objective of this initiative is not only to promote better care but also to improve the organizational aspects of caring for the chronic illness, such as screening , referral system, and periodic health evaluation

Health Centers have to play a major role if this program is to reach the grass root level.

10

FROM ILLNESS TOWELLNESS

Mini-Clinic Initiative for Chronic illness Care in PHC Centres

OBJECTIVES:OBJECTIVES: * To enhance community awareness

about prevention, screening and rehabilitation through the mini-clinics.

* To make use of guidelines and standardize the policy as well as procedures of executing them within mini-clinic settings in P.H.C.C.

* To harmonize and consolidate various activities and operate cost-effectively within mini-clinics.


Specialized Clinics Initiative

Our Vision for Our Vision for HealthHealthGCC is to be a nation of healthy individuals, families

and communities

Characteristics ofHealthcareSystem:

9As +EquitableEfficientConsumer-friendly

Emphasis of healthcareSystem:QualityInnovationHealth promotionPromotion of individualResponsibilityCommunity participation



Building capacity of human resource

1- Supporting and developing the current divisions/departments concerned with control of NCDs in the MOHs as well as establishing specialized departments or divisions in a high structural position in the MOH in those countries which do not have such departments or divisions.

2- Assigning national and Gulf committees )concerned with control of NCDs( to prepare evidence-based guidelines for risk factors in coordination with the EMRO.

3- Supporting and promoting the methods of improving and developing programs of health care of chronic diseases patients within the activities of PHC, as well as overcoming the shortage in the assistant health cadres in this field.


- Concerning the importance of supporting and promoting the role of primary health care in the field of control of non-communicable diseases and positioning the extended medical care as one of the priorities in the strategies.

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).

New Approaches


B) Giving effect to the concept of health promotion within the Healthy Lifestyle, prevention and control of chronic and non-Infectious diseases.

C) Work on adopting the concept of "Chronic Diseases Shared Care" in primary healthcare centers and hospitals, and to strengthen the referral system, and adopt modern approaches in the provision of healthcare services i.e. the establishment of mini-clinics and periodic check-up program.


Quality Performance Indicators –

in Coronary Heart Diseasein Coronary Heart Disease All minimum thresholds are 25%

IndicatorPoints

Maximum threshold

Medical records

CHD 1. The practice can produce a register of patients with coronary heart disease

6

Diagnosis and initial management

CHD 2. The percentage of patients with newly diagnosed angina (diagnosed after ) who are referred for exercise testing and/or specialist assessment

790%

Ongoing Management


IndicatorPointsMaximum threshold

CHD 3. The percentage of patients with coronary heart disease, whose notes record smoking status in the past 15 months, except those who have never smoked where smoking status need be recorded only once

790%

CHD 4. The percentage of patients with coronary heart disease who smoke, whose notes contain a record that smoking cessation advice has been offered within the last 15 months

490%

CHD 5. The percentage of patients with coronary heart disease whose notes have a record of blood pressure in the previous 15 months

790%

CHD 6. The percentage of patients with coronary heart disease, in whom the last blood pressure reading (measured in the last 15 months) is 150/90 or less

1970%


IndicatorPoints

Maximum threshold

CHD 7. The percentage of patients with coronary heart disease whose notes have a record of total cholesterol in the previous 15 months

790%

CHD 8.The percentage of patients with coronary heart disease whose last measured total cholesterol (measured in the last 15 months) is 5 mmol/l or less

1660%

CHD 9. The percentage of patients with coronary heart disease with a record in the last 15 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken (unless a contraindication or side effects are recorded)

790%

CHD 10. The percentage of patients with coronary heart disease who are currently treated with a beta blocker (unless a contraindication or side-effects are recorded)

750%


Other sets of performance indicators

1. Stroke or transient ischaemic attacks.2. Hypertension.3. Diabetes Mellitus (Diabetes).4. Chronic Obstructive Pulmonary Disease

(COPD).5. Epilepsy.6. Hypothyroidism.7. Cancer.8. Mental Health.9. Asthma.


Other sets of performance indicators

1. Ongoing ManagementA. Records and information about patients.B. Patient communication.C. Education and training.D. Practice Management.E. Medicines Management.

2. Patient experienceA. Length of Consultations.

B. Patient Surveys.

3. Additional Services


Continues Medical Education

Health education and counseling of citizens towards proper health behavior and change of traditional life style:

- Intensify the "Educational Programs""Educational Programs" that help to change their living style and to avoid environmental factors and dietary habits that impact their health negatively. Also to encourage social initiatives that endeavor to achieve these goals, disseminate the implementation of check-up clinics, periodic health evaluation and smoking control clinics.


- Work towards giving effect to the slogan – Working together – for control & prevention of NCD and through :

a ) Implementation of the national plan for control of NCDs.

b) Intensive support of the scientific activities (conferences, symposia, workshops) related to control and prevention of such group of diseases.


d) Support of epidemiologic researches on cardiovascular diseases and related risk factors, burden of diseases and consequent economic impact.

e) Support and strengthening of the role of individuals and families in improving health life style and reduction of risk factors.

- Establishing a “ National Committee for control of NCDs to involve representatives from various, related health, medical, academic sectors to adopt, implement and apply the endorsed programmes, policies and plans.

NCDNCD. Management . Management require require an evolutionan evolutionOf health care ……Of health care ……

From typical From typical RadarRadar CareCare to to “ “ Innovative Care”Innovative Care”


PHC / Health System ReformPHC / Health System Reform

Innovative Care for NCDInnovative Care for NCD

““Everything starts with a Everything starts with a dream………….dream………….with some luck and appreciation and a with some luck and appreciation and a bit of application it may evolve into an bit of application it may evolve into an idea. idea. But to develop the idea into a plan and But to develop the idea into a plan and to bring that plan to reality requires an to bring that plan to reality requires an enormous amount of skills, dedication enormous amount of skills, dedication and hard work”and hard work” Richard PoundRichard PoundDr. Tawfik A. M. Khoja 46

Innovative Care for NCD Innovative Care for NCD FrameworkFramework

ICC Framework is based upon a set of ICC Framework is based upon a set of guiding principles:guiding principles:


II.II. Population focusPopulation focus

I.I. Evidence based decision making in Policy Evidence based decision making in Policy making , Service planning , & Clinical making , Service planning , & Clinical management of management of NCDNCD..

Build capacity & infrastructure for the Build capacity & infrastructure for the collection & analysis of relevant collection & analysis of relevant information.information.

III.III. Prevention focusPrevention focus Every health care interaction should Every health care interaction should

include prevention support.include prevention support.

Prioritize health needs rather than the Prioritize health needs rather than the single unit of a patient seeking care.single unit of a patient seeking care.

Innovative Care for NCD Innovative Care for NCD FrameworkFramework

IV.IV. Quality focus to ensureQuality focus to ensure


Routine surveillance, monitoring & evaluation Routine surveillance, monitoring & evaluation to be able to adapt to changes.to be able to adapt to changes.

Learning systems.Learning systems.

Proper utilization of resources.Proper utilization of resources. Accountable providers.Accountable providers. Best patient outcomes.Best patient outcomes.

V.V. IntegrationIntegration The core of ICC framework.The core of ICC framework. Integration, coordination & continuity should Integration, coordination & continuity should

occur across time & health care settings.occur across time & health care settings.VI.VI. Flexibility / AdaptabilityFlexibility / Adaptability

What Do We Need ?What Do We Need ?Knowledge about gravity of the problem.Leadership to do something about it.A clear assessment of current health care

situation.A plan of action.Cost – analysis studies.


Service Characteristics

ExistingExisting ReformedReformed

State Administered Community Developed

Categorically Defined Holistic

Uniform Flexible and Individually Tailored

Deficit-Oriented Strength-Based

Individual as Client Family as Client

Disease centredPatient Centred

Clients as Recipients Families and patients as Participants

Emphasis on Professional Services

Emphasis on Community Support


Eight Essential ElementsEight Essential ElementsFor Improving Health Care For Chronic Conditions For Improving Health Care For Chronic Conditions

(NCD)(NCD)

1.1.Support a paradigm shift from acute to Support a paradigm shift from acute to chronic carechronic care

2.2.Manage the political environment.Manage the political environment.

3.3.Build integrated health care.Build integrated health care.

4.4.Align sectoral policies for health.Align sectoral policies for health.

5.5.Use health care personnel more effectively.Use health care personnel more effectively.

6.6.Centre care on the patient and family.Centre care on the patient and family.

7.7.Support patients in their communities.Support patients in their communities.

8.8.Emphasize prevention.Emphasize prevention.Dr. Tawfik A. M. Khoja 52

Emphasize PreventionEmphasize PreventionWhat You Can Do ?

Policy: Integrate policies Policy: Strengthen partnerships Policy: Support legislative frameworks Health Care Organization: Organize and equip health care team Health Care Organization: Support self-management and prevention Health Care Organization: Use information systems Community: Provide complementary services


pproper (effective) promotion, roper (effective) promotion,

prevention and treatment not to prevention and treatment not to

be seen as abe seen as a costcost but as anbut as an

investment investment in ’health capital’in ’health capital’

Professor Professor David CutlerDavid Cutler, ,

Harvard UniversityHarvard University


COLLABORATION AMONG COLLABORATION AMONG Gulf COUNTREIS AND Gulf COUNTREIS AND SHARING COMMUNITY-SHARING COMMUNITY-BASED PROGRAMMESBASED PROGRAMMES


AT THE ENDAT THE END

WE ARE HERE TO LISTEN, WE ARE HERE TO LISTEN, SHARE, DISCUSS AND LEARN. SHARE, DISCUSS AND LEARN.

LEARNING CYCESTABLISHING LE IS IMPORTANT FOR NCDs RISK FACTOR ANALYSIS AND MANAGEMENT.



Requirements forDevelopment 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, 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.


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 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.


•• Review of the methods of combating NCDs at the level of Review of the methods of combating NCDs at the level of PHC & setting the modern bases for building the capacities PHC & setting the modern bases for building the capacities of the staff through support of family and community of the staff through support of family and community medicine. medicine.

•• The importance to support information systems and The importance to support information systems and statistics at the national level, as related to NCDs and the statistics at the national level, as related to NCDs and the common risk factors as a main element in strengthening this common risk factors as a main element in strengthening this trend putting it on the list of priorities in the Council States. trend putting it on the list of priorities in the Council States.

•• Encouraging and supporting community initiatives to face Encouraging and supporting community initiatives to face common risk factors for NCDs in cooperation with WHO. common risk factors for NCDs in cooperation with WHO.

• • Starting the executive actions to deal with the health Starting the executive actions to deal with the health strategies with regard to nutrition and physical activity at the strategies with regard to nutrition and physical activity at the level of the Council States together with provision of level of the Council States together with provision of technical support on the part of WHO in this respect. technical support on the part of WHO in this respect.

The recommendations formed a basis for The recommendations formed a basis for integrated Gulf programmes, they included:integrated Gulf programmes, they included:

Dr. Tawfik A. Khoja 61QIQI

doha, qatar, 15-16 jumadai 1430h / 10-11 may 2009g dr. tawfik a. m. khoja1

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