PAL-WHO SYSTEM: PRACTICAL APPROACH OF LUNG DISEASES Implementatıon ın Morocco Pr A. EL MEZIANE April, 2006 TTS congress - Antalya

INTRODUCTION Increase of prevalence + Increase of the burden of this disease to governments, health care systems PAL STRATEGY FOR MANAGEMENT RESPIRATORY DISEASES

What is PAL? PAL is syndromic management of patients who attend health services for respiratory symptoms (PHC) Objectives Improvement of : + Quality of respiratory care management + Efficiency of respiratory service delivery + Decrease of the cost

What is the PAL strategy? Standardization of health care procedures Coordination between health care levels Focus on priority respiratory diseases Tuberculosis Acute respiratory infection (pneumonia) Chronic Respiratory diseases (asthma, COPD)

Goal of PAL study ? To estimate short-term impact in cost and efficiency of the standardization of the coverage of the patients consulting for respiratory symptoms in PHC

What are the steps to introduce PAL in country? PAL needs : 1) adaptation to country health environment 2) development of tools 3) implementation within health system PAL adaptation, development and implementation should follow a stepwise process

1 st step: Official approval 2 nd step: Preliminary assessment and discussion in country 3 rd step: Establishment of a National Working Group (NWG) on PAL 4 th step: PAL guideline: principles and formulations 5 th step: Training material development for PAL 6 th and 7 th steps: Baseline and impact studies 8 th step: PAL implementation plan development 9 th step: Mobilization of funding resources 10 th step: PAL implementation STEPS OF PAL

1 st step: Official approval Awareness of country national health authorities regarding PAL possibilities Official formulation of the national health authorities for a preliminary assessment to explore the possibilities of PAL development in country

2 nd step: Preliminary assessment and discussion in country Level of demograghic and epidemiologic transitions Burden of respiratory diseases within health system TB and TB control situations Population health care service coverage (PHC) Organization of health care services Population health insurance coverage Process of decentralization / health sector reform Resources available within health system to manage respiratory cases Distribution human resources within health system

Organization of country referral system Availability of essential drug list or programme Organization of respiratory disease management within health system: guidelines (TB, CAP, asthma, COPD)?, referral system for CRDs?, information system for RDs? Formulation and discussion of work agenda to adapt and develop PAL 2 nd step: Preliminary assessment and discussion in country (continued)

3 rd step: Establishment of a National Working Group (NWG) on PAL Should include, under a clear leadership, all the relevant stakeholders: - NTP - PHC - HMIS - Academies (RD, PH, child health,…) - Health care service planning, HSR, drug policy - Others if needed Should adapt and develop: - national guideline for PAL and - training material for PAL implementation

4 th step: PAL guideline: principles Syndromic management approach: on the basis of respiratory symptoms, cases are categorized: + Severe cases to be referred + Management on spot + Mild respiratory conditions (home care)

4 th step: PAL guideline formulations Definition of health worker tasks by health care level Formulation of equipment needed to carry out tasks by health care level Specification of drugs needed to manage respiratory condition cases Specification of the information system to be used for monitoring and evaluation PAL activities: HMIS NTP information system Registration system for CRDs

5 th step: Training material development for PAL PAL guideline Sessions to explain basic concepts of PAL Case studies which cover the whole guideline content including information system Practical sessions on utilization of pick flow meter, inhalation chamber, spirometry Practical sessions with real respiratory patients

6 th and 7 th steps « IMPACT » study « BASELINE » study Training

6 th and 7 th steps: Baseline and impact studies Assessment of respiratory case management by HWs before and after PAL implementation in pilot sites The 2 studies: use the same protocol on the basis of the WHO model enrol patients, usually aged 5 years and over, who attend PHC facilities for respiratory symptoms involve a high number of GPs (80 to 100) who should be the same in both studies are carried out in the same PHC facilities should be carried out within a short period of time

Formation of the general practitioners at 2 levels Diagnosis: syndromic approach Therapeutic: standartized algorithmes

8 th step: PAL implementation plan development Should be multi-year and progressive in coordination with NTP Coordination unit at intermediate level Equipment by health care level: ex.: pick flow meter at PHC level and spirometry at referral level Training agenda for PHC, emergency room, referral level Cost of implementation by year and health care level

9 th step: Mobilization of funding resources Once the national PAL guideline and the training material available and the quick assessment of PAL impact carried out the mobilization of funds should be explored Funds can be mobilized by MOH (ex.: in the framework of the HSR process) PAL implementation can be funded in the framework of a bilateral cooperation National review meeting on PAL with donors to mobilize funds

10 th step: PAL implementation Establishment of a core of trainers Implementation of some equipment: pick flow meters in PHC and spirometers in referral facilities Organization of training sessions for health workers in line with the implementation plan PAL activities start Monitoring and evaluation of PAL activities

Moroccan Experıence

MATERIAL and METHOD Agreement of authorities Working sessions between members of the OMS and representatives of the Moroccan Health service General view of PAL's strategy: Constituents Objectives and applicability in Morocco

I. MESURES URGENTES ENTREPRISES Mise en place dun système dinformation opérationnel Dans les services de santé de base et dans le PNLAT il faut : Les registres et les imprimés techniques Impliquer la Division des Services de Santé de Base (SSB); Impliquer les SSB dans toutes les étapes de la mise en place de lISR Constitution dun comité national de préparation et de suivi de la mise en place de lISR au Maroc.

ELABORATION OF A GUIDE Guide destinated to the general practitioners Elaborated by a work group: Pneumologists Elaboration inspirated from the anterior PAL guides the national and international published recommandations Aims of the guide To establish a diagnosis from respiratory symptoms To decide a standardized protocol of short and middle term

DATA COLLECT REGISTRY Elaboration of a data collect registry The data are collected in 15 columns for all the social and medical characteristic

Number of order Date of the consultation Name and surname first of the patient Sex and et age Type of the consultation: NC ; CS Duration of the symptoms Medicines taken before the consultation Number of the medical consultations (last month) Symptoms Conditions and concomitant diseases Reminded diagnosis Decision of reference for complementary exams, specialized opinion or at hospital Treatment prescribes Development of the disease during the month following the consultation Final medical diagnosis DATA COLLECT REGISTRY

Eligibility of the study participants The eligibility criteria of the study participants were: - patient 5 years of age and over - patient who attended, for respiratory symptoms, any PHC

Description of medical population of study : general practitioners proposed by the CSB general practitioners agreed to be a part of this study and participated in the « BASELINE » step among them attended the training and participated so in the « IMPACT » step Only the data of the doctors which participated in the two types of studies were taken into account

II. PLAN DE MISE EN PLACE La mise en place de lISR dans les services de santé commencera dès avril 2002 et se déroulera en quatre phases : 1er avril 2002 : une journée dinformation et de présentation de lISR en faveur des enseignants universitaires des facultés de médecine de Rabat, Casablanca, Marrakech et Fès et des délégués du Ministère de la Santé aux provinces et préfectures des régions de : Grand Casablanca, Chaouia, Rabat-Zemmour, El-Gharb, Méknès-Tafilelt, Fès-Boulemane, Tensift et Tadla. Du 5 avril au 15 juin 2002 : Introduction de lISR dans les provinces et préfectures des Régions du Grand Casablanca, Chaouia, Rabat- Zemmour et El-Gharb.

II. PLAN DE MISE EN PLACE 2.1 Formation des médecins pneumophtisiologues : Deux séminaires de formation, de 5 jours chacun, auront lieu du 5 au 30 avril. Dans chacun de ces séminaires, 4 formateurs nationaux encadreront 25 médecins pneumophtisiologues relevant de toutes les provinces et préfectures de deux des 4 régions. 2.2 Formation des médecins généralistes : Nombre des médecins généralistes : 655. Duree de la formatıon : 3 jours Chaque séminaire nécessitera 3 encadrants. 2.3 Formation des majors des centres de santé médicalisés et des CDST et des animateurs du PNLAT : le nombre des animateurs du PNLAT et des majors des centres de santé médicalisés et des CDST est de 324.

III. MISE EN PLACE DUN PROGRAMME DE FORMATION DE LI.S.R. DANS LES FACULTES DE MEDECINE

CONCLUSION