Doha, Qatar, 15-16 Jumada’I 1430H / 10-11 May 2009G
Dr. Tawfik A. M. Khoja
1
‫علَى َو ْج ِه ِِه أ َ ْهدَى أ َ َّمن‬
َ ‫شي ُم ِكبًّا‬
ِ ‫” أَفَ َمن يَ ْم‬
ْ ‫علَى ِص َراطِ ُّم‬
”ِ‫ست َ ِقيم‬
َ ِ‫س ِويًّا‬
ِ ‫يَ ْم‬
َ ‫شي‬
)22ِ‫سورةِالملكِ(آية‬
“ Is then one who Walks headlong, with his face
Grovelling, better guided, Or one who walks
Evenly on a Straight Way ? ”
Dr. Tawfik A. Khoja
2
Holy Quran
3
Dr. Tawfik A. Khoja
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.
Dr. Tawfik A. M. Khoja
4
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.
Dr. Tawfik A. M. Khoja
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Dr. Tawfik A. Khoja
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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
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Psychological Barriers:
All of us at times are prone to promote our own
idea as keenly as we promote our own survival.
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.
Dr. Tawfik A. M. Khoja
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Logistic Barriers:
 A health Center needs to be highly organized.
 Answer questions like:
“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
antihypertensive”?
 Remote, rural, and inner cities areas poses
major logistic problems.

Dr. Tawfik A. M. Khoja
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Ethical Barriers
Financial Barriers:
A practice may have to pay for extra staff to run
an effective screening programme.
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.
Dr. Tawfik A. M. Khoja
10
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.
Dr. Tawfik A. M. Khoja
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Current Health
Care System
The Radar Syndrome
 Patient appears.
 Patient is treated
“find it & fix it”
 Patient is discharged.
 …… then disappears
from radar screen.
Dr. Tawfik A. M. Khoja
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Primary care defined
"Primary care is the provision of integrated,
accessible health care services by clinicians
who are accountable for addressing a large
majority of personal health care needs,
developing a sustained partnership with
patients, and practicing in the context of family
and community.“
Source: Institute of Medicine, Committee on
the Future of Primary Care. Primary Care:
America's Health in a New Era. Washington,
DC: National Academy Press, 1996.
Dr. Tawfik A. Khoja
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Efficient Primary Health Care Must Include
The Following “9 As”. It Must be:
Available
Accessible
Affordable
Acceptable
Adaptable
Applicable
Attainable
Appropriate
Keeping PEOPLE Well
Getting PEOPLE Better
Helping PEOPLE Cope
Assessable
Dr. Tawfik A. M. Khoja
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INTEGRATION
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.
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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.
Dr. Tawfik A. Khoja
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Dr. Tawfik A. M. Khoja
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Dr. Tawfik A. M. Khoja
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Strategic
Resolutions by
the Health
Ministers’
Council for
Cooperation
Council States
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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 .
Dr. Tawfik A. Khoja
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Resolution # 1 Conference 63rd (Geneva, 29/4/1428
Corresponding to 16/5/2007 G)
Control of Diabetes
Decided:
and its endorsement as a commitment to improve
public health and to confront the diabetes problem in
preparation to raise it to HE the Secretary General of
the Council Secretariat of the Cooperation Council
States for the Arab Gulf Countries, and hence to their
majesties and highnesses the princes, the leaders of
the Cooperation Council States to obtain the
political, material and community commitment to
confront this problem.
Dr. Tawfik A. M. Khoja
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Dr. Tawfik A. M. Khoja
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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”.
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Dr. Tawfik A. M. Khoja
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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.
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Examples of some leading gulf Achievements
• 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).
Dr. Tawfik A. M. Khoja
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NCD’s Integration FOR ALLBEYOND THE YEAR 2009G
THUS. WE. NEED
Continuous Quality Improvement Process
Dr. Tawfik A. M. Khoja
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‫بسم هللا الرحمن الرحيم‬
Pearls and
Perils
In
Mini-Clinic
Initiative
for
NCD’s
1
Theme: “Learning
together”
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.
FROM ILLNESS TO
WELLNESS
10
Mini-Clinic Initiative for Chronic illness
Care in PHC Centres
Specialized Clinics Initiative
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.
Dr. Tawfik A. M. Khoja
31
Our Vision for Health
GCC is to be a nation of healthy individuals, families
and communities
Emphasis of healthcare
System:
Quality
Innovation
Health promotion
Promotion of individual
Responsibility
Community participation
Characteristics of
Healthcare
System:
9As +
Equitable
Efficient
Consumer-friendly
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32
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.
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New Approaches
-
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).
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34
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 miniclinics and periodic check-up program.
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Quality Performance Indicators –
in Coronary Heart Disease
All minimum thresholds are 25%
Indicator
Points
Maximum
threshold
Medical records
CHD 1. The practice can produce a register of
patients with coronary heart disease
Diagnosis and initial management
6
CHD 2. The percentage of patients with newly
diagnosed angina (diagnosed after ) who are referred 7
for exercise testing and/or specialist assessment
90%
Ongoing Management
Dr. Tawfik A. Khoja
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Indicator
Points
Maximum
threshold
CHD 3. The percentage of patients with coronary heart
disease, whose notes record smoking status in the
7
past 15 months, except those who have never smoked
where smoking status need be recorded only once
90%
CHD 4. The percentage of patients with coronary heart
disease who smoke, whose notes contain a record that
4
smoking cessation advice has been offered within the
last 15 months
90%
CHD 5. The percentage of patients with coronary heart
disease whose notes have a record of blood pressure 7
in the previous 15 months
90%
CHD 6. The percentage of patients with coronary heart
disease, in whom the last blood pressure reading
19
(measured in the lastDr.15
months) is 150/90 or less
Tawfik A. Khoja
70%
37
Points
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
7
90%
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
16
60%
Indicator
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- 7
coagulant is being taken (unless a contraindication or
side effects are recorded)
90%
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)
Dr. Tawfik A. Khoja
50%
7
38
Other sets of performance indicators
1.
2.
3.
4.
5.
6.
7.
8.
9.
Stroke or transient ischaemic attacks.
Hypertension.
Diabetes Mellitus (Diabetes).
Chronic Obstructive Pulmonary Disease
(COPD).
Epilepsy.
Hypothyroidism.
Cancer.
Mental Health.
Asthma.
Dr. Tawfik A. Khoja
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Other sets of performance indicators
1. Ongoing Management
A.
B.
C.
D.
E.
Records and information about patients.
Patient communication.
Education and training.
Practice Management.
Medicines Management.
2. Patient experience
A. Length of Consultations.
B. Patient Surveys.
3. Additional Services
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Continues Medical Education
Health education and counseling of citizens
towards proper health behavior and change of
traditional life style:
-
Intensify the "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.
Dr. Tawfik A. Khoja
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-
Work towards giving effect to the slogan –
Working together – for control & prevention
of NCD and through :
a )
b)
Implementation of the national plan for
control of NCDs.
Intensive support of the scientific
activities
(conferences,
symposia,
workshops) related to control and
prevention of such group of diseases.
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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.
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Dr. Tawfik A. M. Khoja
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PHC / Health System Reform
NCD. Management
require
an evolution
Of health care ……
From typical Radar
Care to
“ Innovative Care”
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Innovative Care for NCD
“Everything starts with a dream………….
with some luck and appreciation and a
bit of application it may evolve into an
idea.
But to develop the idea into a plan and to
bring that plan to reality requires an
enormous amount of skills, dedication
and hard work”
Richard Pound
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Innovative Care for NCD
Framework
ICC Framework is based upon a set of
guiding principles:
I.
Evidence based decision making in Policy
making , Service planning , & Clinical
management of NCD.

Build capacity & infrastructure for the
collection & analysis of relevant information.
II. Population focus

Prioritize health needs rather than the single
unit of a patient seeking care.
III. Prevention focus

Every health care interaction should
includeDr.prevention
support.
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Innovative Care for NCD
Framework
IV. Quality focus to ensure



Proper utilization of resources.
Accountable providers.
Best patient outcomes.
V. Integration


The core of ICC framework.
Integration, coordination & continuity should
occur across time & health care settings.
VI. Flexibility / Adaptability
 Routine surveillance, monitoring & evaluation to
be able to adapt to changes.
 Learning systems.
Dr. Tawfik A. M. Khoja
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Dr. Tawfik A. M. Khoja
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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.
Dr. Tawfik A. M. Khoja
50
Service Characteristics
Existing
Reformed
State Administered
Community Developed
Categorically Defined
Holistic
Uniform
Flexible and Individually
Tailored
Deficit-Oriented
Strength-Based
Individual as Client
Family as Client
Disease centred
Patient Centred
Clients as Recipients
Families and patients as
Participants
Emphasis on
Professional Services
Emphasis on
Community Support
Dr. Tawfik A. Khoja
51
Eight Essential Elements
For Improving Health Care For Chronic Conditions
(NCD)
1. Support a paradigm shift from acute to chronic
care
2. Manage the political environment.
3. Build integrated health care.
4. Align sectoral policies for health.
5. Use health care personnel more effectively.
6. Centre care on the patient and family.
7. Support patients in their communities.
8. Emphasize prevention.
Dr. Tawfik A. M. Khoja
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Emphasize Prevention
What 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
Dr. Tawfik A. M. Khoja
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Dr. Tawfik A. M. Khoja
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oja
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
55
COLLABORATION AMONG
Gulf COUNTREIS AND
SHARING COMMUNITYBASED PROGRAMMES
Dr. Tawfik A. M. Khoja
56
AT
THE
END
 WE ARE HERE TO LISTEN,
SHARE, DISCUSS AND LEARN.
 LEARNING CYCESTABLISHING LE
IS IMPORTANT FOR NCDs RISK
FACTOR ANALYSIS AND
MANAGEMENT.
Dr. Tawfik A. M. Khoja
57
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, 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. Khoja
58
Primary prevention, based on comprehensive
_population-based programmes, is the most costeffective 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.
Dr. Tawfik A. Khoja
59
The recommendations formed a basis for
integrated Gulf programmes, they included:
• Review of the methods of combating NCDs at the level of
PHC & setting the modern bases for building the capacities
of the staff through support of family and community
medicine.
• The importance to support information systems and
statistics at the national level, as related to NCDs and the
common risk factors as a main element in strengthening this
trend putting it on the list of priorities in the Council States.
• Encouraging and supporting community initiatives to face
common risk factors for NCDs in cooperation with WHO.
• Starting the executive actions to deal with the health
strategies with regard to nutrition and physical activity at the
level of the Council States together with provision of
technical support on the part of WHO in this respect.
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Dr. Tawfik A. Khoja
QI
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