PAL-WHO SYSTEM: PAL-WHO SYSTEM: PRACTICAL APPROACH OF PRACTICAL APPROACH OF

LUNG DISEASESLUNG DISEASES

Implementatıon Implementatıon ın ın

MoroccoMorocco

Pr A. Pr A. EL MEZIANEEL MEZIANE

April, 2006April, 2006

TTS congress - AntalyaTTS congress - Antalya

INTRODUCTIONINTRODUCTION

Increase of prevalence +

Increase of the burden of this disease to governments, health care systems

PAL STRATEGY FOR MANAGEMENT PAL STRATEGY FOR MANAGEMENT RESPIRATORY DISEASESRESPIRATORY DISEASES

What is PAL?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 What is the PAL strategy?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 ?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 What are the steps to introduce PAL in introduce PAL in

country?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

11stst step: step: Official approval Official approval 22ndnd step: step: Preliminary assessment and Preliminary assessment and discussion discussion in country in country 33rdrd step: step: Establishment of a National Establishment of a National Working Working Group (NWG) on PALGroup (NWG) on PAL 44thth step: step: PAL guideline PAL guideline: principles and : principles and formulationsformulations 55thth step: step: Training material development Training material development for PALfor PAL 66thth and 7 and 7thth steps: steps: Baseline and impact Baseline and impact studies studies 88thth step: step: PAL implementation plan PAL implementation plan developmentdevelopment 99thth step: step: Mobilization of funding Mobilization of funding resources resources 1010thth step: step: PAL implementationPAL implementation

STEPS OF PALSTEPS OF PAL

11stst step: step: Official Official approvalapproval

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

22ndnd step: step: Preliminary assessment Preliminary assessment and discussion in countryand 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

22ndnd step: step: Preliminary assessment and Preliminary assessment and discussion in country (continued)discussion in country (continued)

33rdrd step: step: Establishment of a Establishment of a National Working Group (NWG) National Working Group (NWG)

on PALon 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

44thth step: step: PAL guideline: PAL guideline: principlesprinciples

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)

44thth step: step: PAL guideline PAL guideline formulationsformulations

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

55thth step: step: Training material Training material development for PALdevelopment 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

66thth and and 77thth steps steps

« IMPACT » study

« BASELINE » study« BASELINE » study

TrainingTraining

66thth and 7 and 7thth steps: steps: Baseline and Baseline and impact studiesimpact 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

88thth step: step: PAL implementation plan PAL implementation plan developmentdevelopment

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

99thth step: step: Mobilization of funding Mobilization of funding resourcesresources

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

1010thth step: step: PAL PAL implementationimplementation

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 MATERIAL and METHODMETHOD

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 d’un système d’information 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 l’ISR

Constitution d’un comité national de préparation et de suivi de la mise en place de l’ISR au Maroc.

ELABORATION OF A ELABORATION OF A GUIDEGUIDE

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 PLACEII. PLAN DE MISE EN PLACE

La mise en place de l’ISR dans les services de santé commencera dès avril 2002 et se déroulera en quatre phases :

• 1er avril 2002 : une journée d’information et de présentation de l’ISR 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 l’ISR dans les provinces

et préfectures des Régions du Grand Casablanca, Chaouia, Rabat- Zemmour et El-Gharb.

II. PLAN DE MISE EN PLACEII. 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 joursChaque 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 D’UN PROGRAMME DE FORMATION DE L’I.S.R. DANS LES FACULTES DE MEDECINE

CONCLUSION