Practical Approach to Lung health PAL development and implementation in Morocco

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Practical Approach to Lung health (PAL)
development and implementation in Morocco

• NaÏma Bencheikh, MD
• National TB Programme, Morocco
• NTP Manager Meeting, 17-19 June 2003, Morocco

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Welcome to Morocco!

• Morocco
• Population about 29 million
• Ongoing health sector reform
• Demographic transition life expectancy ? 69
  years
• Epidemiological transition
• More chronic conditions asthma, diabetes, heart
  diseases.
• Still communicable diseases STI, hepatitis, TB

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TB is a major problem of public health in Morocco
 

• ? 28,000 to 29,000 new TB cases / year
• In 2002
• Incidence 96 N. cases / 100,000 pop.
• Incidence 42 Smear positive cases /
• 100,000 pop.
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DOTS strategy adopted as of 1991

• Political commitment ? NTP budget ? 3.5
• Development of microscopy network
• Short course chemotherapy DOT
• Regular supply (no anti-TB drug shortage)
• Recording/reporting system in line with DOTS

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DOTS outcomes in Morocco

• Treatment success rate 90 since DOTS
  implementation
• Detection rate over 85

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DOTS impact on TB morbidity

• Slow decrease of pulmonary TB incidence
• Decrease of smear-positive case incidence on
  yearly basis since 1996 2 to 3 decrease per
  year
• Significant increase of extra-pulmonary TB case
  incidence

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TB INCIDENCE BY FORM, MOROCCO 1990-2001
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Involvement of private health sector in TB
control in Morocco

• 30 to 40 of notified TB cases are sent by
  private doctors to public sector
• Survey data from 4 provinces showed that general
  practitioners do not treat TB cases
• 2 surveys in Casablanca showed that chest
  physicians may treat few TB cases their drug
  prescriptions in line with NTP and their
  treatment success rate gt 75

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Involvement of prison health services in TB
control

• Fully integrated to NTP
• 12 main prisons equipped by microscopy lab
• Drug, reagent and stationary supplied by NTP
• Supervision by provincial TB co-ordinators

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Involvement of army health services in TB control

• Represented in the National TB Control Board
• Training ensured by NTP
• Anti-TB drugs supplied by NTP
• BUT, no reporting to NTP

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AIDS/HIV and TB in Morocco

• Morocco is a low HIV prevalence country
• Cumulative number of AIDS cases since 1986 1152
  (up to March 2003)
• 1 to 2 per 10,000 blood donors are HIV
• Among 857 TB patients, 1 was HIV (0,12)
• Sentinel surveillance system data show that less
  than 1 of TB patients are HIV

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MDR and chronic TB cases in Morocco

• DRS survey in Casablanca in 1998 among 510 new
  TB cases, 8.6 primary drug resistance and 2.2
  primary MDR
• Pool of about 150 chronic TB cases nationwide, 40
  to 45 are in Casablanca
• Specific management strategy implemented
  nationwide for chronic TB cases (DOTS-PLUS)

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Why developing and implementing PAL in Morocco?

• To cope with the health sector reform and
  decentralization need of standardized health
  interventions and standardized formulations
  (IMCI, STI, PAL)
• Need of sound cost-effective health procedures
• Need of a better rationalization of health
  services

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Why developing and implementing PAL in Morocco?

• Logical step to sustain TB control process
• NTP activities are fully managed by chest
  physicians TB control co-ordinator at
  province/prefecture level
• TB clinic (CDST) is a referral level not only for
  TB but also for the other respiratory conditions
• Demand for health care services regarding
  respiratory diseases other than TB (asthma)

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Why developing and implementing PAL in Morocco?

• Survey data from PHC facilities
• 20-30 of patients gt 5 years are patients with
  respiratory symptoms in PHC services
• 1 to 2 of are pulmonary TB patients
• About 70 of patients receive antibiotic
  prescription

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Why developing and implementing PAL in Morocco?

• Survey data from referral level (TB clinic)
• About 40 of work activities related to TB
  patients
• About 60 of patients are not TB/TB suspect
  cases
• 25 of patients are CRD cases
• 17 of patients are asthma cases

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PAL development in Morocco

• Integration of PAL development in the 5-year
  strategic plan of NTP covering 1999-2003
• Acquisition of equipment peak flow meters,
  inhalation chambers and spirometers
• Assessment by WHO of the conditions to introduce
  PAL in Morocco (Oct. 2000)

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PAL development in Morocco

• Establishment of a National Working Group (NWG)
  on PAL adaptation, development and implementation
  in Morocco
• NWG includes nurses, GPs, academicians, chest
  physicians, PHC professionals
• Technical assistance of WHO and IUATLD
• Financial support from WHO

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PAL development in Morocco

• Workshops organized by the NWG to develop PAL
  guidelines and training material
• PAL guideline development based on
• Consensus on PAL (May 1998, Geneva)
• International consensus on ARI/pneumonia, TB
  (DOTS), Asthma (IUATLD, GINA), COPD (GOLD), other
  evidence-based findings

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PAL development in Morocco

• PAL guidelines development requirements
• Symptom-based approach for the PAL guideline
  aiming the PHC level
• Disease-based approach for the PAL guideline
  aiming the referral level
• Standardization of health care procedures
• Coordination between health care levels

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PAL development in Morocco

• PAL guidelines development took into account
• Priority respiratory diseases in Morocco
• TB, ARIs, asthma and COPD
• Health care services (PHC, referral system)
• Country health resources
• Human resources
• Equipment resources available
• Essential drug list
• HMIS

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PAL development in Morocco

• Training material developed
• 2 PAL guidelines developed
• PAL guideline for GPs practising in PHC centers
• PAL guideline chest physicians practising in TB
  clinics, emerging rooms and hospital wards

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PAL development in Morocco

• Test of PAL guideline
• Qualitative study in PHC level showed PAL
  guideline is useful for health workers
• Impact study of PAL guideline implementation in
  PHC facilities showed
• Reduction of antibiotic prescription by 30
• Cost reduction on drug prescription by 18

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PAL Implementation in Morocco

• Nationwide PAL implementation and expansion plan
  developed by the NWG (with cost)
• Establishment of a core of national trainers
• Mobilization of financial resources from WHO/EMRO
  through JPRM (176,000 US for training)

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PAL Implementation in Morocco

• Cascade training process
• Training of NTP coordinators of provinces
• Then, training of chest physicians, GPs and
  nurses

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PAL Implementation in Morocco

• PAL implemented in
• 8 regions out of 16
• 34 provinces out of 73
• About 60 population PAL coverage nationwide

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PAL Implementation in Morocco

• Nbr of health workers trained in PAL
• 73 chest physicians
• 1874 general practitioners
• 802 nurses

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PAL monitoring and evaluation system in Morocco

• This system uses
• The existing HMIS
• The NTP recording/reporting system
• CRD register (TB clinic level)
• CRD file and card
• Quarterly evaluation report on PAL
  activities

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Rapport trimestriel des maladies respiratoires
chroniques
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Rapport trimestriel sur les épisodes aigus des
maladies respiratoires chroniques
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• Fiche Individuelle de suivi dans une FSB.
• Formation 
• Nom/ Prénom 
• N ordre CS 
• N Ordre CDST
• Adresse 
• Diagnostic

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Conclusion

• Standardization of respiratory condition
  management by health level will result into
• Improving TB detection and TB diagnosis quality
• Making TB problem remain visible among health
  priorities in Morocco

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• Contributing to strengthen PHC services in the
  ongoing context of the health sector reform
• Better management of health resources
• Promotion of respiratory health in public health
  service settings

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Thank you

• And once again, welcome to Morocco!