PRACTICAL APPROACH TO LUNG HEALTH DEVELOPMENT AND IMPLEMENTATION IN TUNISIA

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PRACTICAL APPROACH TO LUNG HEALTHDEVELOPMENT AND
IMPLEMENTATION IN TUNISIA

• RIDHA DJEBENIANI, N.T.P. MANAGER, TUNISIA
• AGNES HAMZAOUI, P.A.L. COORDINATOR, TUNISIA
• ALI BEN KHEDHER, P.A.L. PROJECT DIRECTOR,
  TUNISIA
• NTP Manager Meeting, Lahore, 26-29 April 2004

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WHAT IS P.A.L.? (1)

• Syndromic approach to the management of patients
  who attend health services for respiratory
  symptoms
• Objectives improvement of
• Quality of respiratory case management
• Efficiency and cost-effectiveness of
  respiratory care within health systems
• PAL components
• Standardization of health service delivery
• Coordination between different levels of health
  care as well as between NTP and the organisation
  and management of general health services

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RATIONALE FOR P.A.L. INTRODUCTION IN TUNISIA (1)

• The provincial chest clinic 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 (ex. asthma)
  
• TB less frequent within health care services than
  CRDs (asthma and COPD)
• TB is basically detected among patients with
  respiratory symptoms within PHC settings the vast
  majority of which are identified as non-TB cases

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RATIONALE FOR P.A.L. INTRODUCTION IN TUNISIA (2)

• Standardized procedures defined for TB and ARI
  (in children below 5 years of age). This is not
  the case for patients over five years of age with
  respiratory symptoms
• Study carried out in Monastir reported that 43.5
  of patients attending primary health care
  settings (PHC) seek care for respiratory symptoms
  (40.5 in females and 48.6 in males)
• There is a high rate of antibiotic prescription
  though data are not yet available

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RATIONALE FOR P.A.L. INTRODUCTION IN TUNISIA (3)

• TB morbidity not high (2003)
• Nbr. 1965 N.cases (any type)
• Incidence (any type) 19.6 per 100,000
  population
• Incidence decreased from 48.6 in 1975 ? 19.6 in
  2003, let 60 decrease
• 100 DOTS population coverage
• Treatment success rate over 85
• Estimated detection rate 85
• Pulmonary TB confirmation rate 90

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RATIONALE FOR P.A.L. INTRODUCTION IN TUNISIA (4)

• Good collaboration between NTP and the other
  sectors
• Sentinel surveillance system for HIV infection in
  TB case implemented for more than 10 years and
  showing very low sero prevalence (lt 0.5)
• Ongoing implementation of standardized management
  of chronic TB cases (DOTS-PLUS)

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REQUIREMENTS TO ADAPT AND DEVELOP P.A.L. IN
TUNISIA

• Political commitment to adapt and develop PAL
  strategy with official request to EMRO/WHO from
  national health authorities
• Assessment of the existing conditions to adapt
  the PAL strategy by WHO staff
• Demographic transition life expectancy 74 years
• Epidemiological transition more chronic
  conditions asthma, COPD
• 100 PHC population coverage
• 70 population covered by the health insurance
  system
• NTP activities fully integrated into PHC network
• Regularly updated essential drug list

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FOCUS OF P.A.L. IN TUNISIA

• Focus on priority respiratory diseases among
  patients aged 5 years or more
• TB
• ARI (pneumonia)
• Asthma
• COPD
• lung cancer,
  bronchiectasis, acute respiratory conditions
  needing urgent care as pneumothorax, pulmonary
  embolism, laryngitis, foreign body
• Cigarettes smoking cessation advice is a constant
  item throughout the case management process

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APPROACH PRINCIPLES

• Syndromic management approach on the basis of
  respiratory symptoms, cases are classified as
• Severe cases to be referred
• Management on spot
• Mild respiratory conditions (home
  care)

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P.A.L. DEVELOPMENT (1)

• Technical and financial support from WHO
• Has taken into account the epidemiological
  situation, the level of economic development and
  resources available in PHC level (human
  resources, equipment, essential drug list)
• Establishment of a national working group for PAL
  in February 2003 includes university chest
  physicians, PHC professionals, a public health
  specialist and a university ENT.

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P.A.L. DEVELOPMENT (2)

• Development of PAL guidelines and training
  material by the NWG from April to November 2003
• PAL guideline development based on
• WHO generic PAL guidelines
• Morocco PAL guidelines
• Peru PAL guidelines
• SPLF guidelines
• BTS guidelines
• GINA guidelines
• GOLD publications
• PAL guide developed for GPs practising in PHC
  centers

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P.A.L. GUIDELINE DEVELOPMENT

• National PAL guideline
• is symptom-based
• is adapted to the equipment resources existing in
  PHC facilities
• promotes essential drugs specified in the
  national list
• specifies the information system to be used
  

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P.A.L. FEASIBILITY TEST (1)

• Baseline survey carried out on respiratory care
  management in january 2004 involving 100 PHC
  doctors (about 5000 respiratory patients)
• Training of these 100 PHC doctors in two 2-day
  training sessions with two groups each,
  respectively in late February and early mars
  2004 2 trainers for each group interactive
  method was used training material consists of
  the PAL guide and clinical cases.
• PAL implementation in pilot sites (where the 100
  PHC doctors are working)
• Study of the impact of PAL in these same pilot
  sites in march 2004 involving the same 100 PHC
  doctors

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P.A.L. FEASIBILITY TEST (2)

• Data collection done but data entry in computer
  still ongoing
• Beside evaluating the burden of respiratory
  disease in PHC setting, the PAL feasibility test
  will quickly assess the impact of PAL on the
  basis of
• - distribution of respiratory conditions
  before and after PAL
• - integration of the management of respiratory
  cases into
• PHC services
• - quality of TB diagnosis among respiratory
  disease cases
• - patterns of drug prescription, particularly
  antibiotics
• - costs of drug prescription

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P.A.L. IMPLEMENTATION (1)

• PAL implemented in 4 provinces out of 24
• Recording/reporting system
• General health service registration system
  General consultation register
• NTP recording/reporting system
• PAL register
• Patient booklet (being finalised)
• Six-monthly evaluation report on PAL
  activities (to be developed)

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EXPECTATIONS FROM P.A.L. IMPLEMENTATION (1)

• It is expected that PAL Implementation will
• improve TB detection and TB diagnosis quality
• improve planning and health resources management
• address the challenge of the burden of
  respiratory diseases in PHC through the provision
  of an essential health care delivery package
• promote respiratory health in public health
  service settings

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EXPECTATIONS FROM P.A.L. IMPLEMENTATION (2)

• secure and empowers tuberculosis control in the
  era of epidemiological transition
• be a further step in DOTS quality improvement
• provide information on TB detection within
  general health care services
• improve the health management information system

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EXPECTATIONS FROM P.A.L. IMPLEMENTATION (3)

• improve the referral system for respiratory
  conditions and TB
• strengthen PHC services to increase attendance
  for respiratory conditions
• reduce the prescriptions of drug in general and
  antibiotics in particular
• strengthen the competence of PHC workers
• strengthen the confidence of the population in
  PHC services
• address inefficiencies in respiratory disease
  management

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NEXT STEPS

• Acquisition of equipment peak flow meters,
  spacer devices
• Update of the essential drug list
• Development of a nationwide PAL implementation
  and expansion plan by the NWG (with costs)
• Adoption of plan by National Health Authorities