Kara WoolsKaloustian MD MS Indiana University School of Medicine Why arent HIV and NCDs addressed as Common Diseases within Primary Care Services The primary care system in many resource ID: 731478
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Health system strengthening for prevention and treatment of NCDs: lessons learned from HIV
Kara Wools-Kaloustian M.D. M.S
Indiana University School of MedicineSlide2
Why aren’t HIV and NCDs addressed as “Common Diseases” within Primary Care Services?
The primary care
system in
many resource constrained settings has developed into a system that delivers episodic care Public Health Sector focus: acute illnessesacute injuriesperinatal carefamily planningchildhood immunizationsLacks continuity for NCD care
Rabkin and El-Sadr Global Public Health 2011
Clinic Queue, western KenyaSlide3
HIV versus NCDsRequirements of a Health Care System
Similarities
Multiple levels of intervention
Community EducationPreventionScreeningTreatmentPalliation Chronic Care: Health care infrastructure must support care continuity (Chronic Care)
Differences
It’s in the details!Slide4
The Care Models that Shaped
the HIV Response
HIV Public Health Approach DOTSChronic
Care Model
Standardized
Tx
protocols
and simplified clinical monitoring
Standardized treatment
with supervision and patient support
Decision support
Optimal use of available human resources
Delivery system design
Involve community members and people living with HIV/AIDS
Standardized treatment with supervision and
patient support
Self-management support
Community Resources
Strategies to minimize costs
Political Commitment Sustained /Increased
Financing
Health Care organization
An effective drug supply and management system
“Strengthening Laboratories”
M&E system
Impact measurement
Clinical information systems
Grubb I et al. A Public Health Approach to Antiretroviral treatment: Overcoming constraints. WHO 2003
Wagner E et al. Improving Outcomes in Chronic Disease. Manage Care Q 1996Slide5
Goal: Political Commitment with Sustained Financing
Challenges:
Stigma, political inertia, lack of funding mechanisms Approach/Innovation: Slide6
Goal: Optimize Delivery System Design
Approach/Innovation
:
Enhance physical infrastructure, alternative structures Mobile clinics, decentralization, down referralEnhanced existing program management structures and created new onesTask shifting, Lay workersLinkage support
Challenges: Infrastructure and Equipment, Inequitable Availability, Program Management Structure, Human Resources, Mechanisms for Referral and Linkage
Alternative Structures, AMPATH KenyaSlide7
Goal: Optimize Decision Support
Approach/Innovation
:
Disease specific Training and MentoringSimplified Standardized Clinical Algorithms Introduction of Technology PDA-based Decision Supported Home Visit, Kenya
Challenges:
Trained health workers, Lack of appropriate technologies Slide8
Goal
: Community Engagement and Patient Support
Approach/Innovation:
Provision of ARTCommunity Sensitization and Education Expansion of Human resources: Peer educators, counsellors, outreach workersTechnology: Mobile phone remindersChallenges: Stigma, Lack of adherence support
Patient Supported Activities, AMPATH KenyaSlide9
Goal: Optimize Commodities Management
Approach/Innovation:
Generics
Introduction of electronic pharmacy systems Strengthening of governmental procurement systems Challenges: Demand side barriers, Procurement, Stock & Inventory managementAntiretrovirals, AMPATH KenyaSlide10
Goal: Data for Decision Making
Approach/Innovation:
Standardized data collection instruments
or Standardized minimal data elementsElectronic Medical Records SystemsStandardized Key indicatorsChallenges: Absence of medical record systems, standard data aggregation protocols, and common indicators Clinical Officer, AMPATH KenyaSlide11
Goal: Optimize Diagnostics
Challenges
:
Scarcity of Laboratories, Lack of appropriate technologies, Human Resources, CommoditiesApproach/Innovation: Enhanced Laboratory infrastructureCentralized LabsPoint of care testing Application to NCDs:Challenging for cancer diagnostics Specialized reagents, equipmentTrained Pathologist, histopathology/cytology technicians Slide12
Case 1: HIV and Chronic Disease Management
, Cambodia
Problem
: 100,000 people living with HIV; Adults DMII (5-11%) and HTN (12-25%)Program Components: Establishment of two chronic disease management clinics (HIV, DM, HTN)ART transforming HIV into a chronic diseaseStigma related to HIVEpidemiologic realities Political Commitment and FundingMOH and MSF Commitment Initial MSF Funding then transition to MOH
Janssen B. et al Bulletin WHO 85(11) 2007Slide13
Case 1: HIV and Chronic Disease Management , Cambodia
Delivery System Design
Physical Infrastructure enhancements
Human ResourcesAdditional training for DoctorsRecruitment of CounsellorsIncentives to staff Janssen B. et al Bulletin WHO 85(11) 2007Angkor Watt, CambodiaSlide14
Case 1: HIV and Chronic Disease Management , Cambodia
Decision
Support:
Simplified management DM - 2 Oral Hypoglycemic AgentsHTN – Standardized guidelines for managementPatient SupportCounseling activities AdherenceLife style changes Peer support groups (HIV, DM)DataEstablished disease tailored databaseSlide15
Case Study 2: Cervical Cancer Services, Zambia
Problem
:
Second highest cervical cancer rate globally incidence 52.8/100,000 and mortality 38.6/100,000 Program Components:Prevention HPV Vaccination Screening*Treatment*Dysplasia:Cryotherapy LEEPInvasive Cervical Cancer Radical Hysterectomy
Chemotherapy
Lusaka, Zambia Slide16
Financing
Primarily through PEPFAR
Part of Pink Ribbon Red Ribbon (PRRR)
Implementation Partners in collaboration with the Ministries
Transition to MOH support is planned
Political Commitment
The Republic of Zambia’s National Cancer Control Plan (NCCP)
Targets: cervical, breast, prostate, and retinoblastoma
Case Study
2:
Cervical Cancer
Services,
Zambia
Leadership Slide17
Case
Study
2:
Cervical Cancer Services, Zambia Delivery System Design Human resourcesNurses: screening & treatment of dysplasiaOB/GYN trainees: required to learn VIA, cryotherapy and LEEP
Inequitable Availability
Campaigns, mobile clinics, primary, secondary and tertiary facilities
Not part
of
"routine
"
primary care
Expansion to ↑ HIV prevalence areas
Referrals
and
Linkages
Initial:
Program Dependent
Current:
Standardized, National
Static
Screening
SitesSlide18
Case Study 2: Cervical Cancer Services,
Zambia
Decision Support
Development of 3 documents as companions to the NCCP: VIA and Cryotherapy Clinical Skills Training Course Trainer’s Guide Visual Inspection with Acetic Acid (VIA) and Cryotherapy: A Reference Manual for Trainers and Health Care Providers VIA and Cryotherapy Clinical Skills Training Course Participant’s GuideCommodities Management
Initial: Supplies procured and managed by implementing
partners Current: Procurement and management of some supplies though government systems
Diagnostics:
(See and Treat) Approach
VIA
as an alternative to
Pap
Smear or HPV Testing*
Diminishes the need for laboratory support servicesSlide19
Case
Study 2: Cervical Cancer Services
Zambia
Data for Decision Making Initial: Partner maintained databases PRRR affiliated partners reported aggregate data quarterly Indicators unique to each programCurrent:National standardized client level data collection toolsStandardized national indicators, defined by NCCP
Cervical Screening Indicators
by
Agency
CIDRZ, PCI
JPHIEGO
DHIS
Total No. women screened
Total No.
unique clients this mo.
No. women screened
HIV status
of screen
ed
No
.
clients received VIA
No.
of
VIA positives
No. clients Positive
VIA
Number of VIA
Negatives
No clients Negative VIA
No. of
VIA
uncertain /unsatisfactory
No.
suspicious for cancer
No.
clients suspected
cancer
No. women diagnosis
of cervical cancerSlide20
Case 3: Cardiovascular Disease, western Kenya
Problem:
CVD is the leading cause of death globally, substantial health and economic burden in low and middle income countries
Approach: Population-based screening for DM and HTN and linkage to careFinancing: Launched a new community-based outpatient health insurance programVedanthan R. Global Heart 10 (4) 2015Slide21
Case
3: Cardiovascular Disease, western
Kenya
Delivery System DesignProgram Management: Leveraged AMPATH infrastructureHuman Resources:CHW: Community education, support linkage and retentionDispensary nurses: Independently manage HTN and DMSpecialty Clinics (Cardiology and Diabetes): Referral for complex multidisciplinary careCommodities Management: Revolving Fund Pharmacies
Dispense medication (at cost) when health facility has a stock-out
Funds collected used to restock Revolving Fund Pharmacy
Vedanthan R. Global Heart 10 (4) 2015Slide22
Case 3: Cardiovascular Disease, western Kenya
Community
Engagement
Portable Community-based screening Patient SupportLink to Peer-Microfinance GroupsHealth Education & Agribusiness adviceDelivery System DesignTreatment provided at Group Meetings Charge per MOH ratesPastakia SD . Manuscript 2016
Bridging Income Generation with Group Integrated Care (BIGPIC)Slide23
Summary and Conclusions
Heath care systems that provide
episodic
care can’t be expected to manage NCDs HIV care systems and structures can serve as models for NCD managementAn appropriate response to NCDs will require a well resourced multi-sectorial responseAn integrated chronic disease management model will likely be the most cost-effective and sustainable approachCountries/Regions will need to prioritize NCDs based on local epidemiology Slide24
Acknowledgements
Fogarty International Center
Dr
. Linda KupferZambia MOH, MCDMCH & PartnersDr. Richard NsakanyaDr. Angel Mwiche Dr. Sharon KapambweMs. Yvonne MulengaDr. Joseph BandaDr. Kennedy LishimpiCDCDr. Laura PorterDr. Fatma Soud
CDC Foundation
Ms. Jennifer Drummond
AMPATH
Dr. Sonak Pastakia
Dr. Raj Vedanthan
Mr. Simon
Manyara
Dr. Jemima Kamano
Dr. Diana Menya
Mr. Benjamin
Adama
Dr. Jeremiah
Laktabai
Dr. Sylvester Kimaiyo
Dr. Robert Einterz
Our patients and the communities in which we work