national department of health€¦ · imci guidelines 5 2015/ 2017 2018 nhi white paper 6 2016 ohsc...

A long and healthy life for all South Africans

National Department of Health

PSSA Conference 2018

Session 6: Primary Health Care – Really Re‐engineered?

Translating Policy into Healthcare Delivery

Trudy Leong

National Department of Health

Essential Drugs Programme

June 2018

2

Translating Policy Into Healthcare Delivery

Objectives

• Primary Health Care in Universal Healthcare Coverage

• Policy development to support Universal Healthcare Coverage

• Implementation of policies to achieve healthcare delivery

• Preview of PHC STGs and EML, 2018 update

3

Universal Health Care Coverage

4


Case Study

Background

• Mother arrives at PHC clinic with 2 year Tshepo. Has a bee sting on his finger - was

playing in the garden.

• Treatment: Ice pack; paracetamol.

• 15-20 minutes later hives on hand spreading to the arm; hoarseness of voice.

• Wheezing noted and immediate medical attention sought.

Examination

• Vital Signs - T 38.5 , P 150, R 40, BP 100/75.

• Mild respiratory distress; Drowsy, pale & responds when spoken to; Generalized

urticaria, no conjunctival oedema, lips and tongue not swollen; Heart tachycardic; No

history of asthma.

• Anaphylaxis diagnosed.

Problem statement

• How to manage anaphylaxis at primary level of care? (Commonly caused by bee stings).

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Universal coverage is a process, not a destination

Phase 1

Phase 2

Phase 3

Phase 4

• Agenda-setting; pilot programmes; developing new systems

• Low population coverage, early stage of UHC

• Initial programmes & systems in place; implementation in progress

• Health systems development & capacity building

• Population gaining access to services with financial protection, but population coverage-not

yet universal (gaps)

• Strong political leadership & citizen demands

• New investments & UHC policy reforms; systems & programme development to meet new demands

• UHC achieved, but focus on improving financial protection & quality of services

• Mature systems & programmes

• Continuous adjustments to meet changing demands & rising costs

• UHC with comprehensive access to quality health services; effective financial protection

South Africa?

6


Policy development timeline - a snapshot (related to medicine access)

1996

National Drug Policy

1

2010

National Core Standards

2

2003

National Health Act

3

2014

AMR Strategy Framework

4

2014

IMCI Guidelines

5

2015/ 2017

NHI White paper

6

2016

OHSC regulations

7

1996/ 2008/ 2014/ 2018

PHC STGs & EML

8

2007 /2014/ 2018

STI Guidelines

9

2015

NDoH HIV Consolidated guidelines

10

2017

National Policy Framework and Strategy on Palliative Care

11

2014/ 2018

Ideal Clinic Framework

12

2018

Norms and standards regulations

13

• Master Health Product List – in progress

• Formulary tool – in progress

• E-prescribing tool – in progress

Initiatives (related to medicine access):

• OHSC

• Stock Visibility System

• Central chronic medicines dispensing & distribution

(CCMDD) programme

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2018

NHI Bill

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From Primary Care to Primary HEALTH Care

Primary care: Foundation of the

heath system

• Point of first contact

• Continuous care

• Comprehensive care – integrated

services

• Coordinated continuum of care

40 years ago, the Primary health

care concept was borne from the

World Health Organization Alma

Ata declaration of 1978

advocating “Health for all”

Primary HEALTH Care

• Reflects the approach to service

provision for a community proposed

in the Alma Ata Declaration

• A broader concept - primary care

services + health promotion, disease

prevention, and population-level

public health functions

• Provided by primary health care

practitioners

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Policies

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Policies I PHC STGs and EML

Translating policy into healthcare delivery

Why PHC STGs and EML?

“For the rational use of medicines in South Africa in accordance with the WHO Essential Medicines concept” - i.e. essential

medicines should be available at all times, in adequate quantities, appropriate dosage forms, with assured quality and

supporting info, at a price the individual and community can afford!

What are the Standard Treatment Guidelines?

• Implementation mechanism of the EML providing guidance on how to

use medicines which appear on the EML

What is the Essential Medicines List?

• Developed to satisfy the priority health care needs of the population

• Determined by the ministerially appointed National Essential

Medicines List Committee (NEMLC).

The review process is continuous as health needs, evidence and healthcare costs are dynamic.

Primary Health Care Standard Treatment Guidelines (STGs) and Essential Medicines List

(EML)

Ideal Clinic Framework supporting HEALTHCARE DELIVERY

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What are the criteria for selection? What are the principles of

selection?

Equity

Evidence based

decision making

1 2 3 4

• Priority health diseases and

conditions contribute

significantly to burden of

illness and injury

• Local epidemiology

• Product is registered in

terms of the Medicines Act

• How well the medicine

works and how safe it is for

use.

• Affordability of medicine in

accordance within budgets

of providers of health care

services

• Must always be considered

e.g. appropriate dosage

form, storage conditions,

adherence

Need: Public Health

Relevance

Quality, Safety &

Efficacy

Cost & Affordability Implications for

Practice

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Progress of decision making

GOBSAT EBM

(Evidence Based Medicine)

HTA

(Health Technology Assessment)

RCTs

Cohort Studies

Case-Control Studies

Case Series

GOBSAT

Systematic

Reviews

Template for medicine reviews developed in collaboration with Cochrane SA.

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Good governance in decision making

• Good Governance is the process of decision

making by which decisions are implemented/ not

implemented (UNESCAP)

• Follows the rule of law & limits corruption.

Equity

Responsiveness

Efficiency

and

Effectiveness

Accountability Consensus -

Orientation

Rule of

Law

Participation

Good

Governance

Strategic

Vision

Transparency

Participation

NEMLC composed of many disciplines; extensive peer

review & collaboration

Consensus-Orientation

NEMLC practises consensus decision-making

Rule of Law

TOR, Confidentiality & COI policies

Transparency

Information accessibility:

LoE & citations in STGs & EML; Decision-making information

published

Equity

UHC & Essential medicine concepts

Efficiency & Effectiveness

Optimisation of limited resources

Accountability

Accountable to Minister of Health & thus, citizens

13


Revision, dissemination and implementation

List of conditions Review of National ABC Analysis (Expenditure and Volume) Departmental Guidelines

Call Up Notice to Pharmaceutical and Therapeutics Committee (PTC) and external commentators

PTC Submissions

External Consultation

Planning

1

1st Review

2

Market Intelligence (Availability & Price)

Pharmacoeconomic Analyses

Reviewer compiles chapter Literature Review

Meta-analyses

Health Technology Assessments

Randomised Controlled trials

Expert Technical Committee Peer Review

2nd Review

3 National Essential Medicines List Committee (NEMLC)

Comments compiled and investigated

Peer Review by Expert Technical Committee

NEMLC approves amendments

Editing – Essential Medicines List extracted from Standard Treatment Guidelines

Training of Trainers workshop and dissemination in Province

Provincial ABC Analysis and Drug Utilisation Review Measure

& Evaluate

6

Editorial

4

Implement

5

Pharmacists can contribute





14

Policies I Ideal Clinic Framework



(Policy to implement ICRM and ICSM)

• Monitoring of consistent access to

essential medicines & laboratory tests

at PHC facilities, using:

• Medicine tracer list for the

medicine room

• Medicine tracer list for the

emergency trolley

• Essential laboratory list

Lists derived from PHC STGS and EML

Ideal Clinic Realisation and

Maintenance (ICRM) programme

Designed to address

deficiencies in the quality of

primary care services,

starting with clinics.

Integrated clinical services

management (ICSM) model is the key

focus

Delivering patient-centric,

integrated health services

to patients.

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How are the policies disseminated and

implemented?

16

Policy implementation I Accessing information

Accessing STGs and EML: EML Clinical Guide

Leveraging innovative technology:

Moving from a solely paper-based approach to using a mobile application for the STGs/EML

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Accessing STGs and EML: EML Clinical Guide

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Navigating the EML Clinical Guide App

Step 1:

Search

Step 2:

Description

Step 3:

Emergency Treatment

Step 4:

Medicine Treatment

Step 5:

Referral

Search Emerge… Medicin… Referral…

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Navigating the EML Clinical Guide App

Step 1:

Paediatric Dosages

Step 2:

Select Medicine

Step 3:

Select Age / Weight Band

Step 4:

Result

Paediatri… Select M… Select A… Result

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Policy implementation I Ensuring access

Monitoring of availability of essential medicines: Ideal Clinic Framework

Routine monitoring of the emergency trolley, as per the Ideal Clinic Framework

medicine tracer list.

Availability of tracer essential medicines

measured on an electronic networked

stock availability monitoring system (SVS)

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Policy implementation I Ensuring access

Monitoring of availability of essential medicines: PHC National Dashboard

*The information herein is strictly confidential and can only be used solely for the intended purpose of improving medicine availability and the monitoring thereof .

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Policy implementation I Patient awareness

• Universal Health Coverage focuses on a

patient-centred health delivery

platform, and requires active

participation/ collaboration of the patient

and community

• Pharmacy month can be used as a

platform to assist in cultivating patient-

centered approach to healthcare

• Pharmacy month theme for 2018 is “Use

medicines wisely”

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Conclusion

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Tsepo’s health need has been met

Case Study: Management and resolution

1. Anaphylaxis STG accessible though EML

app

2. Availability of healthcare (prescriber rights)

3. Ensuring availability of adrenaline

4. Health service provided:

• Accessible and affordable

• Available

• Acceptable

• Quality

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Conclusion

Key learning points

• Guideline implementation needs to be strengthened

• Monitoring and evaluation is an area that requires consideration (assess clinical impact and for health system

strengthening)

• Patient/community education and involvement in decision making processes needed

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Sneak preview of upcoming PHC STGs and EML, 2018

2014 edition 2018 edition

External comments 309 external comments 83 external comments (8 pharmacists, 52 doctors, 2 dieticians, 1 MCC official, 6 other, 14 organisations/societies/programmes).

Medicines Conditions Management

247 medicines 70 therapeutic classes

PHC EML to be published New chapter: Medicines for palliative care New conditions includes: Albinism, tick bite fever, listeriosis Updated management includes: VDS management more acceptable for healthcare workers; Acute asthma management contains pragmatic option; Hypertension algorithm updated.

Other BMI; Framingham risk tool on EML Clinical Guide app

Treatment regimens to be developed to assist e-prescribing; ICD10 codes categorised as per industry standards per STG

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Acknowledgements

• All stakeholders who provided comment on the STGs and EML

• NEMLC and PHC Expert Review Committee: PHC STGs and EML

• NDoH Affordable Medicines Directorate

• NDoH PHC Directorate: Ideal Clinic Realisation and Maintenance (ICRM) programme

• NDoH Programmes Directorate

• NDoH Revenue Services Directorate

• GHSC – TA, USAID

• Cochrane SA: EML medicine review template (scientific, economic and social components)

• MRC/ Open Project/ EM Guidance team/ JEMBI: EML Clinical Guide application

• Private Healthcare Industry Standards Committee (PHISC) and Council for Medical Schemes: Coding of ICD10 codes

• Right To Care: PHC EML and treatment regimens

• South African Pharmacy Council/ PSSA/ NDoH AMD: Pharmacy month theme

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References

• Bee pictogram. http://frugalnurse.com/2016/07/first-aid-bee-stings/

• Child pictogram: http://nationswell.com/can-mom-mom-mentoring-save-babies-lives-video/

• Takase BO et al. Case based paediatrics for medical students and residents, 2013.https://www.hawaii.edu/medicine/pediatrics/pedtext/s05c02.html

• WHO. The right to health: Joint fact sheet WHO/OHCHR/323, August 2007. http://www.who.int/mediacentre/factsheets/fs323_en.pdf

• The United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (2006).

• Republic of South African Government. 1996. Constitution of the Republic of South Africa No. 108 of 1996. http://www.info.gov.za/documents/constitution/93cons.htm#SECTION13

• World Health Organisation. Evans D, From Universal access to universal health coverage presentation, 2009

• Reich MR, Lancet. 2016 Feb 20;387(10020):811-6. doi: 10.1016/S0140-6736(15)60002-2.

• Alma Ata Declaration on Primary Health Care. http://www.who.int/publications/almaata_declaration_en.pdf (accessed 22 May, 2018).

• Ebell MH et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. J Am Board Fam Pract. 2004 Jan-Feb;17(1):59-

67.

• Goncalves, T. What can be said about Health Technology Assessment (HTA) "vs" Evidence-based Medicine (EBM)? http://www.pharma-economics.com/2014/05/what-can-be-said-about-

health.html

• Widerman B. Biliary Atresia and the Evidence Pyramid. https://aapgrblog.blogspot.jp/2014/09/biliary-atresia-and-evidence-pyramid.html

• NHS, National Institute for Health and Clinical Excellence. https://twitter.com/search?q=%23GOBSAT

• United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP). Adapted from UNDP. 1997. Governance for sustainable human development.

http://mirror.undp.org/magnet/policy/



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THANK YOU!

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