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


Welcome to Morocco!: 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


TB is a major problem of public health in Morocco  : 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.    


DOTS strategy adopted as of 1991: 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


DOTS outcomes in Morocco: DOTS outcomes in Morocco Treatment success rate = 90% since DOTS implementation Detection rate over 85%


DOTS impact on TB morbidity: 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


Slide7: TB : INCIDENCE BY FORM, MOROCCO 1990-2001


Involvement of private health sector in TB control in Morocco: 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 > 75%


Involvement of prison health services in TB control: 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


Involvement of army health services in TB control: 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


AIDS/HIV and TB in Morocco: 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+


MDR and chronic TB cases in Morocco: 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)


Why developing and implementing PAL in Morocco? : 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


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) Why developing and implementing PAL in Morocco?


Why developing and implementing PAL in Morocco? : Survey data from PHC facilities: 20-30% of patients > 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 Why developing and implementing PAL in Morocco?


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 Why developing and implementing PAL in Morocco?


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) PAL development in Morocco


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 PAL development in Morocco


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 PAL development in Morocco


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 PAL development in Morocco


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 PAL development in Morocco


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 PAL development in Morocco


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% PAL development in Morocco


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) PAL Implementation in Morocco


PAL Implementation in Morocco : Cascade training process: Training of NTP coordinators of provinces Then, training of chest physicians, GPs and nurses PAL Implementation in Morocco


PAL Implementation in Morocco : PAL implemented in: 8 regions out of 16 34 provinces out of 73 About 60% population PAL coverage nationwide PAL Implementation in Morocco


PAL Implementation in Morocco : Nbr of health workers trained in PAL: 73 chest physicians 1874 general practitioners 802 nurses PAL Implementation in Morocco


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 PAL monitoring and evaluation system in Morocco


Slide30: Rapport trimestriel des maladies respiratoires chroniques


Slide31: Rapport trimestriel sur les épisodes aigus des maladies respiratoires chroniques


Slide33: Fiche Individuelle de suivi dans une FSB. Formation : Nom/ Prénom : N° ordre CS : N° Ordre CDST : Adresse  : Diagnostic :


Conclusion: 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


Slide35: 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


Thank you: Thank you And once again, welcome to Morocco!