Addressing human resource challenges for delivery of NCD services in Bhutan

Transcription

1 Addressing human resource challenges for delivery of NCD services in Bhutan Tandin Dorji Chief, NCD Division Department of Public Health Ministry of Health Royal Govt. of Bhutan

2 Country Profile Area: 38,394 Km 2 Administrative unit: 20 Districts Population (2014): 750,858 Life expectancy (2010): 68.9 GDP per Capita(2012): US$ 2200 MMR (per 100,000 livebirths): 86 IMR (per 1,000 livebirths): 30 U5MR (per 1,000 livebirths): 37.3 Number of hospitals: 31 Number of Basic Health Unit I (BHU I): 20 Number of Basic Health Unit II (BHU II): 185 Number of doctors: 203 (2.8 per 10,000 population)

3 Health System Referral Referral Outside National Referral Hospital (JDWNRH) Regional Referral Hospital (2) Hospital (31) Basic Health Unit (185) Village Health Worker (1300)

4 NCD Trend No. of people affected Alcohol Liver Disease Cancer Diabetes Hypertension Ischaemic heart disease Mental disorder Transport/work related injuries Year

5 NCD Situation Indicator Value* Current smokers 3.5% Ever smoked 13.3% Smokeless tobacco users (89% betel) 43.1% Current alcohol drinkers 28% Consumed 4 or less servings of fruits per day (takes average of 3.4days a week) Consumed 4 or less servings of vegetables per day ( takes 4.8 days a week) 90.5% 96% Physical activity 25.5% *National Health Survey 2012

6 Integration of PEN into PHC Number of hospitals: 31 Number of Basic Health Unit I (BHU I): 20 Number of Basic Health Unit II (BHU II): 185 Number of doctors: 203 (2.8 per 10,000 population) To introduce to the BHUs Healthworkersto be trained and used to screen for, treat and follow up NCD cases Even at the hospitals other Health workers to be trained on NCDs Existing Diabetes clinics to be upgraded to NCD clinics Health worker to be identified as NCD focal point for each district All BHU staff trained on PEN, >350 Medical Officers and Hospital staff to be trained this year

7 PEN at the BHU WHO PEN module adapted Basic Health Unit (BHU) staff (non-physician health workers) trained in 3-day workshops Additional equipment to measure blood pressure and blood glucose supplied to BHUs. WHO 10-year CVD risk prediction charts (with or without cholesterol level) were provided Health education materials were also made available. Medicine supplies were augmented to cater to the basic medical needs of NCD patients at BHUs

8 PEN at the BHU contd. Healthworker at the BHU screens patient, Can prescribe 1 beta-blocker (atenolol), anti-arrhythmic (digoxin), diuretic (Hydrochlorothiazide), antihypertensive (Hydralazine, Methyldopa), Aspirin, Antiasthma (Salbutamol, tab and solution) Can request additional drugs from the district hospital (based on individual patient requirement) Could refer patient to the hospital doctor for expert opinion and further diagnostic tests Future follow-up of patients done from the BHU

9 Piloting of PEN Initiated in 2009 with WHO support for 6 month Two Pilot Districts selected - Paro& Bumthang PEN module adapted Basic Health Unit (BHU) staff (non-physician health workers) trained in 3-day workshops Additional equipment to measure blood pressure and blood glucose and peak flow rates supplied to BHUs. WHO 10-year CVD risk prediction charts (with or without cholesterol level) were provided Health education materials were also made available. Medicine supplies were augmented to cater to the basic medical needs of NCD patients at BHUs 7 BHUs & 2 Hospitals Population covered: 42318

10 Tools used WHO PEN protocols for Physician and nonphysicians ISH risk chart Glucometer & strips OMRON Blood pressure apparatus Height and weight scales Measuring tape

11 Lessons learned Need to ensure uninterrupted supply of essential NCD drugs and supplies Maintaining the record of NCD cases and follow-up Need for guidelines, esp. for proper diet and physical activity Difficulty in calculating BMI during busy clinic hours (BMI chart) Constraints in monitoring and supervision of NCD activities Difficulty in waist circumference measurement Community mobilization Difference in BP measurement between digital and mercury BP apparatus (Out of 380 comparative readings by both OMRON digital & Mercury apparatus, 189(49.7%) readings were found higher with OMRON digital apparatus)

12 Impact study In 2012 impact of PEN in the two pilot districts assessed Assessment over a period of 90 days Conducted by a WHO supported TA Method: -Patients visiting health centresin two districts were enrolled -Measured the blood pressure (BP), height, weight and waist circumference (WC) among those >40years old. -Blood glucose was also measured among those who were overweight/obese (body mass index 23+) or had a high WC(>80 cm in women and >90 cm in men)

13 Outcomes Opportunistic Screening (June to August 2012), Paro & Bumthang No. of clinical record filled up 960 No. of OPD pts. > 40 years overweight or obesity or high WC and high blood glucose No. of OPD pts > 40 ys over wt. or obese or high WC screened for blood glucose/urine albumin No. of OPD pts. > 40 yrs having high BP 864 No. of OPD pts. > 40 years screeneed for BP and BMI/WC 3818 No. of NCD pts. Registered in OPD 2568 No. of OPD pts

14 Results 960 patients had an NCD or high BP or high blood glucose, data analyzed for % had Hypertension (BP >140/90 mmhg) 30.9% had high blood glucose (random >140 mg/dl or fasting >110 mg/dl); 57.1% were overweight, 17.6% obese and 65.2% had a high WC. 13% of all the patients had >20% risk and 3.6% patients had >30% risk for developing cardiovascular disease (CVD). Only 9.7% and 4.2% of those enrolled reported drinking alcohol and smoking, respectively.

15 NCD Risks Factors Behavioural Risk Factors 9.7 Percent 4.2 Alcohol Smoking

16 NCD Risks Factors Physiological Risk Factors Percent High BP High WC High BMI High Blood Sugar High Cholesterol N %

17 Result contd. Among 444 patients who attended three follow-up visits, high CVD risk (>20%) declined by 45% (p=0.003). Among 403 persons with hypertension, use of medication increased by 8.8% (p<0.001) and high BP declined by 50% (p<0.001). Among 115 persons with diabetes, 113 (98%) were on medications, but high blood sugar declined by only 18.5% (p=0.1). The impact study revealed that PEN interventions improved BP control and reduced CVD risks.

18 Major Challenges Behavior change NCDs still perceived as a Ministry of Health concern Geographical terrain Lack of trained human resource Financial constraints

19 Way forward PEN Expansion (All BHU staff trained) Standardization of supplies Supervision and monitoring New NCD Strategic plan Cancer registry National STEPS survey (field survey completed)

20