Doha, Qatar, 15-16 Jumada’I 1430H / 10-11 May 2009G

1. DR. TAWFIK AHMED KHOJA MBBS, DPHC, FRCGP, FFPH, FRCP (UK) Director General – GCC Health Ministers’ Council Doha, Qatar, 15-16 Jumada’I 1430H / 10-11 May 2009G Dr. Tawfik A. M. Khoja

2. ” أَفَمَنيَمْشِيمُكِبًّاعَلَىوَجْهِهِأَهْدَىأَمَّن يَمْشِيسَوِيًّا عَلَىصِرَاطٍمُّسْتَقِيمٍ ” سورة الملك (آية 22) “ Is then one who Walks headlong, with his face Grovelling, better guided, Or one who walks Evenly on a Straight Way ? ” Dr. Tawfik A. Khoja Holy Quran

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4. Key message Barriers to integration, and problems facing implementation of NCD programmes in PHC. Current Health care system (Radar syndrome) and explain the innovative care for NCD framework based upon a set of (6) guiding principles with clear differences between existing and reformed services characteristics. Dr. Tawfik A. M. Khoja

5. some Gulf and regional successful solutions as follows: • a. Two important strategic resolutions from HMC/GCC states. • b. Mini Clinic initiative for chronic illnesses care in PHC UK initiative for quality performance indicators in NCD management and control in general practice as an important international example for integration improvement. Additional some helpful solution in building capacity of human resources, other new approaches and CME, beside the requirements for development in the current stage. Dr. Tawfik A. M. Khoja

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7. Barriers to Integration Cognitive Barriers: • People often have little thought for the future. • Doctor-initiated, i.e. the demand should be predictable Non-urgent. • Easily delegated to other primary health care team members. • Focused on high-risk groups & focused on individuals. • Good records are essential; audit is usually straightforward . Dr. Tawfik A. M. Khoja

8. Psychological Barriers: All of us at times are prone to promote our own idea as keenly as we promote our own survival. Political Barriers: It is not unknown for governments to back out silently of preventive obligations as if influenced by pressure groups who would lose if prevention were successful. Dr. Tawfik A. M. Khoja

9. Logistic Barriers: • A health Center needs to be highly organized. • Answer questions like: • “Who has not had their blood pressure checked for 3 years?” • “Who has not turned up to their request to attend for screening”? • “Who has stopped sending in for their repeat prescriptions for anti-hypertensive”? • Remote, rural, and inner cities areas poses major logistic problems. Dr. Tawfik A. M. Khoja

10. Ethical Barriers Financial Barriers: A practice may have to pay for extra staff to run an effective screening programme. Motivation Barriers: Changing from a crisis-led work pattern to strategic prevention & Integration is one way that practice nurses can lead the way. There is some evidence that they are particularly successful at the meticulous, repetitive tasks on which all good prevention depends. Dr. Tawfik A. M. Khoja

11. Problems Facing Implementation of NCD Programmes • Lack of risk factor surveillance. • Non-harmonization of monitoring & surveillance methodologies. • Lack of reliable mortality data. • Lack of training of professionals in NCDs prevention & control. • Deficiency of information on health care services management for NCDs. • Inadequate Health facilities infrastructural. Dr. Tawfik A. M. Khoja

12. Current Health Care System The Radar Syndrome • Patient appears. • Patient is treated “find it & fix it” • Patient is discharged. • …… then disappears from radar screen. Dr. Tawfik A. M. Khoja

13. Primary care defined "Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.“ Source: Institute of Medicine, Committee on the Future of Primary Care. Primary Care: America's Health in a New Era. Washington, DC: National Academy Press, 1996. Dr. Tawfik A. Khoja

14. Efficient Primary Health Care Must Include The Following “9 As”. It Must be: Available Accessible Affordable Acceptable Adaptable Applicable Attainable Appropriate Assessable Keeping PEOPLE Well Getting PEOPLE Better Helping PEOPLE Cope Dr. Tawfik A. M. Khoja

15. INTEGRATION Integrated health promotion and NCD’s prevention is a coordinated, systematic plan involving various Stakeholders using a combination of approaches to address health determinants and risk factors. Dr. Tawfik A. M. Khoja

16. Health care systems must guard against the fragmentation of services. Care for NCDs needs integration to ensure shared information across setting and providers, this means setting priorities for screening, early detection prioritising surveillance, and management to be applied and followed among Gulf area, through community - based programme as well as PHC team training on: • Evidence-based clinical guidelines management of chronic conditions. • Organizational factors that support the provision of care for patients with chronic conditions. • A proven methodology for accelerating health care improvement in PHC. Dr. Tawfik A. Khoja

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19. Strategic Resolutions by the Health Ministers’ Council for Cooperation Council States Dr. Tawfik A. Khoja

20. CONTROL OF NON- COMMUNICABLE DISEASES IN THE GULF REGION The Executive office circulated the recommendations issued by the various international organizations stressing the need for more support to the regional networks to combat non- communicable diseases and putting an emphasis on the following 4 points: 1. Health services development. 2. Defining risk factors and how to face them. 3. Surveillance of these diseases. 4. Continuous monitering , evaluation &research . Dr. Tawfik A. Khoja

21. Resolution # 1 Conference 63rd (Geneva, 29/4/1428 Corresponding to 16/5/2007 G) Control of Diabetes Decided: Signing the “Joint statement of the Health Ministers’ in the Cooperation Council States about Diabetes” and its endorsement as a commitment to improve public health and to confront the diabetes problem in preparation to raise it to HE the Secretary General of the Council Secretariat of the Cooperation Council States for the Arab Gulf Countries, and hence to their majesties and highnesses the princes, the leaders of the Cooperation Council States to obtain the political, material and community commitment to confront this problem. Dr. Tawfik A. M. Khoja

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23. Resolution # 6-B Conference 64 (Riyadh, 2/2008 G) Approval on the “Gulf charter for Health of the Heart, putting Heart first” project and its endorsement under the name “Riyadh Declaration”. Dr. Tawfik A. M. Khoja

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26. On the 64th conference resolutions # 6-B (Riyadh, 27-28 Muharram 1429H / 5-6 February 2008) Work towards adopting the slogan (2008 for control of cardiovascular diseases) and putting it into effect. Dr. Tawfik A. M. Khoja

27. Examples of some leading gulf Achievements • Health promoting schools (United Arab Emirates) • Health Promotion Council in the Kingdom of Bahrain (National Plan for Control of Chronic Diseases). • Specialized clinics Initiatives (Kingdom of Saudi Arabia). • NIZWA project for Healthy Life Style (Sultanate of Oman). • Facts for Life “ Book (Cooperation Council States). Dr. Tawfik A. M. Khoja

28. NCD’s Integration FOR ALL- BEYOND THE YEAR 2009G THUS. WE. NEED Continuous Quality Improvement Process Planning Quality Improvement Monitoring Dr. Tawfik A. M. Khoja

29. بسم الله الرحمن الرحيم Pearls and Perils In Mini-Clinic Initiative for NCD’s Theme: “Learning together” 1

30. The Objective of this initiative is not only to promote better care but also to improve the organizational aspects of caring for the chronic illness, such as screening , referral system, and periodic health evaluation Health Centers have to play a major role if this program is to reach the grass root level. FROM ILLNESS TO WELLNESS 10

31. Mini-Clinic Initiative for Chronic illness Care in PHC Centres Specialized Clinics Initiative OBJECTIVES: * To enhance community awareness about prevention, screening and rehabilitation through the mini-clinics. * To make use of guidelines and standardize the policy as well as procedures of executing them within mini-clinic settings in P.H.C.C. * To harmonize and consolidate various activities and operate cost-effectively within mini-clinics. Dr. Tawfik A. M. Khoja

32. Our Vision for Health GCC is to be a nation of healthy individuals, families and communities Emphasis of healthcare System: Quality Innovation Health promotion Promotion of individual Responsibility Community participation Characteristics of Healthcare System: 9As + Equitable Efficient Consumer-friendly Dr. Tawfik A. M. Khoja

33. Building capacity of human resource 1- Supporting and developing the current divisions/departments concerned with control of NCDs in the MOHs as well as establishing specialized departments or divisions in a high structural position in the MOH in those countries which do not have such departments or divisions. 2- Assigning national and Gulf committees (concerned with control of NCDs) to prepare evidence-based guidelines for risk factors in coordination with the EMRO. 3- Supporting and promoting the methods of improving and developing programs of health care of chronic diseases patients within the activities of PHC, as well as overcoming the shortage in the assistant health cadres in this field. Dr. Tawfik A. Khoja

34. New Approaches - Concerning the importance of supporting and promoting the role of primary health care in the field of control of non-communicable diseases and positioning the extended medical care as one of the priorities in the strategies. • Adopting new approaches to evaluate medical services for the care of patients of such diseases and giving effect to and developing the role of health centers in this respect (prevention, cure, and rehabilitation). Dr. Tawfik A. Khoja

35. B) Giving effect to the concept of health promotion within the Healthy Lifestyle, prevention and control of chronic and non-Infectious diseases. C) Work on adopting the concept of "Chronic Diseases Shared Care" in primary healthcare centers and hospitals, and to strengthen the referral system, and adopt modern approaches in the provision of healthcare services i.e. the establishment of mini-clinics and periodic check-up program. Dr. Tawfik A. Khoja

36. Quality Performance Indicators – in Coronary Heart Disease All minimum thresholds are 25% Dr. Tawfik A. Khoja

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39. Other sets of performance indicators • Stroke or transient ischaemic attacks. • Hypertension. • Diabetes Mellitus (Diabetes). • Chronic Obstructive Pulmonary Disease (COPD). • Epilepsy. • Hypothyroidism. • Cancer. • Mental Health. • Asthma. Dr. Tawfik A. Khoja

40. Other sets of performance indicators • Ongoing Management • Records and information about patients. • Patient communication. • Education and training. • Practice Management. • Medicines Management. Patient experience • Length of Consultations. • Patient Surveys. 3. AdditionalServices Dr. Tawfik A. Khoja

41. Continues Medical Education Health education and counseling of citizens towards proper health behavior and change of traditional life style: - Intensify the "Educational Programs" that help to change their living style and to avoid environmental factors and dietary habits that impact their health negatively. Also to encourage social initiatives that endeavor to achieve these goals, disseminate the implementation of check-up clinics, periodic health evaluation and smoking control clinics. Dr. Tawfik A. Khoja

42. - Work towards giving effect to the slogan – Working together – for control & prevention of NCD and through : • a ) Implementation of the national plan for control of NCDs. • b) Intensive support of the scientific activities (conferences, symposia, workshops) related to control and prevention of such group of diseases. Dr. Tawfik A. M. Khoja

43. d) Support of epidemiologic researches on cardiovascular diseases and related risk factors, burden of diseases and consequent economic impact. • e) Support and strengthening of the role of individuals and families in improving health life style and reduction of risk factors. - Establishing a “ National Committee for control of NCDs to involve representatives from various, related health, medical, academic sectors to adopt, implement and apply the endorsed programmes, policies and plans. Dr. Tawfik A. M. Khoja

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45. PHC / Health System Reform NCD. Management require an evolution Of health care …… From typical RadarCare to “ Innovative Care” Dr. Tawfik A. M. Khoja

46. Innovative Care for NCD “Everything starts with a dream…………. with some luck and appreciation and a bit of application it may evolve into an idea. But to develop the idea into a plan and to bring that plan to reality requires an enormous amount of skills, dedication and hard work” Richard Pound Dr. Tawfik A. M. Khoja

47. Innovative Care for NCD Framework ICC Framework is based upon a set of guiding principles: • Evidence based decision making in Policy making , Service planning , & Clinical management of NCD. • Build capacity & infrastructure for the collection & analysis of relevant information. • Population focus • Prioritize health needs rather than the single unit of a patient seeking care. • Prevention focus • Every health care interaction should include prevention support. Dr. Tawfik A. M. Khoja

48. Innovative Care for NCD Framework • Quality focus to ensure • Proper utilization of resources. • Accountable providers. • Best patient outcomes. Integration • The core of ICC framework. • Integration, coordination & continuity should occur across time & health care settings. Flexibility / Adaptability • Routine surveillance, monitoring & evaluation to be able to adapt to changes. • Learning systems. Dr. Tawfik A. M. Khoja

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50. What Do We Need ? • Knowledge about gravity of the problem. • Leadership to do something about it. • A clear assessment of current health care situation. • A plan of action. • Cost – analysis studies. Dr. Tawfik A. M. Khoja