Implementation of Package of Essential Non-communicable (PEN) disease interventions in Myanmar: a preliminary evaluation
The effect of Non-Communicable Diseases (NCDs) upon the individual, family and health system are increasingly important for countries around the world as they form a growing proportion of the burden of the disease. NCDs impose a heavy economic burden on the macro-economy from loss of productivity caused by death or illness; on individual and families due to the cost of treatment paid by out of pocket expenditure and inability to earn a livelihood; and on health system due to the need for investment in high end technology. Furthermore, prevalence of NCDs is rising globally: in Myanmar, it can be concluded that almost every adult had at least one NCD risk factor (Myanmar STEP Report, 2014). In general, women are at higher risk of NCD than men in Myanmar. Myanmar has been in the top among South East Asia countries in terms of prevalence of many NCD risk factors. According to the WHO, NCDs are estimated to account for 59% of the total deaths in the country and the probability of dying between ages 30 and 70 years from one of the four major NCDs is 24%.
The project “Strengthening public health capacity to respond to Myanmar’s disease transition” is funded by European Union and implemented by HelpAge International in the beginning of 2015 in collaboration with the University of Public Health (UPH), University of Medicine 2 (UM2) Myanmar and Faculty of Public Health, Thammasat University, Thailand. It aims to strengthen the above health institutions and other health stakeholders in Myanmar to support evidence-based public health policy and improved health services for the prevention and control of NCDs.
The flagship intervention under this project is to roll out PEN interventions throughout all townships in the country by 2020. The goal of the WHO intervention is to close the gap between what is needed and what is currently available to reduce the burden, health-care costs and human suffering due to major NCDs by achieving higher coverage of essential interventions. The intervention has three major objectives:
- improving the efficiency of care of major NCD in primary care;
- improving quality of care of the major NCD in primary health care; and
- have a substantial beneficial impact on health of the people.
Implementation of the package will help to strengthen the health services delivery and the management of the primary healthcare system in diagnosis, treatment and providing evidences for the improvement of the interventions.
The project anticipates rolling out the intervention in Myanmar through a cascaded model of training. Through this intervention we have already completed training of trainers (ToT) in 180 out of the 330 townships and the remaining will be completed by next year. The trained trainers have completed the Basic Health Staff (BHS) training in 39 townships so far.
As a part of the project the implementation team conducted a two days evaluation of the PEN interventions in randomly selected 20 townships on August 29 & 30, 2018 with the objectives to assess the performance of Package of Essential NCD Services to the Community and to learn the good practices and thereby use for future Package of Essential NCD Services to the Community. The evaluation focused on five major areas, namely access, availability, community awareness, supervision, and challenges faced while implementing the interventions at various levels.
Participants from five regions (Nay Pyi Taw, Mandalay Region, Bago Region, Yangon and Mon State)
attended the two days evaluation. A total of 93 participants were selected for the evaluation meeting, including Township Medical Officers, Health Assistants, Township Health Nurses, Public Health Nurses and Township Public Health Officer representing trained trainers. Health Assistants, Lady Health Visitors, Public Health Supervisors and Midwifes represented basic health staff. In addition, lead trainers from University of Public Health, University of Medicine 2, NCD unit, senior officials from Ministry of Health and Sports Myanmar were also participated. Since the implementation of the PEN clinics in 20 health facilities of five regions about 110,000 people have been screened for diabetes, hypertension and chronic respiratory disease. In addition, 64 people were screened for cancer.
The participants from five states and regions were given five identified evaluation questions. Based on the questions, each state and region presented their findings, followed by a discussion. Each session was moderated by a chairperson. After the presentations the teams were divided in to four groups viz training, supply chain, implementation and reporting. The groups were tasked to come up with the major challenges faced during the implementation of the interventions and possible solutions to overcome it in future. In addition, the NCD unit also conducted a qualitative study in two townships on existing NCD services that threw light on the implementation barriers in NCD interventions.
Weak technical skills of the basic health workers were found to be the major problem in implementation of PEN activities at the Sub Rural Health Centers. The trainers came up with the suggestion to simplify the training manual that are being used to train the basic health staff. Currently, similar manuals are being used for both ToT and basic health worker training.
“Now, we, the basic health staff, are providing services for primary care of NCDs. We always need re-orientation to improve our skill and quality services. Not only medical supplies but also training for health staffs is essential for the success the of PEN,” said Daw Khin Soe Soe Mu, Township Public Health Nurse, Amarapura township, Mandalay Region.
The participants recommended that a regular induction training would be the better option for maintaining the quality of program implementation. They also suggested to include more topics on improving the awareness levels of the health functionaries like basic health staff in the manuals. In addition, there are specific logistics issues that are also been looked in to while conducting the training at different levels.
One of the major issues reported was the shortage of medicines, diagnostic kits etc. at the majority of health facilities. On the other hand, a few health facilities reported that they have received more drugs than required. Several instances a combination of medicines is usually prescribed for diabetes. It was found in some of the health facilities partial supply of medicines for diabetes that was an embarrassing situation for the patients who reach out the health facilities. Some of the patients are not being diagnosed in several instances as the equipments like lipid analysers and glucometers reported temperature errors. There were no replacements for those reported errors. Shortage of blood pressure cuffs and glucometer strips also put the health workers in difficult situations.
The group recommended that appropriate allocation of drugs is necessary to maintain the supply chain intact. There is a need for a policy, especially for the distribution of essential drugs up to the sub health center levels. The health department should ensure the availability of equipment and supplies throughout the year.
We trained early detection, primary health care, and referral system for basic health staffs.
PEN package especially focus on diabetes, hypertension, respiratory related disease and cancer. PEN will provide to reduce the burden of NCD in the country because they get primary health care service even from the sub-centre” said Dr.Lin Htin Kyaw, Township Medical Officer, Tharsi Township, Mandalay Region.
A shortage of Information Education Communication (IEC) materials was another problem reported by most of the health centers, especially the communication material that is used to mobilize the community. It was recommended that adequate IEC materials shall be made available to the centers well in advance and maintain the stock throughout the year.
The PEN clinics run only on Wednesdays as per the instruction of Ministry of Health and Sports. However, patients, even those from the same village as the clinic, weren’t aware that this service was only available on Wednesdays and come other days, creating a chaotic situation at several health facilities. This indicates the lack of public awareness and communication on PEN clinics. Many of the health staff reported poor cooperation of the community in mobilising people and providing necessary support to the health team in implementing the initiatives.
U Khaing Oo, Health Assistant from Dala township, Yangon Region, said that “PEN project is cost effective services for the people provided if the services are sustainable. People know about the risk of non-communicable disease, but they have poor practice on the prevention of NCDs. We have to do more on NCDs” he said.
Widespread awareness to the community on PEN clinics should be initiated to reach out to more and more people. In addition, the reasons for not visiting the clinics should also be explored to improve reach of the interventions. Social mobilization activities such as health talks, video shows and folk performances should also be included as a part of IEC activities.
One of the major problems is the geographical coverage in services. It was suggested that introducing mobile clinics to the more remote, unreached areas would be a good way to get more coverage in diagnosis and treatment of NCDs. At present only two people are available to provide services at the PEN clinic. Due to the heavy patient load it was suggested to include more people to so that they can provide services to more patients. Supervision of services seems to be another big challenge since the beginning of the implementation. A frequent supervisory visit, especially the supportive supervision, is required for improving the program quality. Another weak areas are the follow up visits by the patients followed by lack of adherence of medications by the patients. Behavioural change communication activities should be initiated to address this problem.
Reporting and referral seem to be another implementation challenge across the country. There are six reporting forms currently being used to report the progress of the interventions. These include 4 separate monthly reporting forms and 2 quarterly reporting forms. Lack of human resources at sub rural health centers overburdened the existing basic health staff to perform the reporting. Their clinical workload tends to be prioritized over reporting leading to poor quality of reports or misreporting. Further, inadequate supply of reporting forms were reported in almost all the centers. The group recommended that there is a need for simplifying the reporting forms and ensure the availability of reporting forms in all centers across the states and regions.
If the patients are referred to secondary and tertiary health facilities for further investigations, they are reluctant to go, due to less urgency of the nature of disease.
In addition, there are certain barriers that prevent them to seek treatment at the referral centers such as financial, socialproblems etc. It was recommended that if the government provides transportation services for the referral patients along with raising community awareness we can tackle this.
While responding to the identified challenges and suggested recommendations, the national ledership emphasised on addressing these issues in five broad categories viz operations, supplies, supervision, reporting, health promotion and capacity building. For the next 6 months to one-year period, the following activities will be focused on:
- It was decided that state and regional public health department will be actively involved in the supervision of the PEN implementation process. Township public health department and urban health centre will provide support in patient care on PEN clinic days. State and regional public health department will ensure the implementation of PEN interventions in Urban Health Centres.
- In order to ensure the availability of medicines and supplies, the NCD unit will be directly involved in the process of procurement in consultation with the higher authorities. In addition, the state and regional public health department will procure seven basic medicines and they will make sure the demand estimations are based on latest available data.
- It was decided that at least one quarterly supervisory visit by the NCD unit/regional/state/township department to ensure the quality of the implementation.
- Adequate reporting forms will be made available in all health facilities. It was also decided to review the existing reporting forms, for them to be revised as a simpler one. The NCD director will take lead in reviewing the forms.
- To address the health promotion initiatives at the township level a monthly advocacy meeting will be organized by the township public health department. The NCD unit will ensure the availability of IEC materials in all advocacy meetings.
- It was decided to have at least one refresher training at township level for the basic health staff to maintain the quality of delivery of PEN interventions.