Improving access to chronic medication using the Central Chronic Medicine Dispensing and Distribution (CCMDD) delivery model at healthcare facilities in Umzinyathi District Mrs SS Mazibuko Manager: Pharmaceutical Services Health Systems Trust Conference 05 May 2016
Presentation Outline Background to CCMDD Non-Communicable Diseases Communicable Diseases Medicine Delivery Models Umzinyathi District Socio-Economic Status Introduction of CCMDD Strategic Analysis of CCMDD Good Governance Principles Application of Good Governance Principles in Central Chronic Medicine Dispensing and Distribution (CCMDD), Umzinyathi Conclusion Performance against set targets Way forward
Non-Communicable Diseases Noncommunicable diseases (NCDs), also known as chronic diseases, are not passed from person to person. They are of long duration and generally slow progression** Over 38 million people died globally from NCDs in 2012** Of those over 28 million deaths were from low and middle income countries** Burden of disease study concluded-prevalence of NCDs is on the rise country wide * Over 50% of deaths and 33% of the burden of disease in SA are attributable to NCDs 2013 Stats SA mortality and causes of death report * Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw D. The burden of noncommunicable diseases in South Africa. The Lancet. 2009;374(9693):934-47.
Communicable Diseases Rapid ART scale up activities including changes in guidelines- Increased uptake Expected and projected case loads: Puts strain on overstretched public facilities Compounds Human Resource Shortages Adds to medicine shortages Declining quality of care *Annual Performance Plan 2016/17-2018/19
Pre-NHI Chronic Medicine Delivery Models Public Sector: The only delivery route for medicine was health care facilities: Limited operating hours Long waiting times Overburden on DoH infrastructure and Human Resources Private sector: Longer operating hours Shorter waiting times Delivery at home Collection at alternate sites e.g. Post Offices
Umzinyathi-NHI Pilot District First five years of NHI to focus on implementing sustainable innovations and strengthening the health system April 2012: Ten districts to pilot NHI, including Umzinyathi in KZN
Population distribution per municipality (District Health Plan 2016/17) Umzinyathi District Umzinyathi District Map (IDP 2014/15)
Socio-Economic Status-Umzinyathi Umzinyathi is classified as Socio Economic Quintile 1- ranking amongst the poorest districts in the country*. Msinga ranks number 1 as the most deprived local municipality in South Africa, with Ward 16 being the most deprived ward** *South African Multiple Deprivation Index ** District Health Barometer 201314, HST Publication
Introduction of CCMDD in umzinyathi December 2013-Operational Planning Meeting Project Manager and team members appointed by District Manager Project Plan developed-milestones, timelines Facilities identified for participation, prioritized in terms of PHC headcount Sample per sub-district to ensure comprehensive district representation 9
Strategic Analysis- CCMDD Potential Risks CCMDD-new project: roles and responsibilities not clear; No Standard Operating Procedures; Budget Implications; Medicines being stored and distributed by external party-kzn Service Provider (Medipost); Patient Protection-rational prescribing; Need for good governance was identified.
Application of Pharmaceutical Leadership Development Program (PLDP) training Appointed CCMDD project manager had undergone the PLDP, facilitated by Management Sciences for Health, funded by USAID. One of the modules outlined good governance in healthcare
Definition of Good Governance Used with flexibility; There is no single definition that is universally accepted; The United Nations Development Program identifies 9 interdependent principles that characterise good governance (UNDP 1997)
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Application of the Good Governance Principles in the CCMDD Project in Umzinyathi District Strategic vision Participation Transparency Consensus orientation Effectiveness and efficiency Accountability Responsiveness
Strategic Vision- Media DG:Health 15
Strategic Vision cont.. NDoH support visit to Umzinyathi district: addressed potential Pick up Points (PuPs); and management teams. Outcomes of the support visit: Increased awareness; Buy in of influential stakeholders; Mobilization of resources 16
Appointment of CCMDD facility champions PHC Co-ordinators-change management agents Incorporation of relevant district programme managers into CCMDD district task team: HAST Chronic Disease & Mental Health Quality Strategic Vision cont.. Operation Sukuma Sakhe (OSS) 17
Inclusion of external stakeholders into district task team: HST (CCMDD M&E), HST (Integrated Chronic Services Management& Quality Assurance), Medipost, Medilogistics Monthly Operational Planning Meetings Participation Establishment of Facility CCMDD Committees, members including: Community Care givers, Councillors Local Izindunas Operation Sukuma Sakhe Forum including other government departments; Community Involvement at War Rooms
Participation-CCMDD Symposium
Transparency Development of the CCMDD Manual Monthly CCMDD reports to the district executive management Monthly reports from : Medipost Medilogistics HST Training and development of SOPs Continuous support on the implementation of SOPs Development of CCMDD Audit tools Inclusion of these tools in the CCMDD manual
Transparency cont.. Setting of CCMDD targets; Target attainment monitoring charts developed by Medipost and issued to facilities for notice board display; Marketing material received from HST and NDoH and put up in all facilities and also put in strategic places like local taxi ranks, churches and schools. CCMDD Banners sponsored by MSH and used in all NHI Roadshows and CCMDD Launches
Consensus Orientation Clinic Committee members and local ward councilors appointed as CCMDD Facility Committee members Pharmacy and Therapeutics Committees at district and sub-district level involvement. Multi-disciplinary approach.
Accountability Terms Of Reference (TOR) formulated and enforced for: District CCMDD task team; Sub-district CCMDD committees; Facility CCMDD Committees TOR include roles and responsibilities of internal and external stakeholders Umzinyathi CCMDD project manager part of the NDoH CCMDD task team-reporting monthly
Effectiveness, Efficiency Involvement of UKZN-School of Public Health, scientific study conducted. Aim: To assess the impact of the CCMDD project on operational efficiency and client experiences at PHC facilities in Umzinyathi District between January 2014 and February 2015
Responsiveness Implementation of CCMDD in Umzinyathi Implementation in a phased in approach, utilizing the Plan-Do- Study-Act (PDSA) Quality Improvement Cycles. Reflection after each cycle, giving an opportunity to improve. PDSA Quality Improvement Cycle
Reflections after PDSA Cycle 1 Challenges Remedial Action Resistance to change-affecting program uptake. PHC Co-ordinators appointed as change agents. No external Pick up Points(PuPs) contracted for CCMDD. Other benefits of CCMDD emphasized, even in the absence of external PuPs. Patient cards being taken out monthly, benefits of CCMDD not experienced by either the patients or the DoH staff. Network challenges- 3G modems not working effectively SOP on data management received from NDoH, communicated and implemented. Hung modems outside windows if necessary, to get better connection. Clothed modems in condoms when raining.
Mitigating Challenge 27
Reflections after PDSA Cycle 2 Challenges Remedial Action No facility ownership of the program Appointment of CCMDD Champions Poor support/inadequate drive at sub-district level Inadequate feedback received during district quarterly meetings District task team expanded to include PHC Supervisors Establishment of quarterly sub-district CCMDD meetings No-coordinated routine training forum Sub-district CCMDD meetings used as training platforms No standardised format of communicating information; Information not cascaded to all stakeholders involved in CCMDD; SOPs not implemented; Development of a CCMDD Manual, which has since been adopted by the rest of the KZN districts.
Reflections after PDSA Cycle 2 Challenges Remedial Action Irrational Medicine Prescribing Script Verification by 2nd person at referring facility; Script Verification Checklist formulated and made part of the CCMDD Manual. Uncertainty at facilities regarding impact of decreasing patient headcount at PHC Patient Prescriptions not scanned routinely SOP formulated and forwarded to PDoH for comment. GPS Tracking Clocking System utilised by Medipost to monitor clinic administrators
Reflections after PDSA Cycle 2 Challenges Patient s prescriptions renewed before time, resulting in Service Provider generated reports showing high dormant numbers of patients No DoH generated reports on CCMDD Remedial Action Communication regarding patient review interval; Medipost updated medicine labels outside parcels, and highlighted Repeat 6 of 6 Appointment of contract CCMDD PAs from 15 January 2016 Training on Rx Solution electronic pharmacy software-as a database for patients and parcels on CCMDD
Reflections after PDSA Cycle 3 Challenges No budget monitoring for CCMDD Patients Difficulty in scanning parcel bar codes by site administrators for adherence reports, due to Tablet specification. Remedial Action Rx Solution with database of medicine grouped according to the different budget items. Going back to using laptops, so that electronic scanners can be utilised, to fast track adherence scanning. Site agents will be supplied with different sim cards to manage the connectivity challenges.
Results-Good Governance Only 2 Provinces attained 100% of 2015/16 National CCMDD patient enrollment targets. KZN surpassed target reaching 138%. Umzinyathi in KZN reached 97% patient enrolment, and 100% fixed facility enrollment by March 201516.
Way forward PHC internet connectivity CCMDD video taken during one of the facility launches. Video is being pruned and will be played in DoH facility waiting rooms as part of Educational Material.
Conclusion- 2 Media Excerpts Umzinyathi is one of the country s 11 NHI pilot districts, and if the decentralized delivery system works here, it could be rolled out in other parts of the country Sunday Tribune May 31, 2015
March 2016
Conclusion Good governance at different levels of the District Health System has had a positive effect on the CCMDD project in Umzinyathi, taking us a step closer towards the realization of Universal Health Coverage.
Acknowledgements Mr Mndebele-Umzinyathi District Manager Umzinyathi District Health Team Pharmaceutical Services NDoH KZN PSD Sub-district PHC HST SIAPS/MSH