Experience of the Association of Family Doctors Groups and Council of Ministers of the Kyrgyz Republic СМ on improving services for non communicable diseases Director of AFDG and CV KR S.T.Mukeeva November 2-5, 2015

Non communicable diseases (NCD) – the main challenge of the XXI century. Political Declaration to fight against non communicable diseases High-level Meeting of the UN General Assembly, New-York, 2011 NCD- the main challenge XXI century, which undermines social and economic development throughout the world and poses a threat to achievement of the internationally level of development goals.

AFDG and CM KR exercised and implementation of the system of continuous quality improvement in a pilot districts of 5 regions, according to the clinical protocol on the basis of evidence-based medicine in the following priority diseases at the level of primary care health organizations: hypertension from 2006 to 2009, bronchial asthma from 2007, Basis of antenatal care of pregnant women (antenatal care)-2010, acute coronary syndrome from November 2011 by means of SWAP in Naryn region. From 2006 to 2010 at the expense of Swiss Red Cross in all districts of Naryn and Talas regions it has also been implemented a system of continuous quality improvement on hypertension, bronchial asthma, antenatal care with involving all FAS. System of continuous quality improvement nursing process (NP) from October 2011, on tuberculosis from the end of 2011, by the means of USAID, project «Quality Health Care». From 2013 Supervisor visits with monitoring on implementation of standards of diagnostics and treatment of tuberculosis and infection control on tuberculosis. From 2015 the same project «Win the tuberculosis» USAID

System of continuous quality improvement on hypertension 2006-2009 № Name of regions Amount theme   regions-/cities Regions of SCQI on hypertension Total in GFD Total nurses in GFD Educated doctors/% Educated nurses% KR 41/11 27 2203 6043 I Batken region 4/2 3/1 148 604 39-26% 91-15% II Djalal-Abad region 8/4 3 311 1019 33-11% 81-26% III Issyk-Kul region 5/2 161 343 31-19% 123-36% IV Naryn region 5/1 6 103 470 47-46% 88-19% V Osh region 7/0 317 1801 29-9% 112-6% VI Talas region 4/1 5 86 302 39-45% 65-21% VII Chuy region 8/1 336 767 33-10% 110-14% VIII Bishkek city 601 552 0  IX Osh city 130 170 total 26/1 251-11% 670-11% 63,4%

System of continuous quality improvement chronic obstructive pulmonary disease, bronchial asthma - in 16 regions (39%) by the expense of Swiss Red cross, educated 110 doctors and 303 nurses. Basis of antenatal care at the expense of SWAP from 2008 in 27 regions, educated 236 doctors and 501 nurses. acute coronary syndrome in NCO, educated 47 doctors and 143 nurses (SWAP) Tuberculosis in 6 regions, educated 66 doctors and 205 nurses. Monitoring of tuberculosis and infection control all 8 districts of Chuy region and Tokmok city, 11 districts 6 regions-USAID

Results of implementation of SCQI on hypertension with 2006 to 2009 according to data of 2 regions   Regions Naryn region Talas region Years 2006 2007 2008 2009 Total patients with tuberculosis 6032 7154 7120 7461 2598 2673 2738 3146 The number served with urgent conditions on 100 patients 22,4 7,1 6,3 6,1 12,4 7,8 8,1 The number of hospitalized on 100 patients 13,2 12,6 10,5 9,1 25 24,6 24,2 20,7 The number of served on 100 patients 18 28,4 16,9 14,8 35,4 35,2 29,5

Results of implementation of SCQI on BA according to 2 regions   Naryn regions Talas regions Years 2006 2007 2008 Total patients with hypertension 321 329 390 170 175 184 Number of served with urgent conditions on 100 patients 20,2 25,2 11,3 42,3 58,3 28,3 Number of hospitalized on 100 patients 33,3 35,2 26,4 55,3 35,4 36,4 The number of served on 100 patients 67,2 77,1 32,3 114,7 82,8 75,5

Registration of risk factors Standard №4 Registration of risk factors of cardiovascular diseases in the ambulatory patient's chart Registration of risk factors

counseling on lifestyle changes at hypertension-Group of Family Doctors No. 1 % Received counseling On change lifestyle restriction of salt Physical exercise combat overweight On smoking danger On alcohol danger Regular medication Month

he system of continuous quality improvement for hypertension As a result of the implementation of the program of continuous quality improvement in the treatment of hypertension 1,318 primary health care organizations to improve the quality of care for the main indicators of quality of care for hypertension in the period from 2006 to 2009. For example, the proportion of the adult population (18+ years) who visited primary care organizations to check their blood pressure increased from 63% to 80% in the period from 2006 to 2009. The proportion of patients who were discharged appropriate first-line treatment (in accordance with the clinical protocol) increased from 64% to 79%. As a result of the implementation of the program of continuous quality improvement in the treatment of hypertension 27 primary health care organizations to improve the quality of care for the main indicators of quality of care for hypertension in the period from 2006 to 2009.

Conclusions: With adequate training of family doctors to improve detection, diagnosis and treatment of NCD according to the clinical protocol; reduce hospitalization, call the joint venture, i.e. control the NCD СSQI gives to doctors clear tools of the intra-audit service quality, unites the team, increases job satisfaction. With proper motivation and system monitoring tools that would give a good result for the control of NCD in Primary Health Care

Conclusion Implementation of СSQI on clinical protocol on basis of evidence-based medicine has shown that: Basis non-infectious illness can regulate on the level of organization of health, primary health care; reduce the burden on the budget of hospitals and ambulances; improve satisfaction with services like health care provider and patient; involve the patient and the community in the prevention and treatment of a particular disease;

Problems Understaffing of doctors of GFD-158 with one doctor and 61 GFD without a doctor -outward migration. Staff turnover - internal migration. Low motivation- even with a minimum of equipment, it is idle due to lack of management leadership CFM and GFD - no consumables, no skills, leadership misunderstanding the significance of improving the quality of services.

Deficiencies in quality management Delay in the establishment of a coordination structure in quality management for the entire health care system. Insufficient attention is paid to the establishment of internal initiatives to improve matters, and implementation of clinical guidelines and protocols based on evidence medicine. Informational system does not reflect the quality issues. Quality issues are not included in the current funding mechanisms. No practice of involving patients and population of the strategy of improving the quality

Problems Non-interest in expanding the practical skills of specialists of GFD even in the presence of the equipment: - close to the narrow specialists with no load; - there is no systematic audit of quality of medical services inside of organization of medicine; -no amount or volume manipulation is not included in the payment; -demotivation due to extreme loads and high sense of responsibility; -payment of labor is fixed, can be obtained with no real results.

Systemic barriers to health Lack of political commitment to strengthen primary health care. Weak interagency cooperation. Weak evidence-integration into practice. Problems of accessibility: a doctor - staffing problems; -and to quality drugs for the treatment of patients with cardiovascular diseases. Non-effective system of stimulating as the physicians and patients. Weak management, especially intra-audit service quality. Not suitable information solution. Problems of access and financial burden. Не во всех селах есть аптеки для выписки рецептов по ДП.

Проблемы PROBLEMS -an interior migration, a change of train staff untrained; -administrative costs- not printed in normative legal acts, clinical protocol. It does not provide the necessary supplies, test strips; -no free drugs on control of blood pressure, diabetes, asthma (not enough for additional package); -no school of patients on hypertension, diabetes, asthma - insufficient training on healthy lifestyle, risk factors, -not commitment to the systematic acceptance of drugs- reception only if the deterioration of, the cheap drugs due to the high cost of it; -

Thank you for your attention!