Mrs SS Mazibuko

Manager: Pharmaceutical Services

Health Systems Trust Conference

05 May 2016

Improving access to chronic medication using the Central

Chronic Medicine Dispensing and Distribution (CCMDD)

delivery model at healthcare facilities in Umzinyathi District

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 non-

communicable diseases in South Africa. The Lancet. 2009;374(9693):934-47.

*

**http://www.who.int/mediacentre/factsheets accessed 28 Apr 2016

**

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

Umzinyathi District Population distribution per municipality (District Health Plan 2016/17)

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)

.

Strategic vision

Participation

Transparency

Consensus orientation

Effectiveness and efficiency

Accountability

Responsiveness

Application of the Good Governance Principles in the CCMDD Project in Umzinyathi District

Strategic Vision- Media DG:Health

15

• 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

Strategic Vision cont..

• 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

– Operation Sukuma Sakhe (OSS)

17

Strategic Vision cont..

Participation • 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

• 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.

• SOP on data management received from

NDoH, communicated and implemented.

Network challenges- 3G modems not

working effectively

• 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

• District task team expanded to include

PHC Supervisors

Inadequate feedback received during district

quarterly meetings

• 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

• SOP formulated and forwarded to PDoH

for comment.

Patient Prescriptions not scanned

routinely

• GPS Tracking Clocking System utilised by

Medipost to monitor clinic administrators

Reflections after PDSA Cycle 2 Challenges Remedial Action

Patient’s prescriptions renewed

before time, resulting in Service

Provider generated reports

showing high dormant numbers of

patients

Communication regarding patient review

interval;

Medipost updated medicine labels outside

parcels, and highlighted Repeat 6 of 6

No DoH generated reports on

CCMDD

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 Remedial Action

No budget monitoring for CCMDD

Patients

• Rx Solution with database of medicine

grouped according to the different

budget items.

Difficulty in scanning parcel bar codes by

site administrators for adherence

reports, due to Tablet specification.

• 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