A Joint WHO-Ministry of Health Meeting on WHO Integrated Management for Emergency and Essential Surgical Care. 7-8 August 2007 Lusaka, Zambia

Transcription

1 Report Facilitators Meeting A Joint WHO-Ministry of Health Meeting on WHO Integrated Management for Emergency and Essential Surgical Care 7-8 August 2007 Lusaka, Zambia 1

2 Contents...Pages 1. Executive Summary Background Objectives Field visits to health facilities Joint WHO meeting for facilitators Discussions Recommendations and Action Plan Conclusions Acknowledgements Annexes...9 Annexe 1: Participants list Annexe 2: Programme Agenda Annexe 3: WHO training tools for improving skills of health personnel (Available at 2

3 1. Executive summary A Joint WHO-Ministry of Health meeting on the WHO Integrated Management for Emergency and Essential Surgical Care (IMEESC) for Facilitators was held during 08 August, 2007 in Zambia. The overall objective of this meeting was to strengthen capacities of health personnel in emergency and essential surgical care (EESC). Field visits were made for a situation analysis for access to life saving emergency and essential surgical and anesthesia interventions to some primary healthcare facilities in Lusaka province. The field visit team comprised of focal persons representing WHO/HQ and WHO Country office, MoH. This workshop was conducted jointly by technical focal points of WHO/Zambia, HQ/EHT/CPR and MOH, and inaugurated by the Health Minister Dr Chituwo (an orthopedic surgeon). The WHO Integrated Management of Emergency & Essential Surgical Care (IMEESC) toolkit and the WHO manual Surgical Care at the District Hospital were handed over by WHO to the Health Minister in an official launching ceremony. The workshop had national and local media coverage (TV and news papers) and the Health Minister emphasized the importance of training health personnel in to manage basic surgical conditions, trauma and pregnancy related complications at primary health facilities. The meeting led to establishment of a committee (task force) by MOH and WHO country office for EESC to develop strategies for rolling out the IMEESC package in line with the Global Initiative for Emergency and Essential Surgical Care (GIEESC), integrate the EESC to first referral level health facility and local adaptation of the WHO IMEESC toolkit for strengthening capacities through a standardized training for the frontline health personnel performing life saving emergency and surgical (including anaesthesia) interventions in Zambia. The impact of the proposed comprehensive package (personnel, supplies and facilities) will be closely monitored and assessed. 2. Background 1 Zambia is a landlocked country of 752,612 sq km in central-southern Africa. It is one of the most urbanized (40% in 1999) and politically-stable countries in the region. At 13.8 persons per sq km, Zambia s overall population density is low, but there are significant in-country variations. Zambians suffer from a considerable burden of preventable and treatable diseases, reflected in the high morbidity and mortality of the region. In fact, life expectancy has steadily decreased from 50.4 years for males and 52.5 years for females in 1980 to just 37 years (average between the genders) by This decline is attributable to HIV/AIDS. The disability-adjusted life expectancy (DALE) was only 30.7 in 1999, placing Zambia at 188 of 191 WHO member nations. Other health indicators are similarly poor; the 1996 maternal mortality was recorded at 649 deaths per 100,000 live births, and under-five mortality as well as infant mortality have steadily increased from 1980 to 2000 with under-five mortality jumping from 174 to 202 per 1000 live births and infant mortality rising from 92 to 112 per 1000 live births. Although essential medicine supply in hospitals usually only meets 30-40% of demand, rural health centres have better treatment access due to kits supplied by donors. Concern has been raised over lack of transparency in supply and distribution channels, resulting in discontinued support from some donors. In rural areas, access to safe water is limited (35-37% of households) but access to sanitation is greater (66% of households use pit 1 All statistics taken from WHO Country Cooperation Strategy: Zambia World Health Organization Regional Office for Africa. Brazzaville,

4 latrines and only 29% have no sanitation). Cholera and dysentery are endemic, with outbreaks usually occurring in low-income settlements where water supply is from shallow wells located close to the pit latrines or where rivers and streams contribute significantly to the water supply. 99% of urban households and 50% of rural households are within five km of a health facility. Inequalities related to urban v. rural and female v. male disparities are increasing, and the level of poverty within the nation is increasing. In addition, low levels of education, high national debt, and the highest level of medical brain drain among all African nations all challenge health improvement in Zambia. High numbers of refugees from neighbouring nations also strain the existing infrastructure. Zambia s per capita GNP is approximately $400, but healthcare expenditures are significantly increasing. In 2000, $10.50 per capita was spent on healthcare; this number rose to $14.9 in 2001 and was expected to rise by 30% by Heavily aid dependent, much of this money comes from international donors, but 38% of health expenditures are out-of-pocket payments. International donors are responsible for financing 53% of the total national budget and 40.7% of the total health budget, 37.5% of which was recurrent expenditure and 63.5% of which was capital expenditure. Such aid dependency threatens the long-term sustainability of health reforms. The main international donors are the World Bank, The African Development Bank, the European Union, the United Nations (especially WHO, UNICEF, UNDP and UNFPA). The main bilateral donors are the UK (DFID), the Netherlands, Sweden (SIDA), Japan (JICA), USA (USAID), Denmark (DANIDA), and Ireland. The WHO has specifically collaborated with the Zambian government in surveillance, prevention, response, and elimination of communicable diseases, as well as health system reform, reproductive, women s and child health, health in sustainable development, nutrition, environmental protection, emergency action, essential medicines and vaccines, blood safety and clinical technology, evidence for health policy and health promotion. Government health sector reforms began in 1992, aiming to decentralize and delegate planning, management and decision-making of health services to the health boards and restructuring the health delivery systems. Such reform culminated in the formation of the Central Board of Health (CBOH), the District Health Boards (DHBs) of which there are 72, and the Hospital Management Boards (HMBs) of which there are 20. These organizations are comprised of MOH appointees. The central MOH is responsible for policy and strategic directions for the health sector and the CBOH is the national administrative agency for technical management of health services and interpretation and implementation of health policy. DHBs and HMBs are responsible for direct community engagement. Decentralization has strengthened capacity to manage district level health services but due to significant aforementioned socioeconomic challenges, such reforms have not shown substantial improvement in health service delivery. Accordingly, access to health remains a primary concern, especially among poor households and rural communities. 3. Objectives - Joint WHO- MOH meeting towards strengthening capacities of health personnel on IMEESC at regional health facilities in Zambia 4

5 - Introduction of the WHO IMEESC toolkit towards a standard training - Visits to health facilities for a situation analysis. 4. Visit to the health facilities and situation analysis for access to emergency and essential surgical interventions The field visits were made in Lusaka province for a situation analysis on access to life saving emergency and essential surgical and anesthesia interventions to various levels (tertiary, secondary and primary health facilities). The field visit team comprised of focal persons representing WHO/HQ, WHO country office and MOH. The following health facilities were visited: Kafue District Hospital, Chibombo District Hospital and Twalumba Community Rural Health Centre Some country hospitals are unable to carry out sometimes even basic emergency surgical interventions due to lack of continuous oxygen supply and anaesthesia equipment, which explains the difficulty of patient referral especially in urgent situations, resulting in death and disability. 5. Joint WHO- MOH Facilitators Meeting A Joint WHO-MOH Facilitators Meeting was held for the inauguration of WHO EESC Project and need assessment for EESC in Zambia. The meeting participants represented key policy makers, health providers, directors of surgical, obstetrics, anesthesia and nursing departments and WHO country office. Message of Dr. Stella Anyangwe, WHO Representative to Zambia, detailed the goals of the GIEESC, emphasizing Zambia's commitment to giving "visibility to 5

6 emergency and essential surgical care in order to improve the lives of all who are directly and indirectly affected."the WHO IMEESC toolkit was introduced, its applicability demonstrated in the day to day practice, training, and guidance on policy decisions at all levels of healthcare aiming to reduce death and disability in trauma, pregnancy related complications and infection (including HIV). The meeting had media coverage and was broadcasted on the national TV network among the top stories with the address of the Health Minister. 6. Discussions The discussions were on the following issues: - Lack of specialists and inadequately trained health personnel at first referral level health facilities raises the concern on the safety of surgical and anaesthesia interventions. - Experiences of introduction and implementation of the IMEESC training project in the 15 countries were shared. - Research is required on the situation analysis of access to safe emergency and essential surgical interventions at the first referral health facilities in Zambia. - Establishment of GIEESC in December There is an urgent need to strengthen capacities in emergency and essential surgical care at primary health care facilities in Zambia in order to reduce death and disability in injuries. - WHO IMEESC tools are useful for integration into the medical education and training programs. - WHO guidance for the training curriculum of the WHO IMEESC tool kit should be adapted for medical students in their curriculum. - MOH expressed the need to adapt IMEESC into emergency, surgical and orthopaedics programs in Zambia. - Project proposals for strengthening capacities in emergency and essential surgical care at primary health care facilities in collaboration with WHO/HQ/Country office and MoH, Zambia are needed. - The need for both training in procedures and functioning equipment particularly anesthesia and regular supply of oxygen was emphasized. - A situation analysis on access to emergency and essential surgical interventions in Zambia should be done and written up as a paper for publication. - Interest was generated about the possibility of organizing TOT on IMEESC with the key providers at district hospitals in the Copperbelt province in September Recommendations and Action Plan This meeting resulted in the following recommendations and action plan: - The IMEESC was seen as a way towards improving the first referral level health facility s services. The WHO GIEESC package was hence forth unanimously accepted. - The meeting resulted in the establishment by MOH of a committee on EESC - The committee members include MOH, WHO Country Office, Universities and Professional Societies of surgery and anesthesia. 6

7 - A TOT workshop for strengthening capacities in EESC at first referral level health facilities to be held in A report for the Facilitators meeting will be prepared for dissemination including WHO website. - WHO IMEESC toolkits will be sent to WHO country representative for the training workshops. - WHO country office along with WHO HQ will assist in the adaptation of the WHO IMEESC toolkit for local needs. 8. Conclusions The meeting concluded with a consensus by MOH and WHO country office and EESC was seen as a way towards improving the first referral level health facility s services incorporating the WHO IMEESC package. A task force or committee on EESC to be established to develop strategies for strengthening capacities for the frontline health personnel performing life saving emergency and surgical (including anaesthesia) interventions in Zambia. This will be done through a standardized training in EESC through the national professional societies, medical and nursing schools, in coordination with WHO country office and MOH Zambia. 9. Acknowledgment and collaborations for support - Directors and staff of health facilities visited - MOH Zambia - WHO country office Zambia, and WHO/AFRO - Departments of Essential Health Technologies, Evidence and Information for Policy (Patient Safety), Making Pregnancy Safer, Violence and Injury Prevention, Child and Adolescent Health - Zambian Surgical Association. 7

8 Annex 1: Participants list in the meetings Professor K.S. Babo Zambia Medical Association tel: Kachinga Sichizya Cure Hospital University Teaching Hospital Neurosurgeon tel: Laston Chikoya Surgical Society of Zambia University Teaching Hospital Neurosurgeon tel: lchikoya@yahoo.com Christopher Mazimba Medicine & Injection Safety Project (JHPIEGO) Chief of Party tel: /6/7 cmazimba.misp@jhpiego.net Kasonde Bowa University of Zambia-School of Medicine Surgical Society of Zambia Consultant Urologist tel: kbowa@yahoo.com James Muthali University of Zambia-School of Medicine Surgical Society of Zambia Association secretary & Orthopaedic surgeon tel: jcmunthali@yahoo.com John Kachimba Surgical Society of Zambia President tel: jskachimba@yahoo.com Prof. Yakub Mwila University of Zambia-School of Medicine Dean tel: Joseph Nikisi Zambia Medical Association Vice President tel: /6/7 jnikisi@jhpiego.net Dr. Deam Phiri Ministry of Health, HQ Monitoring & Evaluation Specialist tel: deanphiri@yahoo.co.uk Mabvuto Kango Ministry of Health, HQ HIV Specialist & Acting Non-Communicable Disease Specialist tel: kango@ .com Cansius Banda Ministry of Health, HQ Spokesperson tel: bandacanisisius@hotmail.com Dr James Simpungwe Prof. K.S. Babo Laston Chikoya Christopher Mazimba Prof. Yakub Mwila Joseph Nikisi Dean Phiri Dr James Simpungwe Peter Songolo WHO country office NPO/DPC tel: songolop@zm.afro.who.int Kasonde Mwinga WHO country office Acting Country Representative Dr Meena Nathan Cherian Project: Emergency & Essential Surgical Care Clinical Procedures Unit (CPR) Department of Essential Health Technologies WHO HQ, Geneva, Switzerland tel: ; fax: cherianm@who.int 8

9 Annex 2. Program Agenda - Meeting and discussions with WHO Country Office - Visits to health facilities for a Situation analysis. - WHO Meetings with directors of teaching hospitals and rural health facilities, Ministry of Public Health - Introduce and facilitate the use of WHO IMEESC tool kit - Discussions - Collaborative approach to surgical training on emergency and essential surgical procedures and linked equipment - Recommendations and follow up action plan - Conclusions of meetings and visits 9

10 Annexe 3: WHO training tools for improving skills of health personnel Needs Assessment and Evaluation Form for RR ese ssoouu rcr ce LLi ii mm iit itte edd HH eaal e ll tthh t CC aar ree FFaa cic ii ll lii ittyy t Essential Emergency Equipment in Emergency Room* *At an entry point in any health facility such as: Emergency room/ Admission room / Treatment room/ Casualty room 1. Name/Address of Health Care Facility Country 2. Type of Health Care Facility (please check one) Primary or First referral level facility/ District Hospital/Rural Hospital Health Centre 3. Human Resources in emergency room (please indicate number of health staff) Doctors Nurses Clinical or Health officers Technicians Paramedical staff 4. Physical Resource (a) Infrastructure Yes No Is there an area or room designated for emergency care? Is there running water? If yes: Interrupted / Uninterrupted (please circle one) Is there an electricity source? If yes: Interrupted / Uninterrupted (please circle one) (b) Equipment Yes No Is a list of essential emergency care equipment available? Is following available - Oxygen Cylinder: Interrupted /Uninterrupted (please circle one) - Oxygen Concentrator: Interrupted /Uninterrupted (please circle one) - Equipment for oxygen administration available (tubes, masks) Essential Emergency (EE) Equipment Yes, in some equipment Yes, in all equipment No Is the EE equipment in working order? Is there access to repair if equipment fails? Is there access to repair within the health care facility? Is there access to repair outside the health care facility? - If yes, how far (in km): 1-25 / / / >200 (please circle one) Is there an agreement for the maintenance of the equipment with the supplier? Does the health care staff in the emergency room get training in the use of the equipment? Is information available on supply, repair, and spare parts for the equipment? 5. Quality, safety, access and use Are the best practice protocols for management of essential emergency procedures available? Are the protocols for safe appropriate use of equipment in essential emergency procedures available? Yes, in some procedures Yes, in all procedures No How often is room to room inspection performed to ensure that EE equipment and supplies required for the essential emergency procedures are available and functioning? (please circle one) Daily / weekly / monthly / 6-monthly / yearly / once in years / never Are the information, education and training materials on emergency procedures and equipment available in the emergency room for health care staff use? Are there introductions of any new procedures/interventions? - If yes, which procedure/intervention: (please specify) Has referral to other health facility decreased because of skills and knowledge of procedures and intervention? Are records maintained? 6. Policy Is there a policy to promote training for health care staff in the essential emergency management of trauma, obstetric care and anaesthesia? Is there a policy to update the protocols for the emergency management of trauma and obstetric care adapted to local needs? Are there any guidelines on donation, procurement, and maintenance of all EE equipment? Is there a list of extra health personnel to be contacted in disaster situations? For guidance use WHO generic list of Essential Emergency Equipment Department of Essential Health Technologies World Health Organization, 20 Avenue Appia, 1211, Geneva 27, Switzerland Fax: Internet: Yes Yes No No 10

11 WHO Generic Essential Emergency Equipment List Checklist describes minimum requirements for emergency and essential surgical care at the first referral health facility Capital Outlays Quantity Date checked Resuscitator bag valve and mask (adult) Resuscitator bag valve and mask (paediatric) Oxygen source (cylinder or concentrator) Mask and Tubings to connect to oxygen supply Light source to ensure visibility (lamp and flash light) Stethoscope Suction pump (manual or electric) Blood pressure measuring equipment Thermometer Scalpel # 3 handle with #10,11,15 blade Scalpel # 4 handle with # 22 blade Scissors straight 12 cm Scissors blunt 14 cm Oropharyngeal airway (adult size) Oropharyngeal airway (paediatric size) Forcep Kocher no teeth cm Forcep, artery Kidney dish stainless steel appx. 26x14 cm Tourniquet Needle holder Towel cloth Waste disposal container with plastic bag Sterilizer Nail brush, scrubbing surgeon's Vaginal speculum Bucket, plastic Drum for compresses with lateral clips Examination table Wash basin Renewable Items Suction catheter sizes 16 FG Tongue depressor wooden disposable Nasogastric tubes 10 to 16 FG Batteries for flash light (size C) Intravenous fluid infusion set Intravenous cannula # 18, 22, 24 Scalp vein infusion set # 21, 25 Syringes 2ml Syringes 10 ml Disposable needles # 25, 21, 19 Sharps disposal container Capped bottle, alcohol based solutions Sterile gauze dressing Bandages sterile Adhesive Tape Needles, cutting and round bodied Suture synthetic absorbable Splints for arm, leg Urinary catheter Foleys disposable #12, 14, 18 with bag Absorbent cotton wool Sheeting, plastic PVC clear 90 x 180 cm Gloves (sterile) sizes 6 to 8 Gloves (examination) sizes small, medium, large Face masks Eye protection Apron, utility plastic reusable Soap Inventory list of equipment and supplies Best practice guidelines for emergency care Supplementary equipment for use by skilled health professionals Laryngoscope handle Laryngoscope Macintosh blades (adult) Laryngoscope Macintosh blades (paediatric) IV infuser bag Magills Forceps (adult) Magills Forceps (paediatric) Stylet for Intubation Spare bulbs and batteries for laryngoscope Endotrachael tubes cuffed (# 5.5 to 9) Endotrachael tubes uncuffed (# 3.0 to 5.0) Chest tubes insertion equipment Cricothyroidectomy 11

12 This list was compiled from the following WHO resources: WHO training manual: Surgical Care at the District Hospital WHO Emergency Relief Items, Compendium of Basic Specifications* WHO/UNFPA Essential drugs and other commodities for reproductive health services. WHO Essential Trauma Care Guidelines * For specifications refer to this book Department of Essential Health Technologies World Health Organization, 20 Avenue Appia, 1211, Geneva 27, Switzerland Internet: 12