LATIHAN BAGI PENGURUSAN PENYAKIT TIDAK BERJANGKIT DI PERINGKAT

LATIHAN BAGI PENGURUSAN PENYAKIT TIDAK BERJANGKIT DI PERINGKAT PENJAGAAN KESIHATAN PRIMER

Sekalung Penghargaan • Dr Nazrila Hairizan Nasir, Ketua Perkhidmatan FMS • Dr Sri Wahyu Taher, FMS KK Simpang Kuala Kedah • Dr Mastura Ismail, FMS KK Seremban 2, N. S • Datin Dr Zilfalillah Md Said, FMS KK MBAS Terengganu • Dr Noraini Jalil, FMS KK Sg Besar, Selangor • Dr Nurhayati Isa, FMS KK Padang Rengas Perak • Dr Norma Sabtu, Peg NCD Melaka • Dr Noor Hashimah Abdullah, Peg NCD Kelantan • Dr Yusmah Muhamad, Peg NCD Johor • Dr Salmiah Baharudin, NCD Selangor • Dr Bariyah Kadas, NCD JKWPKL • En Saiful Adli bin Suhaimi, Bhg Pendidikan Kesihatan

Sekalung Penghargaan Bhg Kawalan Penyakit • Dr Rotina Abu Bakar, Pakar Perubatan Kesihatan Awam, BKP • Viola Michael , Peg. Dietetik, BKP • Siti Farrah Zaidah bt Mohd Yazid, Peg Dietetik, BKP • Matron Nor Anizah Sipol, Penyelia Jururawat BKP • En Mohd Nazri bin Abdullah, PPP BKP Bhg Pembangunan Kes Keluarga • Dr Noraliza Noordin M • Dr Nasrul Muhaimin Mokhtar, BPKK • Dr Hartini Mohd Ridzuan, KPP BPKK • Matron Nor Azlina binti Mohd Sab, Ketua Penyelia Jururawat BPKK

Primary Care as Focus of NCD Agenda Bahagian Pembangunan Kesihatan Keluarga Kementerian Kesihatan Malaysia 21 April 2016 fatanah@moh. gov. my

TEN (10) PRIORITY HEALTH PROGRAMS TO BE IMPLEMENTED 2015 -2018 1. Health Insurance Scheme 2. Primary Care As Focus of NCD Agenda 3. Senior Consultants Allowed To Do Private Practice 4. Promote And Support Non-Profit Organization 5. Establishment Of Low Risk Maternity Centers 6. Develop Cluster Hospitals 7. ICT Transformation 8. Reformation Of Housemen’s Training 9. Career Pathway For Medical Officers 10. Transformation Of Pre-Hospital Care

Four Major Groups of Non-Communicable Diseases Four Major Lifestyles Related Risk Factors Modifiable Risk Factors Tobacco Use Non-Communicable Diseases Heart Disease and Stroke Cancers ü ü ü Chronic Lung Diseases ü Diabetes Unhealthy Physical Diets Inactivity ü ü ü Harmful Use of Alcohol ü ü ü

Prevalence (%) Introduction 20 18 16 14 12 10 8 6 4 2 0 Prevalence of Diabetes, ≥ 18 years (2006, 2011, 2015) 17. 5% 15. 2% 11. 6% 9. 2% 8% 4. 5% Undiagnosed Diabetes Known Diabetes 7% NHMS 2006 *3. 5 million adults > 18 years 7. 2% 8. 3% NHMS 2011 NHMS 2015 Source: National Health and Morbidity Survey , MOH Malaysia (2006, 2011, 2015)

Prevalence of Hypertension, ≥ 18 years (2006, 2011 & 2015) 35 32. 2% 32. 7% 30. 3% Prevalence (%) 30 25 19. 8% 20 17. 2% Undiagnosed HPT 15 Known HPT 10 5 0 NHMS 2006 12. 8% 13. 1% NHMS 2011 NHMS 2015 *6. 1 million adults > 18 years Source: National Health and Morbidity Survey , MOH Malaysia (2006, 2011, 2015)

Prevalence of Hypercholesterolemia, ≥ 18 Years NHMS (2006, 2011 and 2015 Prevalence (%) 47. 7% 35. 1% 38. 6% 20. 7% 26. 6% 8. 4% NHMS 2006 NHMS 2011 *9. 6 million adults > 18 years Undiagnosed Hyper. Chol Known Hyper. Chol 9. 1% NHMS 2015 Source: National Health and Morbidity Survey , MOH Malaysia (2006, 2011, 2015)

Prevalence of obesity and overweight, ≥ 18 years (WHO 1998) 35 29. 1 30 29. 4 30 15. 1 17. 7 Prevalence (%) 25 20 15 16. 6 14 10 5 0 obesity 4. 5 1996 2006 *Obese: 3. 3 million adults > 18 years *Overweight: 5. 6 million adults > 18 years 2011 overweight 2015

Background: PHC as NCD Focus • PHC clinics as 1 st point of contact • Malaysia has the infrastructure to shift management of NCDs in the PHC clinics, closer to the community, including K 1 M • Integration with community activities (eg PPKK, KOSPEN) • Team approach in NCD management • Increase capacity (numbers, quality), • Establish/strengthen network of related hospital specialist services to these primary care clinics • Measurable targets to be achieved

Issues and challenges • High load of patients to doctor • (30 m & 13 m) = 40 -50 m (total encounters) • Human Resources (as of June 2015) • 3, 430 MOs (281 FMS) • 25, 405 Nurses (10, 660 SN) • 3, 764 MAs • Increasing scope of services • Level of care depends on capacity of clinics • Lack of building space and equipment, Poor maintenance • Increasing demands by clients : Increasing complaints

Population with NCD • • • Diabetes Cardiovascular Chronic Respiratory Mental Illness Cancer Clinic (KK) Undiagnosed Ø Poor promotion Ø Behavior modification Ø Hard policies • • • Accessibility Acceptability availability Diagnosed Ø Poor quality Ø Inadequate number Ø Equipment Ø Space Human • Resource • Training ↑ Posts ↑ Infrastructure Ø Poor Monitoring ICT - EMR Ø Drugs and Reagent Budget

Strengthening Chronic Disease Management at Primary Care Level

Primary Care as Focus of NCD Agenda 1. 2. 3. 4. The Life Course Framework Mapping of services Indentify NCD indicators Nurses to handle NCD cases

Pre-pregnant women Pregnant women Newborn/ infant Children Schoolgoing children Adult male / female Adolescent Elderly

Newborn/ infant Children Schoolgoing children Adult male / female Adolescent Elderly

List of NCD Indicators (42) 42 indicators: • Promotive – 4 • Preventive – 17 • Curative – 6 • Rehabilitative – 3 • Resources – 12 Promotive – 4 indicators 1. Number of PPKK (KK) involved in NCD activities 2. Number of referrals to Klinik Kesihatan from KOSPEN 3. Number of materials disseminated 4. Number of Media Campaigns

Preventive NCD Indicators (17) 1. Percentage of high risk female clients practice effective family planning methods 2. Percentage of Diabetes Mellitus among gestational diabetes mothers, diagnosed at 6 -8 weeks postnatal 3. Percentage of gestational diabetes mellitus (GDM) 4. Percentage of overweight toddlers (children 1 -4 years attending health clinic) 5. Percentage of children aged 18 month who fail M-CHAT screening(Autism) 6. Percentage of overweight and obese Standard 1 school children 7. Percentage of overweight and obese Standard 6 school children 8. Percentage of overweight and obese Form 3 school children 9. Percentage of Obese Adolescents (>+SD) from those screened with BSSK 10. Percentage of Adolescents with High Risk Behaviour among those screened with BSSK. 11. Dose 2 HPV vaccination coverage 12. Percentage of Thalassaemia screening among Form 4 students 13. Percentage of ten (10) commonest NCD risk factors identified among adult (women and men) using BSSK screening 14. Improved coverage (percentage) of Pap Smear 15. Percentage of high risk women detected performed mammogram 16. Percentage of elderly been screened using BSSK having risk for Diabetes 17. Percentage of elderly been screened using BSSK having risk for HPT

List of NCD Indicators (42)- cont Curative – 6 Indicators 1. 2. 3. 4. 5. 6. Percentage of KK implemented QA Asthma achieve >75% full mark (6/6) Percentage of patient achieve appropriate management of asthma (6/6) Percentage of Diabetes (DM) control in Klinik Kesihatan (TPC data) Percentage of Hypertension (HPT) control in Klinik Kesihatan (TPC data) Percentage of client successful in quit smoking (in 6 months) Percentage of patients with Anxiety, Stress and Depression from DASS Rehabilitative – 3 indicators 1. 2. 3. Percentage of stroke cases improved in activity of daily living (ADL) after 6 months rehabilitation intervention using MBI scale (Modified Barthel Index) Percentage of person with disabilities (PWD) in Community Base Rehabilitation (CBR) undergoes health screened using PDK Ku Sihat format No of cases of child injury (0 - 10 years)

List of NCD Indicators (42)- cont Resources - 12 indicators: 1. Human resources – 3 2. Capacity Building - 1 3. Infrastructure – 3 4. Equipments – 1 5. Drugs – 2 6. Reagents – 1 7. Visiting specialists - 1 Human resources – 3 indicators 1. Number of Medical Officer required for NCD activities in Health Clinic 2. Number of health clinics with PHC team 3. Number of K 1 M with NCD

List of NCD Indicators (42)- cont Capacity building – 1 indicator 1. Number of health personnel undergone NCD training Infrastructure – 3 indicators 1. Improving Data Collection of Screening Activities - e. BSSK (NCD Risk Factors) 2. Development of electronic Medical Record for PHC 3. Development of Web. Based Monitoring System - Asthma

List of NCD Indicators (42)- cont Equipment – 1 indicator 1. Equipments procured under concession (chemistry analyser, Hb. A 1 C and glucometer) Reagent – 1 indicator 1. % NCD Reagent Expenditure (NCD test reagent expenditure/Total PH reagent expenditure) Drugs – 2 indicators 1. Percentage of proforma approved/ Total of proforma submitted 2. Percentage of NCD drugs expenditure/Total Public Health drugs expenditure Visiting Specialists at Klinik Kesihatan 1. Number of Health Clinic visited by Hospital Specialists (Discipline)

Population with NCD Clinic (KK) Undiagnosed Ø Poor promotion Ø Behavior modification Ø Hard policies • • • Accessibility Acceptability availability Diagnosed • • • Diabetes Cardiovascular Chronic Respiratory Mental Illness Cancer

NCD Focus Agenda – The Approach 1. Adopts the approach of personalised care: a) Implementation of Family Doctor Concept b) Establishment of Primary Health Care Team (PHC Team) 2. Requires: 1. Trained personnel 2. Equipments 3. Financial allocation 4. Training

PERSONALIZED CARE IN MCH Personalized care di MCH - JM dan SN yang menjaga zon -zon di kawasan operasi: -Kes antenatal -Kes kanak JM SN A F SN JM B JM SN ZON C E SN JM JM SN D JMSN

FAMILY DOCTOR CONCEPT Pegawai perubatan (MO) juga perlu 2 menjaga zon-zon MOSN JM di kawasan operasi (*1 MO berkemungkinan menjaga >1 zon A 1 JM SNMO F 2 B JM SN MO ZON C E MOSN JM 1 1 JM SN MO D 2 MO SNJM

FMS, MO, PPP, SN, OT, PT, DIETITIAN, FDCPSP FDC ZON C PHC TEAM ZON D ZON B KK FDC ZON A ZON F FDC ZON E PHARMACIST MLT, XRay, PPK

NCD Focus Agenda – The Approach 1. Adopts the approach of personalised care: a) Implementation of Family Doctor Concept b) Establishment of Primary Health Care Team (PHC Team) 2. Requires resources: 1. Trained personnel 2. Equipment 3. Financial allocation 4. Training

Resource Requirement No. 1. 2. 3. 4. 5. Items Budget Required (RM) Human resource requirement 300, 299, 244. 49 6, 695 posts of various categories Equipments for optimal NCD control 127, 724, 300. 00 [MEET Gap List 2016] Total of 5, 203 equipments for 2016 Drugs for NCD management 341, 133, 861. 00 Total of 16 additional drugs for NCD Training needs at Primary Care Level RM 2, 934, 530. 00 Training at national level, zonal training and in-service training at KK/PKD level GRAND TOTAL: RM 772, 091, 935. 49

NCD Training Needs at PHC Level No. of Name of Courses Estimated Budget Courses (RM) 5 Kursus Pemantapan Pengurusan Diabetes 202, 730. 00 Mellitus di Klinik Kesihatan ( Primary Health Care ) 5 Kursus Pemantapan Pengurusan Penyakit Darah Tinggi 154, 570. 00 dan Strok di Klinik Kesihatan ( Primary Health Care ) 5 Kursus Pemantapan Pengurusan COPD & Asthma 201, 270. 00 di Klinik Kesihatan ( Primary Health Care ) 5 Kursus Pengukuhan Saringan Kesihatan Mental di 121, 830. 00 Klinik Kesihatan ( Primary Health Care ) 5 Kursus Pengurusan Kanser di Klinik Kesihatan 202, 730. 00 ( Primary Health Care ) 5 Kursus Pengurusan Faktor Risiko Penyakit tidak Berjangkit 156, 670. 00 di Klinik Kesihatan ( Primary Health Care ) 5 Kursus Pengurusan Khidmat Berhenti Merokok 202, 730. 00 564 Latihan Dalam Perkhidmatan di Peringkat Daerah 1, 692, 000. 00 [4 sesi latihan setiap daerah] 599 RM 2, 934, 530. 00

NCD Focus at PHC: Action by States

NCD Focus at PHC: Action by States 1. The whole KK is NCD 2. NCD screening and intervention throughout Life Course Approach § Increase number of screening § health clinics, community, outreach 3. Implementation of Personalised Care (NCD): § Family Doctor Concept (FDC) § Establishment of PHC Team 4. Monitoring of Indicators

NCD Focus at PHC: Acton by Primer 5. Resource allocation § Distribution of HR § Nurses to handle NCD cases 6. Training in NCD for KK staff § Training at JKN/PKD/KK level § Staff in MCH and OPD § Staff in KD and K 1 M 7. Monitor training § Training allocation RM 2, 000/PKD § Reten

NATIONAL & STATE FMS REPS

No. Negeri NATIONAL REP Hypertension and stroke Diabetes Datin Dr Zil Falillah Dr Faudzi bin Abdullah Asthma and COPD Dr Rozita binti Ismail Cancer Dr Maimunah binti Mahmud CVD Risk Factors Mental Health Dr Baizury Dr Nurhayati binti Bashah binti Isa Smoking and Tobacco Dr Iskandar Firzada bin Haji Othman Dr Mohd Fozi Dr. Norsiah bt. Dr Mohd Fozi Dr Rosli Omar Dr Idora Ibrahim Kamaruddin Md Noor Kamaruddin Dr Abdul Jalil Bin Dr Suzaini Bt Mat Dr Suzaini Bt Dr Jamilah Bt Dr Zamri Bin Dr Abdul Jamil Bin 2 Kedah Ahmad Daud Mat Daud Abdullah Mansor Ahmad Dr Siti Kamariah Dr Rohaizan Dr Ranjini Dr Yusmawati 3 Pulau Pinang Dr Yusnita Yusof Dr Anita Jain Dr Adlina Bakar Ahmad Rodzi Ambigapathy Mohd Yussof Dr Mohd Shaffari Dr Sofiah Zainal Dr Zawawi Abu Dr Subashini 4 Perak Dr Zarina Baharin Dr Liliwati Ismail Dr Rozianita Marzuki Abidin Bakar Ambigapathy Dr Ruziaton Dr Azah 5 Selangor Dr Noraini Jali Dr Ho Bee Kiaw Dr Nor Azila Isa Dr Nik Mazlina Dr Salmah Nordin Hashim Samad Dr Zil Azwan Dr Baizury Dr Norhaslira Dr Nazrila Hairin 6 JKWPKL&P Dr Rohayah Ismail Dr Hazira Hanum Dr Sheela Selvam Abdullah Bashah Abdul Rahim Nasir Negeri Dr. Azainursuzila Dr Nor Asiah Dr Narayanan 7 Dr Mastura Ismail Dr Iliza Idris Dr Mariam Manap Dr Sabariah Idris Sembilan Binti Ahad Hashim A/L Sundram Dr Ezra binti Dr Hazlin binti Dr Rosnani binti Dr Azman bin Dr Siti Zaleha Dr Suhaimi bin 8 Melaka Dr Jalil bin Ishak Mohamed Talib Kasim Othman binti Sulaiman Mohd Isa Dr Fatima Dr Sakinah 9 Johor Dr Zaharita Bujang Dr Norlizah Madi Dr Yunus Shariff Dr Norlizah Paidi Dr Abdul Hafiz Hassan Sulong Dr Sharipah Dr Mohd Daud Che Dr Iskandar Dr Radziah Dr Muhd Khairi Dr Adienuar Dr A Khalek Abdul 10 Pahang Fotimah Bt Yusof Firzada Osman Rashid Taibi Ahmad Norawi Rahman Syed Abdullah Dr Kamilah Dr Ranimah Datin Dr Zil 11 Terengganu Dr Mazlinah Muda Dr Azlina Elias Dr Azila Abas Dr Azlin Amat Mohammad Yahya Falilah Datin Dr Wan Dr Nik Harlina Dr Mohd Dr Rahiza Bt Dr Norashidah Dr Tuan Zailina Bt Dr Nik Azhan Bin 12 Kelantan Nazariah Wan Roza Bt Nik Sukarno Bin Abdul Rahman Bt Abdullah Tuan Ngah Nik Mohamad Hassan Kazim Saud Dr Nik Harlina Dr Chin Ying Dr Rumihati Dr Mohd Nazri 13 Sabah Dr Lee wai Khew Roza Bt Nik Dr Ng Yoke Lan Dr Lee wai Khew Woei Abdul Hamid Mohd Daud Kazim Dr Norraliza Md Dr Rohayah Dr Maziah Dr Maurice Steve 14 Sarawak Dr Jusoh Senik Dr Juslina Omar Dr Sally Suriani Zin Abdullah Ishak Utap 1 Perlis 15 WP Labuan Dr Mohd Fozi b. Kamaruddin Dr Sri Wahyu Bt Taher Dr Mazliza Yusof

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Cadangan Pembahagian Perjawatan Mengikut Perkhidmatan di KK Berdasarkan Outfit (Jururawat)