Practical Approach to Lung Healt

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					                       Stop TB Department, World Health Organization, May 2006 - working draft

                        PLANNING FRAMEWORK
                      Practical Approach to Lung Health

1. Rationale:
Data from countries show that, among patients, aged five and more, who visit PHC
facilities for any reason, up to one-third and more seek care for respiratory symptoms.
In high HIV settings, respiratory symptoms are the commonest symptoms in HIV-
positive patients. Surveys' findings indicate that: i) not all respiratory patients who are
eligible for TB screening are referred for TB assessment (ei.: as low as 5% of the
respiratory patients who meet TB suspect definition); ii) non negligible proportion of
the patients referred to TB laboratory does not fit the definition of TB suspect; iii) a
substantial proportion of the respiratory patients referred to TB laboratory for sputum-
smear microscopy may not be examined.

It is clear that most of the data suggest that respiratory conditions account for a non
negligible part of the demand of care in PHC; however, TB accounts for a very small
proportion among all respiratory conditions in most countries (less than 2% and even
less than 1%). Clinical symptoms presented by pulmonary TB patients are broadly
similar to the symptoms developed by the non-tuberculous respiratory patients,
particularly those with persistent symptoms. Also, patients are usually managed on
the basis of symptoms in PHC settings in many countries. This management is most
often carried out without standardization and in a chaotic manner resulting in
unnecessary and inappropriate referral, abuse in drug prescription, and waste of

The development and implementation of a comprehensive and systematic approach to
manage patients with respiratory symptoms in PHC setting are likely to improve the
quality of respiratory care and, subsequently, create conditions resulting in increasing
TB case detection and improving the quality of TB diagnosis.

The Practical Approach to Lung health (PAL) strategy is an integrated approach to
manage respiratory conditions with a focus on PHC. The rational backing PAL is that
this strategy is able to improve the identification and management of TB with respect
to the other respiratory illnesses as well as the identification and management of non
tuberculous respiratory conditions with respect to TB.

Country experiences in PAL development and implementation suggest that PAL
contributes to i) improving the national health policy since PAL defines health policy
and intervention for the 1st leading cause of care demand in PHC setting; ii)
improving TB case detection, and the quality of TB diagnosis; iii) decreasing the
referral of respiratory patients from PHC settings, and therefore improving the
integration of respiratory care and TB control in PHC services; iv) reducing drug
prescription, particularly antibiotics and adjuvant drugs; v) improving the quality of
the management of chronic respiratory patients within the district health system; vi)
improving and strengthening the competency of PHC workers; and vii) improving
health planning and formulation of resources needed within the health system.

                      Stop TB Department, World Health Organization, May 2006 - working draft

2. Goals, objectives and SDAs
GOAL: Stop TB Strategy goal and objectives
 To dramatically reduce the global burden of TB by 2015 in line with the MDGs
  and the Stop TB Partnership targets.
 To achieve universal access to high-quality diagnosis and patient-centered
 To reduce the human suffering and socioeconomic burden associated with TB
 To protect poor and vulnerable populations from TB, TB/HIV and multidrug-
  resistant TB
 To support through operational research and field testing the development of new
  tools and enable their timely and effective use

OBJECTIVES: Stop TB Strategy component 3
To contribute to health system strengthening through implementation of PAL strategy
aiming to improve within the district health system:
    The quality of care for every patient who seek care for respiratory symptoms
    The efficiency of health care delivery for respiratory illnesses in general.

SDA: to implement PAL strategy

3. Strategic components of PAL:
PAL aims at developing an integrated strategy to manage respiratory conditions, with
a focus on PHC services. PAL need to be adapted to national health policies and
priorities as well as to the available health resources. PAL strategy includes two

       Standardization of clinical care through the adaptation and development of
        clinical practice guidelines focusing on priority respiratory diseases and
        targeting, particularly, the improvement of TB case detection as well as the
        quality of TB diagnosis within PHC system. These guidelines are based on
        the principle of using key symptoms and signs that lead to diagnostic
        classification, determination of degree of severity and appropriate decision of

       Coordination based on the collaboration among health workers at the same
        and different levels of the health system, as well as within and among the
        various categories of health workers in order to make the most efficient use
        of available resources. Coordination also implies a clear definition of the role
        of each health worker category and each health care level in providing
        respiratory care services. This contributes to establishing efficient referral
        system for respiratory condition cases in general and for TB suspects and TB
        cases in particular. In addition, coordination is needed among TB and
        HIV/AIDS control programmes, general health services, PHC department,
        Essential Drug Programme, health management information system (HMIS),
        the existing training network, and others.

                         Stop TB Department, World Health Organization, May 2006 - working draft

  4. Activities corresponding to the SDA on implementation of PAL
 Activities        Input              Indicators (per          Data collection          HSS
                   description        SDA)                     method                   contributi
                   (= Budget          Measurement unit                                  on
                   item)              (per activity)                                    (outside
NWG                Establishment      NWG created              List of the NWG
                   of a NWG                                    members available

PAL guideline      Adaptation and     National PAL             PAL guidelines
                   development of     guidelines finalized     available
                   national PAL
                                                               Training material
Training           Development of     Training material        available
Material           training           finalized
                   material to
                   implement PAL

Feasibility test   Elaboration and Feasibility test            Report produced on
                   implementation carried out                  the short term
                   of the feasibility                          impact of PAL
                   test protocol                               implementation

PAL                Development of     The national plan        The national plan
implementation     a national plan    for PAL                  for PAL
plan               for PAL            implementation           implementation
                   implementation     finalized                officially approved
                                                               and available

Resource           Integration of     PAL strategy is          PAL is officially
mobilization to    PAL                incorporated within      included in the
implement          implementation     the national process     national policy
PAL                within the         of resource              regarding health
                   national process   mobilization for         financing
                   of health          health

PAL                Existence of a     Equipment                Health management
implementation     clear national     purchased and            information system
                   leadership for     health professionals     and TB recording-
                   PAL                trained                  reporting system
                   implementation                              provide routine
                   and resource                                information on the
                   mobilized                                   quality of
                                                               respiratory care in
                                                               PHC setting

                       Stop TB Department, World Health Organization, May 2006 - working draft

5. Activities and explanations:
NWG: a national working group (NWG) on PAL adaptation and development needs
to be created in country. The NWG is usually under the leadership of the national TB
Programme and involve key partners at country level such as HIV/AIDS control
programme, PHC services, Essential Drug Programme, national health academic
institutions, HMIS department, health resource planning department, etc…

PAL guidelines: the NWG has the responsibility to develop the PAL guidelines.
They should be based on the international standards of clinical care for respiratory
illnesses that have gained general acceptance. They should focus on the priority
respiratory conditions encountered within the district health system. They should be
adapted to the national conditions and health policy priorities while taking into
account the organization of the district health services and the skills of the existing
health professionals (general practitioners, medical assistants, nurses, etc…) who have
to use them.

Training material: should be developed by the NWG. It should target the
implementation and the appropriate utilization of PAL guidelines by health workers in
their daily tasks. The training material includes: i) a document explaining the concept
and rationale of PAL strategy; ii) PAL guidelines; iii) a training module for health
worker including case studies which cover all the content of the guidelines; iv)
documents on how to use, clean and maintain equipment such as peak flow meter,
inhalation chamber, nebulizer, spirometry and oxygen supply; and v) a facilitator

Feasibility test: should be undertaken by the NWG, The objectives of this test is to
assess the impact, in the short term, of the implementation of PAL on health care
delivery to patients with respiratory symptoms in PHC settings, particularly in terms
of: i) patient referral; ii) quality of the process of TB identification among respiratory
patients; iii) quality and cost of drug prescription. The feasibility includes two surveys:
the first before PAL implementation and the second after PAL implementation.

Plan for PAL implementation: should be developed by the NWG. It could be
developed for, in a first phase, a specific region or for the whole country. It should be
multi-year, stepwise and in line with the long term strategic plan of the NTP. It should
include a budgetary component. The plan should be developed in coordination with
PHC Department, HIV/AIDS Programme and discussed with the other relevant
stakeholders dealing with national health issues.

Resource mobilization to implement PAL: The availability of PAL guidelines,
training material, results of the short term impact of PAL and a plan of PAL
implementation are key conditions to be successful in mobilizing resources for PAL.
The PAL implementation plan should be included within the national health planning
process. The resources needed for PAL implementation plan can be mobilized
through government funding policy or in the framework of the bilateral or multilateral
funding policy of country.

                      Stop TB Department, World Health Organization, May 2006 - working draft

PAL implementation: should be under the leadership of a clearly identified
coordination unit ideally within the NTP (if not within PHC Department). As soon as
funds are available, the PAL unit should proceed to their budgeting in order to
procure the equipment needed and organize the training of health professionals in line
with the plan of PAL implementation. When PAL activities are carried out within
district, the PAL coordination unit should initiate the monitoring and supervision
activities and collect information on routine basis, through the TB recording/reporting
system and the HMIS, in order to evaluate the quality and the performance of PAL.

6. References:
Pio A, Chaulet P. Standardization of district-based packages of care for the
management of tuberculosis and other respiratory diseases among youth and adults.
World Health Organization, Geneva, 1997.

Scherpbier R, Hanson C, Raviglione M. Basis for the development of algorithms for
assessment, classification and treatment of respiratory illness in school-age children,
youths and adults in developing countries. World Health Organization, Geneva, 1998.

Report of the first international review meeting - Practical Approach to Lung Health
strategy. World Health Organization, Geneva, 2003.

Brochure on PAL. World Health Organization, Geneva, 2003.

Ottmani S, Scherpbier R, Chaulet P, Pio A, van Beneden C, Raviglione M.
Respiratory care in primary care services - A survey in 9 countries. World Health
Organization, Geneva, 2004 (WHO/HTM/TB/2004.333).

Ottmani S, Scherpbier R, Pio A, Chaulet P, Aït Khaled N, Blanc L, Khaltaev N,
Raviglione M. Practical Approach to Lung health (PAL): a primary health care
strategy for integrated management of respiratory conditions in people of five years of
age and over. World Health Organization, Geneva, 2005 (WHO/HTM/TB/2005.351;

Ten Asbroek A, Delnoij DMJ, Niessen LW, Scherpbier RW, Shrestha N, Bam DS,
Gunneberg C, van der Hor CW, Klazinga NS. Implementing global knowledge in
local practice: a WHO lung health initiative in Nepal. Health Policy Plan 2005, 20,

Fairall LR, Zwarenstein M, Bateman ED, Bachman ED, Lombard C, Majara B,
Joubert G, English RG, et al. Effect of educational outreach to nurses on tuberculosis
case detection and primary care of respiratory illness: pragmatic cluster randomized
controlled trial. BMJ 2005, 331, 750-754.

Rosen MJ. Chronic cough due to tuberculosis and other infections: ACCP evidence-
based clinical practice guidelines. Chest 2006, 129, 197S-201S.

Shrestha N, Samir KC, Baltussen R, Kafle KK, Bishai D, Niessen L. Impact of
respiratory care guidelines on prescribing costs in Nepal. IJTMIH (accepted).

                      Stop TB Department, World Health Organization, May 2006 - working draft

Ottmani S, Mahjour J. "Practical Approach to Lung Health: The PAL strategy for
integrated respiratory care" In TB a comprehensive international approach. Taylor and
Francis Editor (in press).

Murray JF, Pio A, Ottmani S. PAL: a new and practical approach to lung health
(submitted to IJTLD).

Country PAL guidelines: Algeria, Bolivia, Chile, El-Salvador, Guinea, Jordan,
Kyrgyzstan, Morocco, Nepal, Peru, Syria, Tunisia, South Africa, and Uganda.

7. Countries involved in PAL adaptation, development and
Algeria, Bolivia, Chile, Estonia, Egypt, El-Salvador, Guinea, Jordan, Kyrgyzstan,
Morocco, Nepal, Peru, South Korea, Lebanon, Lithuania, Oman, Syria, Tunisia, South
Africa and Uganda.

8. Collaborative institutions and organizations involved in PAL
Erasmus University, Rotterdam, the Netherlands
Finnish Lung Health Association
Forum of International Respiratory Societies
Global Alliance for Chronic Respiratory Diseases
International Union Against Tuberculosis and Lung Disease
Maastricht University, Maastricht, the Netherlands
Medical Research Council of South Africa, Cape Town, South Africa
National Institute of Public Health of Algeria, Algiers, Algeria
National Institute of Public Health of Uganda, Kampala, Uganda
Tartu University Medical School, Tartu, Estonia
University of Free State, Bloomfontein, South Africa