Improving the availability of early detection of risk factors for Non-communicable diseases.
Ministry of Health

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Health statistics in Bahrain indicate in 2011 that the proportion of deaths from non-communicable diseases(NCDs) have reached (64%) of the total deaths in Bahrain. where it was registered 1620 deaths (39.9%) due to heart disease, vascular, (16.8%) due to cancer, (18.4%) because of diabetes, (6.9%) due to respiratory diseases, (18.0%) due to other non-communicable diseases. NCDs in addition to the common preventable risk factors associated with these diseases, such as smoking, unhealthy diet, physical inactivity and excessive alcohol intake, are the leading cause of death in the Kingdom of Bahrain. Although specialized clinics such as diabetic, chronic non-communicable diseases and health promotion clinics are available in all health centers, besides regionally located antismoking and nutrition clinics, there’s a lack of collaboration between all these services and the referral process between them, is not clear for neither them nor the patients. For an example, public health department in the ministry implement a work place NCD screening campaign in October 2010 had screened 1139 employees. Those with risk factors were asked to go back to their health centers to follow up, but the participant had no idea to which clinic they should go exactly? With all information mentioned above (between 2007-2011) there was; • Lack of a national system and database for monitoring and follow-up and evaluation of quality standards for non-communicable diseases • Lack of cross sectional involvement of non-governmental organizations, private sector and civil societies. • Lack Involvement of individuals and their families to share the responsibilities of the treatment and prevention of NCDs. • Lack of a national surveillance system for non-communicable diseases. • The absence of a culture of clinical audit, review and evidence based practice.

B. Strategic Approach

 2. What was the solution?
• Decrease the incidence of NCDs through early detection of risk factors that leading to these diseases, by collaboration of all concerned health sectors in government, NGO and the community. • Focus on screening programs, health promotion, and awareness of the benefits of healthy life style habits to population. • Create a culture where the community, know the risk factors, be aware of their role in the prevention, contributes to the control of his or her illness and to teach others.

 3. How did the initiative solve the problem and improve people’s lives?
Although many services are available in primary health care dealing with the treatment of NCDs such as NCD clinics, investigation and treatment, nutrition Clinics, quit smoking clinic, diabetic specialized Clinic, mental health, health promotion and social worker services and the presence of qualified health workers in all governmental primary health care centers only to provide curative services, there is no focus on services for early detection of risk factors, promotion, awareness. Vulnerable groups such as women and elderly are easily missed. There were no proper monitoring and follow up of detected cases with risk factors. The expenditure on the preventive care and health promotion has not match the needs up to date. Changing disease patterns call for reallocation of some resources from curative to preventive services to make better use of available resources and decrease the cost of secondary and tertiary care which is more expensive Our mean strategic plan of our project is based on the following concepts: • Reductions of risk factors and prevent the development of NCDs. • Reduction of NCD complications. • Protect patients from cardio vascular disease. • Reduce the need for referral to the emergency department. • Reduce admissions rate to the hospital • Minimizing the building new facilities and hospital. The target of our project is Bahraini citizens aged between 18-65 years old. This project reinforces the role of institutional knowledge assets to achieve best practice competitiveness through the following: • Raising the availability of the service for early detection in order to reduce the risk for NCDs. • Focus on integrated services for early detection throughout the health care system (pull system). • Re-engineering the role of the physician to focus on early detection versus focusing on treatment. • Re-engineering of nursing and give them a greater role in early screening, guidance and awareness process. • Focus on health promotion. • Strengthening the role of community to take responsibility and become actively involved in taking care of their health • Access for the most vulnerable. • Creating resource groups (nurse, health educator, educated patient, doctor). To support the patients and their families • Promote effective partnership with other sectors within and outside the Ministry of Health.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Focus on raising the availability resources in preventive services , monitoring and follow up of detected cases with risk factors and the most vulnerable for NCDS ,through implementation of this project in primary health care level where by using available resources, Re-engineering the roles of medical team such as doctors, nursing ,health educators specialist, social workers specialist, in primary health care level with collaboration between all these services with concerned sectors such as emergency sector in the hospital ,health Promotion Department, public health Department ,involvement of community partnership, regional multidisciplinary council, the ministry of Education, the ministry of youth and sports affairs, ministry of Social development and volunteers, through health promotion, encouragement physical activity, reduction on exposure to tobacco smoke , emphasized the effect of harmful use of alcohol ,highlight on healthy diets ,enhance awareness sessions about impact of obesity ,asymptomatic high cholesterol ,high blood pressure and high blood sugar to Strengthening the role of community in their health , to achieves our goals in improving of quality of their life, and to be a sector of the national economy added value (healthy citizen contributes to the development) and reduction of the incidence and mortality rates of non-communicable diseases.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The program was implemented by primary health care leadership in the ministry of health level/ Kingdom of Bahrain (government), collaboration with concerned sectors (private and government sectors) to provide the services to all citizens. Till 2015, 30% of the attendees to the health center whom examined in the early detection clinics had 99-100% of risk factor, most of them had 1-2 risk factor and chance of developing a cardiovascular disease within the following 10 years, showed 63% of them had < 10%, with levels of blood pressure and lipid improvements. In the non-communicable disease clinics in the primary health centers, the trend of the attendants for follow up was sustained with no high outbreak cases during 2012-2015. The national anti-tobacco committee launched with primary health care early detection clinics and quit smoking clinics, the result (during 2014-july 2015) showed 13% quit in males, and 50%in the females, NCDS campaign which implemented in a work place, where the employees screened and launched with primary health care centers, 83.3% were Bahraini citizens and 16.2% were non-Bahraini, 86.6% of the were referred to their local health centers. 40% of the screened were overweight and 33.5% obese, they were referred to follow up in the nutritional clinics in primary health care centers.
 6. How was the strategy implemented and what resources were mobilized?
Primary health care leadership formed on January 2012 to implement the project whom were put the strategic plan, polices and the main activities for self-assessment ,training the staff ,update the guideline for follow up and monitoring , arranged several meetings with stakeholders to study the obstacles and challenges to overcome them, field visits were done to all health centers to evaluate the available resources , of the clinics and staff, equipped the clinics with all the requirements for early detection of risk factors of non-communicable diseases ,standardized all forms to record the detection cases that have been screened ,fixed all visual signs and educational leaflet and posters for all people in health centers ,design feedback form for clients and update the guideline and the statements for calculation for estimation of cardiac diseases for the health care doctors , the nurse for follow up and referral to the concerned clinics and departments for early detection of risk factors (person is not regular in the treatment to be transferred to a clinic of non-communicable diseases, and those with high risk factors to the health promotion specialist , to the nutrition clinic to deal with the obese and overweight clients, quit smoking clinic or the social worker and mental clinics. And enhanced the collaboration between the medical and nursing sectors in primary health care with emergency sector of the hospital( refer the emergency cases with uncontrolled non-communicable diseases whom attended to accident emergency as pull system to health centers) , public health department for collecting the statistics for evaluation ,arranging the NCDS campaign where the multidisciplinary team screened the employees in their work place ,to detect the risk factors and encouraged for an healthy lifestyle and provided health promotion programs in workplace .The project collaborated with quit smoking committee which is responsible to arrange for awareness campaigns and educational activities on harmful effects of tobacco and opened Tobacco cessation clinic in one health center at each region. With health promotion department to provide health promotion and awareness sessions for referred clients in their health centers whom are most vulnerable to get non-communicable diseases, and for public in different media. With regional multidisciplinary council, The Ministry of Education to provide free of charge of halls for exercise and the Ministry of youth and sports affairs to provide coach volunteers to training and follow up the client, Ministry of Social development to provide the social centers for healthy cooking classes and calorie counting. The strategy of the project implemented without addition resources, it started in one health center( Hamad Kanoo health center) on May 2012 ,with four doctors (out of 10 doctors), each doctor to choose 5- 10 people from his or her the daily list for detection the high risk factors ( hit rat ) and then referred them to the nurse in the early detection clinic where the registration done and take the full history of the individual, measure the vital signs and estimate the chance of developing a cardiovascular disease within the following 10 years, and request the laboratory investigations required, and follow up the high risk factors and as needed , if it that a person is one of the non-communicable diseases, not on regular treatment refer to a clinic of non-communicable diseases., or if one of vulnerable refer either to health promotion specialist , nutrition clinic, quit smoking clinic, mental clinic or social worker, on the same day, where all of them are available in the health center. The implementation of strategic plan for the availability of the early detection of risk factors clinics in all health centers in Bahrain had completed in December 2016.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The project was implemented through the optimal use of resources, • The primary health care leadership with their staff in different level of responsibility supported from high executive leadership in the ministry of health and government with involvement of concerned sectors governorate were contributed in the design and /or in implementation of the project. • Re-engineering the roll of the physicians, nursing staff, health promotion specialist, social worker who were available in same primary health center without recruit new staff or build new place. • Creating the concept of collaboration with community, civil society, private sector and regional governorate as partnership to take the responsibility and became actively involved in awareness of patients or clients to taking care of their health. • involvement of the governmental organizations (the ministry of youth and sports through volunteers, such as sports trainers, Sports (Khalifa) City and the Ministry of Social Development where trained healthy cooking and how counting the calories, and the ministry of education. • Creating resource groups (nurse, health educator, educated patient, doctor). To support the patients and their family. • Developed the concept of work between staff work in specialized clinics (non-communicable diseases, mental health, nutritional, quit smoking) to create an educated patient’s dependent on themselves know the right time to ask for help.

 8. What were the most successful outputs and why was the initiative effective?
The most successful outputs of our project goals for male and female(age18-65), to ensure healthy lives, through sustainable approach of all health system for early detection and prevention of risk factors for NCDS: 1. 30% of the attendees (male and female) to primary the health centers examined in the early detection clinics, had 99-100% of risk factor, the composite risk factors show most of them had 1-2 risk factor The calculation of chance of developing a cardiovascular disease within the following 10 years, showed that 63% had < 10%, with levels of blood pressure and lipid improvements, but through NCDS campaign, in 2014 the composite risk factors showed in screen employees 52.0% had 3-5risk factors and 45.8%had 1-2 risk factors. 2. In 2014, total number of 5149 employees) were screened by NCDS campaign launched with primary health care centres (early detection clinics),. Out of 5149 employees ,83.3% were Bahraini citizens and 16.2% were non-Bahraini, 43.8% male and 56.2% female, wait circumference by sex 57.2% in male and 84.6% in female, 86.6% of the were referred to their local health centres. 40% of the screened were overweight and 33.5% obese, and mainly highlight in most vulnerable women to a healthy lifestyle, were referred for follow up in the nutritional clinic, encouragement physical activity, healthy diets, enhance awareness sessions in impact of obesity in their equity of their life 3. The national anti-tobacco committee launched with primary health care quit smoking clinics, the result (during 2014-july 2015) showed in males there was 13% quit, and in the females, it was 50%. Anti-tobacco Committee Collaborate with the competent authorities inside and outside the Ministry of Health to facilitate the implementation of Antismoking Law. 4. Creation of an educated groups, were implemented further programs for most vulnerable people, the results showed that 85% of diabetic patients now know how to measure and control their sugar, 100% can rely on themselves in taking insulin doses, and 21% now know how to measure blood pressure. 5. Following up the outcomes of mortality rates from NCDS and their risk factors had from 2008-2014 showed a reduction in the rate of death due to hypertensive, pulmonary diseases but increase in incidence of diabetes disease and its complications, which is major challenges, need refocus in a comprehensive set of health, more detection of diabetes disease, update their treatment and rehabilitation more NCDS campaign, health promotion activates and follow up.

 9. What were the main obstacles encountered and how were they overcome?
If the health workers in government and private organizations and community were not collaborated together to provide competent care, patients were at higher risk of having negative health consequences, receiving poor quality care, or being dissatisfied with their care. The following points were the main obstacles encountered during the implementation of the project and overcome: • Inadequate Staff and staff resistance to change their roles, which overcame by empower them through training more nursing staff, workshops, field visits to their work place and involved them during the project implementation, participated in decision and solutions to the obstacles during the application. • Lack of follow up in the health system for detecting early risk factors, which overcame by review and updated the polices and a clinical guideline for the staff. • Loss of the visual signs, educational leaflet and posters for tracks the placed in the health center for the availability of the early detection clinic, which re-arrange them back through continuous field visits by the team of project to the health centers. • The most vulnerable people were loss their follow up, the team of the project created a clear mechanism to attracted them, follow-up with more awareness, education sessions in impacts of risk factors of NCDS and the important of the early detection. • Reform the indicators for early detected risk factors cases, with adequate information and accountability done by the team of the project which were not available and integrated with public health department, besides the non-communicable diseases clinics indicators, , the outcomes of the NCDS campaign and national health promotion activities which done by health centers collaborated with concerned departments.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Previously, the concept of health care systems was curable, with lack of the service for early detection of risk factors for NCDS, lack of collaboration with concerned sectors to achieve the goals to enhance equality life and decline the morbidity and mortality rate resulting from non-communicable disease. The key benefits of the project were major change in the delivery of services for early detection of risk factors, easy access, responded to the community needs which impact on in their productivity with better quality of life in the following points: • At the level of availability and accessibility of the service to the community it has become present in all primary health care centers in Bahrain, according to their registration to health center, with easy access and communicated with the nurse for their need without appointments or by telephone contact. • Achieved the collaboration between all concerned medical and non-medical sectors and perform their strategic according to their roles to achieve the goals and provide prevention through promotion and awareness programs, and develop an educated healthy client dependent on themselves know the right time to ask for help. • The transition from the phase estimation to forecasting to cover the target group and their need. • Access for the most vulnerable people, creating resource groups (nurse, health educator, educated patient, doctor). To support the patients and their family. • Attract patients with non-communicable disease (pull system) whom attended accident emergency department in Salmaniya hospital, for close follow up in their health centers at non-communicable disease clinic and for re-evaluation. • Strengthen the role of patient to take responsibility for his health as partnership and the transition to the stage of interdependent. • Implemented several promotions of healthy lifestyles programs about the risk factors and their impact and how to overcome them in the celebrations that are held in national and international events in health centers, in malls and work place where the tests done for attract client who are in risk of such non-communicable disease. • Implemented policies and protocols which specify in the roles and responsibilities of the different healthcare providers to encourage client and patient’s management at primary health care other than hospitals. • The continuous assessment of the statistics and indicators for early detection of risk factors clinics in all health centers and for specialized clinics for the cases whom referred to them and to health sectors concerned to continue focus on the achievement of the outcomes of the implementation of awareness programs as needed.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Not applicable

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Special measures put in place to ensure that the initiative benefits to the most vulnerable for non-communicable disease and the creation of knowledge practice groups (nurse, educated, educated patient, doctor), • Early detection services have direct effect on improving women and girls health over all moreover, it provide them prevention of diseases and it complications. • Implemented all policies and protocols which specify roles and responsibilities of the different healthcare to detected the most vulnerable such as woman whom shows high rat in obesity and other risk factors to prevent NCDS and provide management at primary health care other than hospitals. • Implemented several promotions of healthy lifestyles programs about the risk factors and their impact and how to overcome in medical and non-medical sectors. • Create a culture where the most vulnerable people, know the risk factors, aware of their role in the prevention, contributes to the control of his or her illness and to teach others. • availability and accessibility of the service to the most vulnerable people that has become available in their primary health care centers in all areas of Bahrain, which make easy access to communicate with the nurse for any inquiry or need either by attend the clinic without appointments or by telephone contact. • Attract the most vulnerable people (pull system) whom attended accident emergency department in Salmaniya hospital for close follow up in their health care centers at and for re-evaluation.

Contact Information

Institution Name:   Ministry of Health
Institution Type:   Academia  
Contact Person:   Dr. Naeema ALsubaeei
Title:   Consultant for primary health care services and pu  
Telephone/ Fax:   0097339678600
Institution's / Project's Website:  
E-mail:   y.alyousif@pmc.gov.bh  
Address:   Ministry of health p.o.box 12
Postal Code:  
City:   Manama
State/Province:  
Country:  

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