Pandemic Preparedness Clinics

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

The Ministry of Health (MOH) has roped in primary care physicians to help treat flu cases and mitigate against community spread. ?Pandemic Preparedness Clinics? (PPCs), recruited on a voluntary basis and rewarded with incentives, now form a vital part of the Singapore?s National Flu Pandemic Response Framework.

Purpose of health policy or idea

Whenever there is sustained community transmission of an infectious disease such as SARS or Influenza, hospitals can be expected to be overwhelmed and unable to cope with the large numbers who fall sick. Learning from the experience of the 2003 SARS outbreak, when the involvement of primary healthcare providers (especially from the private sector) in mounting the national response was less than satisfactory, the Ministry of Health has decided to mobilize primary care clinics early as part of its national response to the ongoing Influenza A (H1N1) global pandemic.   

Since May 2009, participating primary care clinics are being designated as"Pandemic Preparedness Clinics" (PPCs) to signify that they are supported by the Ministry of Health with Personal Protection Equipment and antivirals (e.g. Tamiflu) from the national stockpile, and enlisted to help manage the flu outbreak in the community. All government polyclinics (which see 20% of daily outpatient cases) are automatically part of the PPC framework, but the participation of private clinics (which see the majority of outpatients) is voluntary.  

PPC doctors and staff undergo training seminars and workshops to update themselves on the recommended clinical protocols and practices, including N95 mask fitting. They are required to adhere to MOH's prevailing guidelines, which in the case of the present H1N1 outbreak, include stocking up on at least a week's supply of Personal Protection Equipment and ensuring their clinic set-up is such that they are able to separate flu and fever cases from the other patients. Members of the public who develop flu-like symptoms or influenza-like illness (e.g. fever, cough, sore-throat, runny nose) are advised to visit the nearest PPC or polyclinic for initial assessment and treatment. A government website ( http://www.street-directory.com/hpb.ppc) identifies the exact location of these clinics so that the public are able to go to the ones nearest to their homes.  

Primary care doctors would exercise their clinical judgment in prescribing anti-virals (e.g. Tamiflu) on a case by case basis, taking into account the patient's risk of developing influenza related complications, the prevalence of Influenza A (H1N1) in the community and after weighing the risks and benefits of treatment. Depending on the severity of their illness and other risk factors, patients may be referred to the hospital for further management. The hospitals would focus on managing more complex cases.  

The decision to activate or stand down this framework will be made by MOH based on surveillance data.

Figure 1: H1N1 ready symbol of Pandemic Preparedness Clinics

Main points

Main objectives

Being scattered throughout the island, PPCs help ensure easy access of patients with flu-like illnesses to medical assessment and treatment. The public can recognise PPC clinics through a prominent decal displaying a "H1N1 ready" symbol, pasted in front of the clinic (see figure 1).   

Since there are 18 polyclinics throughout the island, the GP clinics are also being organised into groups according to 18 clinic zones created around the 18 polyclinics, according to geographical location. Each polyclinic will provide advice and logistical support to the GP clinics within the zone.

Type of incentives

As incentive, PPCs receive the following: 

1. Free supply of PPE, according to the norms in Table 1.
2. Free supply of Tamiflu for clinic staff, in accordance to prevailing MOH guidelines for the appropriate use of Tamiflu by clinic staff. 
3. Assured supply of Tamiflu from the national stockpile for treating patients, to be prescribed based on MOH guidelines. PPCs will be charged for this Tamiflu supply at a price that is standardized across all clinics, including the government-run polyclinics.
4. Free publicity regarding PPC status (including listing on MOH website and free supply of PPC decals for easy identification by members of the public).

Table 1: PPE norms

	Per week per clinic	Per re-supply (4 wks) per clinic
N 95 Mask	40	160
Surgical Mask	100	400
Gown	30	120
Gloves	700	2800

 

Commitment from Pandemic Preparedness Clinics

In return, PPCs are expected to: 

1. comply with MOH guidelines on the use of Tamiflu for treatment of patients. In addition, the use of Tamiflu has to be recorded real-time using the MOH's portal called "Health Check System" through internet connection from the clinic.
2. Maintain the same operating hours as before the pandemic began. Clinic are to inform MOH via email if they need to close due to unforeseen circumstances.
3. Comply with infection control measures spelt out in MOH advisories.
4. maintain an active email account, and provide the email address to MOH to facilitate speedy communications particularly during times of pandemic.

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Political and economic background

Singapore responded successfully to the SARS crisis of 2003 and even earned open praise from the World Health Organization for its swift and decisive measures to contain the SARS outbreak, including:

1. a robust, highly coordinated and proactive strategy to the SARS outbreak that has involved preventive measures such as closure of schools, home quarantine restrictions, and the prompt tracking of SARS transmissions; 
2. an open and transparent approach towards release of information about SARS, outreach programs to the community and business sector, and willingness to work with international health care authorities; 
3. ground-breaking use of technology, such as thermal imaging sensors at airports, in a bid to balance the needs for border checks with the desire to maintain international freedom of travel; 
4. a medical system that is providing SARS victims with world-class treatment; and 
5. an emphasis on providing a clean and hygienic environment within Singapore that mitigates the potential for the spread of any disease, including SARS. 

Since then, significant investments have been made to strengthen institutional capabilities for the surveillance, detection, diagnosis, emergency mechanism and treatment of emerging infectious diseases.  

But mistakes there were, and among the lessons learnt is the importance of involving the frontline general practitioners (GP) early in any national response plan. GPs see 80% of daily outpatient attendances in Singapore and therefore act as forefront fighters - no less than specialists in the hospitals - in infectious disease outbreaks.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Initiators of idea/main actors

• Government

• Providers

• Patients, Consumers

Approach of idea

The approach of the idea is described as:
new:

Stakeholder positions

The Singapore Medical Association and College of Family Physicians are enthusiastic and supportive of the idea, as are the majority of general practitioners, who see it as part of their role to step up in times of crisis and to serve the community.  

The public is also assured that their neighbourhood clinics are well prepared, and the healthcare workers in the small clinics (usually numbering 3-4) also feel assured that they are receiving the same level of personal protection as their counterparts in the government polyclinics. 

Actors and positions

Government
Ministry of Health	very supportive		strongly opposed
College of General Practitioners	very supportive		strongly opposed
Providers
Private GP´s	very supportive		strongly opposed
Government Polyclinics	very supportive		strongly opposed
Patients, Consumers
General Public	very supportive		strongly opposed

Actors and influence

Government
Ministry of Health	very strong		none
College of General Practitioners	very strong		none
Providers
Private GP´s	very strong		none
Government Polyclinics	very strong		none
Patients, Consumers
General Public	very strong		none

Positions and Influences at a glance

Adoption and implementation

Within the first week of the scheme's introduction in May 2009, 800 clinics (out of a total of about 1200) had signed up. The first workshop in May 2009 attracted a full house of over 200 participants despite the short notice given. Experts from both the MOH and the Professional Associations (SMA and CFPS) gave presentations on the latest H1N1 updates, pointers on how to deal with suspected cases, and tips on how to organise a PPC clinic, and explained the logistics supply chain and Health Check System. There was also on-site mask fitting by N95 suppliers. By September 2009, 603 clinics had been designated "pandemic ready".  

Expected outcome

Singapore confirmed its first case of Influenza A (H1N1) on 27 May 2009. As of October 2009, an estimated 700,000 Singaporeans have been infected and 18 deaths have been attributed to the virus. 

At the time of writing, the Ministry of Health (MOH) has secured supplies from GlaxoSmithKline (GSK) for one million doses of its Influenza A (H1N1) vaccine. This is part of a phased and diversified approach in securing sufficient quantities of the vaccine for the Singapore population. The vaccines are expected for delivery by the end of this year, but no decision has been taken on mass immunization yet.   

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

The exercise served to connect the MOH directly with general practitioners who were required to respond through the Health Check System, which is an important communication tool in times of crisis. For instance, they will play a crucial role should vaccination become a national policy. 

References

Sources of Information

• MOH & SMA. Pandemic Preparedness Clinics - revised Primary Care Flu Pandemic Response Framework SMA News June 2009

Author/s and/or contributors to this survey

Lim Meng Kin

National Univrsity of Singapore

Suggested citation for this online article

Lim Meng Kin. "Pandemic Preparedness Clinics". Health Policy Monitor, 01/10/2009. Available at http://www.hpm.org/survey/sg/a14/4