Integration of Nuclear Medicine into the National Health Care System (West Asia Region)
1. INTRODUCTION Nuclear Medicine had its beginning in the West Asia region as far back as in the early 60's. The first interaction of the Member States with the IAEA, as the distinct group of West Asia, was in 1995 for radioimmunoassay procedures.Therefore, the new initiative of the IAEA is very timely to meet the demands of the region in terms of addressing the health problems that beset the member states at the present time. These problems are in the areas of: cardiovascular disease, diabetes mellitus, infection and cancer. These problems have been brought about mostly by industrialization and urbanization. (pls. see Table 1) Figure 1: Map of West Asia Region
It is known that the Gross Domestic Product (GDP) per capita is high in most of the region, but health prioritization is low in a number of states. It has been noted that Nuclear Medicine facilities and manpower as well as radiopharmaceuticals are available but remain underutilized because of traditional beliefs, fear of radiation, and lack of awareness and education as well as promotion and marketing in the field of Nuclear Medicine. (Table 3) The advantages of Nuclear Medicine are well established. Nuclear Medicine techniques are non-invasive and provide an added feature of physiologic, metabolic and molecular information. They are likewise cost- effective and hence should be integrated into the present health care system of West Asia. The presence of several Nuclear Medicine facilities equipped with modern planar gamma camera and SPECT systems, and most importantly the capability to produce radiopharmaceutical kits (like Iran and Syria) are added features which will contribute in the promotion of Nuclear Medicine to the fullest. However, problems in infrastructure with respect to high quality state of the art equipment, radiopharmaceuticals, trained manpower and quality assurance programs have been identified in several countries of the region. In a few member states, there is lack of basic nuclear facilities. In the field of education, training and research in Nuclear Medicine, there has been also lack of training centers and accreditation programs in some member states as well as standardization of procedural techniques. Overall, there is a lack of general awareness among the user groups about the usefulness of nuclear medicine applications. It was also noted in general that there is a lack of expertise in networking, electronic archiving and storage of patients' data and images. It would be very cost effective to use PC-based Networking and Internet for Tele-Nuclear Medicine among member states and international groups. These are causes of some areas of concern and may need special attention. The assistance provided by the IAEA under RAW/6/010 aims to address the major health problems, as well as support for infrastructures, of West Asia where Nuclear Medicine could play a major role. The project has been designed in the hope that there will be active participation and utmost cooperation among the Member States and according to the Agency's Technical Cooperation Strategy. STRATEGIC CONTEXT:
The objective of the IAEA as stipulated in the Statute (Article-II) is: …To accelerate and enlarge the contribution of atomic energy for peace, health and prosperity throughout the world……. In other words, the objective of the Agency, apart from promoting peace, is also to contribute to the socio-economic development of the world. This objective is to be met through the following function captured in Article IIIA of the Statute: "To encourage and assist research on, and the development and practical application of atomic energy for peaceful uses and if requested to do so, to act as an intermediary for the purposes of securing the performance of services or the supplying of equipment, or facilities by one member of the Agency for another; and perform any operation or service useful in Research on or development or practical application of; atomic energy for peaceful purposes…." In line with the above, the mandate of the proposed thematic project on health care is defined as follows: To accelerate and enlarge the contribution of nuclear medicine for health and prosperity in W. Asia .
The program's vision is to be responsive to the health challenges in West Asia Member States and assist them in the integration of the nuclear medicine technology in the health care system to the best benefit of people in West Asia. The project visualizes a minimum annual growth rate of 5% in the application of nuclear medicine procedures in the areas being addressed by the thematic project. One consultant from the region will be responsible for maintaining a database in order to determine this factor at the end of the project in the year 2004.
A SWOT analysis of the status of nuclear medicine in West Asia revealed the following with respect to the various elements of vision: Strengths of the proposed program:
Weaknesses of the proposed program:
Possibilities (Opportunities):
Threats:
GOVERNING PRINCIPLES:
PRIORITY SETTING: Criteria for priority setting: The Thematic Project will use the following criteria in setting priorities:
Prioritization of problems to be addressed and tasks to be undertaken under the programme: After an in-depth discussion of the most relevant health problems in the West Asia region, a list of diseases was prepared. The list included: coronary artery disease, Diabetes Mellitus, infection and infectious diseases, cancers and degenerative disorders. This was followed by preparation of an inventory of the nuclear medical facilities for West Asia. These facilities ranged from adequately staffed and equipped Nuclear Medicine departments to departments with bare minimum basic requirements. Subsequently an analysis of nuclear medical technology capability for the region was carried out. This was based on detailed consideration of availability of and accessibility to relevant radiopharmaceuticals, appropriate nuclear medicine equipment, level of accountability of technology among the user group (clinicians) and the cost-effectiveness of a given investigation to solve medical problems. A synthesis of all the above points resulted in a set of health issues that could be addressed effectively by the available nuclear medicine capabilities in the region (Pls. see Tables 2). STRATEGIC OBJECTIVES, OUTCOMES AND PERFORMANCE INDICATORS
To contribute to the overall improvement of health care in West Asia using Nuclear Medicine techniques. b.1 Clinical b.1.1. To improve on the management of diabetes and its complications: To introduce/expand the application of various established diagnostic and therapeutic radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective radiopharmaceuticals and reagents. Outcome: Member States using new and adapted technology in the management of diabetes mellitus and prevention of its complications. Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the management of diabetes mellitus. Number of new techniques introduced. Number of new radiopharmaceuticals and reagents used and number of patients investigated and treated. b.1.2 To improve on the management of coronary artery disease. To introduce/expand the application of various established diagnostic and therapeutic radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective radiopharmaceuticals like Sistamibi, Rhenium-188 etc. Outcome: Member States using new and adapted technology in the management of coronary artery disease. Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the management of coronary artery disease. Number of new techniques introduced. Number of new radiopharmaceuticals used and number of patients investigated and treated. b.1.3 To improve on the management of thyroid cancer. To introduce/expand the application of various established diagnostic and therapeutic radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective radiopharmaceuticals and reagents. Outcome: Member States using new and adapted technology in the management of thyroid cancer. Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the management of thyroid cancer. Number of new techniques introduced. Number of new radiopharmaceuticals used and number of patients investigated and treated. b.1.4 To improve on the management of general bacterial infections. To introduce/expand/promote the application of various established diagnostic radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective radiopharmaceuticals like Tc-infecton, Tc-HIg, Ga-67, Indium-111 etc. Outcome: Member States using new and adapted technology in the management of general bacterial infections. Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the management of general bacterial infections. Number of new techniques introduced. Number of new radiopharmaceuticals used and number of patients investigated and treated. b.1.5 To improve on the management of H. pylori infection. To introduce/expand the application of various established diagnostic radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective radiopharmaceuticals. Outcome: Member States using new and adapted technology in the management of H. pylori infection. Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the management of H. pylori infection. Number of new techniques introduced. Number of new radiopharmaceuticals used and number of patients investigated and treated. b.1.6 To improve on the management of breast cancer. To introduce/expand the application of various established diagnostic and interventional radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective radiopharmaceuticals. Outcome: Member States using new and adapted technology in the management of breast cancer. Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the management of breast cancer. Number of new techniques introduced. Number of new radiopharmaceuticals used and number of patients investigated and treated. b.1.7 Improving on the management of cancers in general (prostate, lymphoma, lung etc.) To introduce/expand the application of various established diagnostic and therapeutic radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective radiopharmaceuticals. Outcome: Member States using new and adapted technology in the management of cancer. Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the management of cancer. Number of new techniques introduced. Number of new radiopharmaceuticals used and number of patients investigated and treated. b.1.8 Improving on the treatment/ palliation of metastatic bone pain To introduce/expand the application of various established therapeutic radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective therapeutic radiopharmaceuticals. Outcome: Member States using new and adapted technology in the palliation of metastatic bone pain. Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the palliative treatment of metastatic bone pain. Number of new techniques introduced. Number of new radiopharmaceuticals used and number of patients investigated and treated. b.1.9 To Improve on the treatment of joint diseases. To introduce/expand the application of various established therapeutic radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective therapeutic radiopharmaceuticals. Outcome: Member States using new and adapted technology in the treatment of joint diseases. Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the treatment of joint diseases. Number of new techniques introduced. Number of new radiopharmaceuticals used and number of patients investigated and treated. B.2 Human Resources: b.2.1 Improving Regional Human resources To promote continuous professional development of nuclear medicine health professionals through group training, expert missions and improvement of information and communication technologies (ICT). Organize a number of regional and national training courses on topics enumerated in column b.1. Improve ICT in West Asia. Organize expert missions on specific areas for on-site training. Outcome: Training of a large number of nuclear medicine physicians, technologists and physicists. Improvement in the quality of nuclear medicine practice in the region. Performance indicators: Number of medical doctors, technologists and physicists trained. Number of new investigations/therapeutic procedures introduced. Number of regional/national training courses conducted. Number of expert missions fielded. b.3. Instrumentation b.3.1 Improving the maintenance and up-gradation of existing nuclear equipment in the West Asia countries: Carry out a thorough assessment of the status of existing nuclear equipment in the region, preparation of a database. Provide assistance to institutions in the Member States for maintenance and upgradation of nuclear medicine equipment by developing a link with the other new/on-going TC projects in the region on instrumentation. Outcome: Training of nuclear medicine technologists, engineers and physicists on preventive maintenance, quality assurance and upgradation of nuclear equipment. Performance indicators: Availability of a database. Number of technologists trained. Number of gamma cameras up-graded. b.3.2 Improving quality assurance and technical support facilities To create an awareness among the medical community about the importance of quality assurance in nuclear medicine and educating them on how to avail the technical expertise and support from the IAEA to further the growth of quality nuclear medicine practice in the region. Outcome: Increasing awareness about quality assurance among the nuclear medicine community in West Asia. Enhanced standard of nuclear medicine practice. Performance indicators: Number of nuclear medicine centers in the region incorporating quality assurance programmes in their routine day to day nuclear medicine practice. b.3.3 Improving technical assistance to the Member States in the procurement of appropriate equipment. To educate and advise the professionals in the Member States on preparation of specifications for the procurement of various nuclear medicine equipment including gamma cameras, SPECT systems, computers, gamma probes, radiation monitoring devices etc. To advise on how to carry out acceptance tests for equipment. Outcome: Increasing awareness about current trends in nuclear equipment and various facilities and options offered by the manufacturers. Performance indicators: Number of nuclear medicine professionals trained in the field. b.4 Radiopharmaceuticals b.4.1 Introducing/Improving in-house preparation of routinely used radiopharmaceutical kits: Prepare a status report on the current practice of hospital radiopharmacy in the region through a task force with a specific mandate. Field expert missions to advise individual nuclear medicine departments to prepare their own radiopharmacy cold kits and Quality Assurance. To assist the West Asia Member States for the procurement of radiopharmaceutical kits like Sm-153, Ga-67, P-32, Sistamibi etc. at a reasonable price by identifying alternate sources and suppliers. Outcome: Increasing number of nuclear medicine departments becoming self sufficient in routinely used radiopharmaceuticals like Tc-99m, DTPA, MDP, Pyrophosphotate, Phytate etc.
Performance indicators: Formation of a task force. Report of the task force. Number of nuclear medicine centers in the region doing their own hospital radiopharmacy. 6. STRATEGIES FOR PROGRAMME DELIVERY In order to have an impact the activities must be intense, broad based, repetitive and encompass all fields of nuclear medicine practice. The following strategies and activities are recommended for programme delivery. At the regional level Regional group training programmes (training courses, workshops, seminars etc.) Multi-centre studies Task force meetings Information and communication technology (ICT) based programmes Equipment support At the national levels National group training programmes (training courses, workshops, seminars etc.) National awareness meetings Expert missions Short term fellowships Equipment support Reagents supply 7. COORDINATION OF THE PROGRAMME The Thematic Project will be coordinated by the IAEA from its headquarter at Vienna with the Project and Technical Officers responsible for the project. Each Member State will nominate one National Project Co-ordinator, preferably a senior nuclear medicine physician with broad expertise and experience in both in-vivo and in-vitro nuclear medicine. The National Project Co-ordinator may induct sub-coordinators from other fields like radioimmunoassay, instrumentation, technologist training etc. as and when necessary. The National Project Co-ordinators will be responsible for coordinating the activities of the Thematic Project in their respective countries, interact with the project and technical officers of the IAEA and participate in the National Co-ordinators’meetings of the Thematic Project. 8. PARTICIPATING COUNTRIES: Iran, Jordan, Kuwait, Qatar, Syria, UAE, Uzbekistan and Yemen.
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