Peer Educator Networks for Diabetes and chronic NCD in Cambodia MoPoTsyo Patient Information Centre www.mopotsyo.org
Chronic Non Communicable Diseases % of Overweight in Cambodians rising Mortality from NCD > 50% Double Disease care burden Health care system not adapted
Data1: Stroke in Cambodia put in perspective by Global Burden of Disease 1990-2010 Ischemic Stroke Cambodia High Income C. Low Income C. Incidence +17% -13% +6% Mortality +9% -37% -14% DALY s Lost +4% -34% -16% Hemorrhagic Stroke Incidence +35% -8% +22% Mortality -16% -38% -14% DALY s Lost -17% -39% -25% from Lancet Glob Health 2013;1:e259-81 Rita Krishnamurthi and the group of Chris Murray
Data 2: Cambodia s 1 st STEP Survey 2010 : 8 risk factors 1. Tobacco : 2/3 smoke or use &>50% passive smokers. 2. Alcohol 25% abstainers (10% heavy drinkers) 3. Fruit & vegetables 4% eat <5 per day 4. Physical Activity Median=4 hours/day 5. BMI 23.0-27.5 is 25.5% BMI >27.5 is 6.9% 6. High Blood Pressure 11% 7. Blood Glucose: 1.4% IFBG & 2.9% is Diabetic 8. Cholesterol 20% >200mg/dl
Data 3: Non Communicable Diseases Prevalence estimations High Blood Pressure & Diabetes Mellitus are priority needs; 50% of DM seem to have CKD Health System Design problems: 1. Chronic care is not part of the system design 2. SHP design follows the acute care system Health System Culture problems: 1. Clinical care, Doctor powered, but not patient centered, 2. Risk of verticalisation, biased towards diabetes, but where is hypertension? Health System Resource problems Degrees of medical complexity Cost of NCD Poverty Question: Where are the patients? DM D B R CKD and 1 in 5 has high cholesterol HBP
National Strategies on NCD 1st 2007-2010 Donor aid 2007 until 2009 Donor aid was earmarked for other programs than NCD until 2013 NCD, 1% Services Delivery and Support Services, 21% Administr, 8% MCH, 12% 2 nd is draft 2013-2020 waiting to be signed. Communicable Diseases, 57% From 2013 onwards :15% must be allocated to NCD Q: How to get value for money out of this 15%? A: Chronic patients are dying to be involved!
Part of strategy for chronic NCD Training Diabetic patients to become Peer Educator for other chronic patients.
Involvement of chronic patients Unmet needs create opportunity: Chronic patients meet at the home of the community-based Peer Educator
The strengths of PEN Ministry of Health Mandate & Coverage Plan Operational Districts and health authorities Primary Care (Model A ) People centered Provincial or National Hospitals Clinical care focus (Model B) Specialized doctors in charge Primary objective: HEALTH Health SERVICES provision & utilization Mixes Demand + Supply Supply side driven PEN are pro-active & do Outreach Members Only Follow-Up Passive clinic service until the door Treat anybody (patients) Targets: responsible self-managers Targets: Patients (failures) Chronic continuum of care Must be as low cost as possible Acute treatments only until discharge High prices help finance the Provincial clinic & Hospital Model A + Model B
Popular with patients and good health outcomes 8,369 Diabetic patients (DM cases registered) 7,170 High Blood Pressure patients 20 Pharmacies (Private&Public) contracted 537,883 adults screened for DM 12 Public Hospitals 129 Health C areas with a Peer Educator Discount voucher system created for poor Glucose control : in 9 busiest PE s, 484 DM 69% has HbA1c <7.8% Financing: +/- 40% patients, 60% donors Unit Cost estimations of 2012: 1 screened adult USD 0.07 1 peer educator/year: USD1278.40 1 diabetes patient/year: USD 42.13 1 hypertension p/year: USD 18.37
Some pro s & con s Difficulties & Risks Due to policy vacuum: Vulnerability to claims? Create linkages? Lack of trust & confidence Opportunities Extra HR + motivation Flexibility for innovation General Issues: Verticalisation & narrow scope Gvt is off the hook Hypertension adherence is low Long term Issues: Governance Capture by private interests Informed demand for service evolves into supplier..$$ If large groups of chronic patients pay themselves negotiated fees affordability + voice + pressure for quality Good health outcomes
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