beyond scaling up: organising people with diabetes to manage their disease in cambodia
DESCRIPTION
This presentation was given at the 'Beyond Scaling Up: Pathways to Universal Access' workshop which was held at the Institute of Development Studies, Brighton on the 24-25 May, 2010. This event was co-sponsored by the Future Health Systems Research Programme Consortium and the STEPS Centre. Van Pelt presented on the self management of diabetes in Cambodia through the mopotsyo network.TRANSCRIPT
www.mopotsyo.org 1
A Peer Educator Network
“P.E.N.” for chronic NCD
care + prevention
Self management by People With Diabetes
(PWD)
www.mopotsyo.org 2
Cambodia’s TransitionDouble Disease Burden : CD + Chronic NCD
Low Income Country
13,500,000 population
>1,000,000 chronic NCD
> 255,000 People With Diabetes
90% of PWD get no care
72% of PWD are unaware
International consensus on
LIC health priorities
excludes care for chronic
NCD (spooky WB 2007 report )
www.mopotsyo.org 3
Universal Access to what ?
Scale-up only for CD, not NCD
Allocation of resources to selected needs;
Chronic NCD are left to markets: Market Failure
Annual Health Donor Millions USD
$6.3
$9.3
$43.7
$0.8
Admin
MCH
Comm.Dis.
Non Comm Dis.
www.mopotsyo.org 4
Result of neglect of NCD:
Severe LIC Health System failures
1. Weak agency on behalf of chronic NCD patients.....
2. No one tells them what they need to know
3. Patients bear the full costs of their disease O.O.P.
4. No chronic care, no realistic model except the current
veterinary model (biological patient)
5. Incentives favor disease/cure instead of health & self-help;
6. Standard care package is unaffordable for average citizen;
7. Prescription has been mostly “captured”
8. Not enough trained health professionals
www.mopotsyo.org 5
But, in fact….
plenty of opportunities in LIC !1. If you purchase Out-Of-Pocket…you decide
2. Costs can be slashed, real value can be improved.
3. Enough “patients” who are eager to learn
4. Slow disease means enough life-time left to learn
5. Lay people (non-medical) have less conflict of interest than medical staff in sharing knowledge;
6. Lay people are inter-sectoral
7. Lower cost favors adherence by PWD/chronic patients
8. Set cost to patient at <10% of GNI per capita
9. Lay people are cheap;
10. Task shift to lay people reduces health system stress
www.mopotsyo.org 6
Real Public Policy challenge from NCD in LIC =
to push & favor optimal mixes of these opportunities
Patients become People
who get their act
together, take initiative
and involve in design,
management &
governance of their
problems and
solutions….as part of
the overall health
system
Agency
of
Chronic
patients
Peer Educator in
Public Health Role
Peer Educator in relation
to fellow Patients
Patient Self-Management
4 different levels of self management
Affordability to patient becomes a key
www.mopotsyo.org 7
Pyramid’s Ground Floor:
Self-Management by PWD1. Joining in 6 group lessons at home of PE
2. Get >monthly blood glucose at PE
3. Self-Measuring urine glucose (multiple ways)
4. Result Recording in own patient book
5. Healthy eating (follow food pyramids)
6. Sufficient physical activity
7. Improving maintaining weight
8. Buying medicines monthly + adherence to prescription
9. Not smoking, not heavy drinking
10. Joining in 6-monthly assessments
11. Join in monitoring, community actions
12. ….if HBP, peer educating on HBP…..eventually hosting
Patient Self-Management
www.mopotsyo.org 8
Low mid-level: Peer Educator as Expert PWD
in relation to other PWD
1. Sharing & Counseling,
2. Registering & Assessing
3. Informing & training,
4. Hosting at home
5. Monitoring-service providing-supplying-selling
6. Guiding to professional health services
7. Welcoming & helping to navigate the hospital
8. Confronting…..coaching...blaming…abandoning ..?
Peer Educator in relation
to other Patients
www.mopotsyo.org 9
High-Mid level: Peer Educator as
Public Health Expert
1. Organising Screening chronic NCD
2. Health Promotion on Risk Factor Control
3. Actual facilitator of access to services
4. Local Eyes & Ears: Monitoring and reporting
5. Mobilising members when necessary
Peer Educator in
Public Health Role
www.mopotsyo.org 10
Pyramid’s Top
Self-Management at Agency level
1. Patient representation at health policy level
2. Purchasing public health services (health promotion,
screening, getting better deals, bringing costs down)
3. Revolving Drug Funds (at least governance)
4. (e.g. Laboratory) Services
Agency
Chronic
patients
www.mopotsyo.org 11
Potential Risks/Weaknesses
1. Weak peer : weak patients
2. Narrow view of health
3. What is right balance
between under- and over
incentivising;
4. Compete with professionals
5. Co-morbidities
6. Credibility in diabetes
means local credibility on
more diseases
7. Timely referral
8. Multiple roles: counseling,
sharing, informing, service
providing, explaining,
guiding, welcoming at
hospital, blaming…?
• Standards of
care…...whose?
• Agency Governance /
capture
www.mopotsyo.org 12
In summary: public policy challenge with regards to
care for chronic NCD in Low Income Countries
1. End the “defaitism” on care for chronic NCD.
Yes, it can be a black hole but not if…
2. We help chronic patients in LIC get
themselves organised instead of letting them
down as we do now……....………....No?
www.mopotsyo.org 13
Acknowledgements
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