CambodiaDiabetes self-help groups

MoPoTsyo Patient Information Centre

Maurits van Pelt

Our Main Message

Diabetes Peer Educator networks

should be integrated in

the primary health care system

But most Health Policy makers say

“Chronic Disease interventions are not cost effective”

“Chronic Diseases are a black hole, especially for secondary prevention

among patients……..”

External assistance focus by programs budgets only 1% for Non Communicable Diseases (NCD) although they cause more than half of disease and death

8%

9%

58%

1%24%

P1 – Mgt&AdminP2 – MCHP3 – CDCP4 – NCDP5 – Serv Del

Cambodia Health Sector Donors .

We say: This lack of policies….breeds poverty!

Markets move fast to grab opportunities;

Markets create confusing information;

Product safety concerns increase Willingness-to-Pay

Biggest spender on product promotion wins

Consumers do not know what would be their best choice

The market’s natural response is supply side centred;

All factors combined: It leaves many unmet needs…

Premature disability replaces productivity

Elements of the Diabetes context

Lack of trained Doctors and Nurses;After training, they are severely underpaid;Public health system is only for acute cases;Chronic patients supplement health staff income…;A profitable patient is an ignorant one…;

Question: If formal health staff has no incentive to transfer knowledge + skills to chronic patients……then who has ?

Diabetics are: Rich.. ? Overweight.. ? Old.. ? Too low educated to self-manage?

We often assume that we understand the problems

We set priorities for low income countries….

This can be terrifying..

Proposed thesis :

“Diabetes Peer Educator Networks are a worthwhile investment for Low Income

Countries in Asia like Cambodia”

Demand side organisation in NCD

A Diabetes Peer Educator Network in an Operational District (a.k.a. zône de santé) led by a manager (a.k.a. DPM) in charge of community

based Diabetes Peer Educators

The Diabetes Peer Educator

Is a self-managing Diabetes patient who may have any profession except health service provider &

Is Literate Is Volunteer Was trained 6 weeks in Diabetes Peer Education Has passed the Peer Educator exam

What do DM patients actually need ?

A) Understand how they can keep their blood glucose and blood pressure always within the safe margins:

• lifestyle (type of food, exercise, kg) • right medication• self-measuring

B) Understand how they can keep this affordable;

Immediate Effects: Distribute urine glucose

strips for self - testing: one per adult;

Detect DM earlier (70% did not know it)

Increase reservoir of aware DM from 30% to 41% in Yr 1 (Yr 2 > 50%)

Peer Educator Assesses: Presence of Urine glucose Fasting Blood Glucose Blood Pressure Heart rate BMI Waist circumference Feet inspection, nerve d. etc.

…..reports to her/his DPM

Benefit 1: Earlier Detection

Benefit 2:

DM patients self-testing urine during last month

15%1%

84%

Did not do urine self test

Did 1 or 2 urine self tests

Did more than 2 urine selftests

Transfers Knowledge + skills

Benefit 3:

BMI Changes in rural program

66%

11%

23%

weight improved becoming too skinny / even skinnier becoming too fat / even fatter

Lifestyle changes <12 months

Benefit 4: No stress on health services

• Benefit 4:Rural Program: the number of diabetes Dr consultations during the first 15 months in the first 388 registered diabetics

01

23

45

67

891011

121314

15

0% 10% 20% 30% 40% 50%

nr

of

med

ical

co

nsu

ltat

ion

s

Avoiding early medicalisation728 Medical Consultations in 15 months Average 1.8 consult per patient, 160 DM did not yet meet with the Doctor

Benefit 5: Cost Containment

1 million patients: 350.000 DM + 700.000 High BP

Annual drug bill remains too high if supply side controls while the demand side pays (USD 250 million).

Annual drug bill can be low, if demand side controls AND pays (USD 40 million, is mostly affordable…);

There will still be a role for targeted subsidies for new poor DM;

Benefit 6: Quality of Life

DM Patients feel better because they:

- Regain control over their health- Spend less than before on health care- Can get health information that they need

Benefit 7:

133 randomly selected DM patients more than 3 months registered in Rural Program Fasting Blood Glucose (norm is FBG<126 mg/dl)

FBG < 12652%

FBG 126 - 20043%

FBG > 2005%

Biological outcomes

Benefit 7:

Ang Roka OD HbA1c result July 2008(124 DM patients randomized)

67%

16%

17%

HbA1c < 7.5%

7.5 < HbA1c < 9%

HbA1c >9%

Overall lower BG

Benefit 7: Blood Pressure among DM

-10.0%

10.0%

30.0%

50.0%

Rural Diabetics Blood Pressure after 6 months (N=133)

baseline 45.1% 36.1% 18.7%

after 6 months 45.1% 37.3% 17.6%

Syst≤130 or Diast≤75

Syst≤140 Diast.≤90

Syst>140 or Diast>90

Example Ang Roka OD 133.000 inhabitants

Example Ang Roka OD 133.000 inhabitants

Peer Educator network running costs

USD 6700 per year for 665 (2nd year-) diabetics

USD 10 per diabetic per year at current levels

A Peer A Day Keeps the Doctor Away!

www.mopotsyo.org