GHF2010 – PS33 – Innovative Strategies for Chronic Disease Management

Session Outline

Parallel session PS33, Wednesday, April 21 2010, 14:00-15:30, Room 2
Chair(s): Pascal Bovet, Institute of Social and Preventive Medicine (IUMSP), University of Lausanne, Switzerland, Janet Voûte, Partnership Advisor to the Assistant Director-General, Non-Communicable Disease Department, World Health Organization, Switzerland
Engaging Primary Healthcare Centres and the Community for Prevention of Non-Communicable Diseases in Resource-Poor Settings
Sanjib Sharma, Internal Medicine, B. P. Koirala Institute of Health Sciences, Nepal
Diabetes and Peer Educator Networks in Cambodia
Maurits Van Pelt, Director, MoPoTsyo Patient Information Centre, Cambodia
How to Improve Retention Rates in NCCD Programmes in Rural Africa: The TAHADIRA Trial
Niklaus Labhardt, Swiss Tropical Institute, University of Basel, Switzerland
The National Health Fund: An Innovative Financing Strategy for the Management of Chronic Diseases 
Anya Cushnie, Policy and Practice, Royal Tropical Institute, The Netherlands

Session Documents

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Session Video

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Session Report

Submitted by: Yunjin Moon (ICVolunteers); Contributors: Lura Pollozhani (ICVolunteers)

Photo by John Brownlee,

What are the things we can do when resources are scarce? In low-income countries, the lack of financial and human resources leads to serious consequences for health. Three different experts discussed innovative strategies for managing chronic diseases in the context of Nepal, Cambodia and Cameroon. The session was held under the chairmanship of Pascal Bovet from the Institute of Social and Preventive Medicine at the University of Lausanne. The significance of involving the community and integrating care of chronic diseases in nurse-led, routine primary health care was emphasised. In conclusion, the session stressed the creation of knowledge and networks.

Mr. Sanjib Sharman, from the Koirala Institute of Health Sciences, shared his experiences in Nepal. He highlighted the importance of engaging primary healthcare centres and communities, which have limited financial and human resources, in preventing non-communicable diseases. He is very concerned that most people come to hospital when their illness has reached a serious stage. Fully 87.7% of the first-detected diabetic patients already have serious complications. “If you want to treat them you need to involve them”, said Mr. Sharman. An awareness and education programme for the local community is subsequently accompanied by screening and follow-up by volunteers and health workers. More than 20,000 people have been screened for hypertension, diabetes, kidney diseases and cardiovascular risk factors to date. The result shows that the burden of chronic kidney diseases and cardiovascular risk factors is high in Nepal. Yet the acceptable diagnostic yield of the abnormalities suggests that the trial of targeted screening and interventions is feasible and warranted. “What should be done at the initial stage is consolidating the population which is already suffering and finding out what can be done to deal with this problem of hypertension and diabetes”, concluded Mr. Sharman.

The situation in Cambodia, affirmed Mr. Maurits Van Pelt, Director of the MoPoTsyo Centre, has many parallels with Nepal. Nine out of ten people with diabetes are without care. His presentation on Diabetes & Peer Educator Networks was also focused on involving local stakeholders. The underlying principle of the peer educator network is that the former diabetic patients themselves educate others. Detected patients are provided with counselling on lifestyle and coping skills. “It’s like a death sentence to have diabetes in Cambodia.” The patients have to report their progress to their Manager every month, make an appointment with accredited doctors and go through follow-up. More people are self-screening these days and health expenses have decreased. The advantages of the network are manifold: it can open new markets without overload to official health services, restore health and productivity, facilitate earlier diagnosis and care, reduce costs and increase adherence, empower links with professional health service providers, create inter-sector taskforces, and promote financial sustainability. Notwithstanding the challenge of reinforcing formal education and governance, Mr. Van Pelt concluded, peer educators are more credible and have stronger incentives to genuinely promote lifestyle changes. This can be a new defence mechanism of affordability, where ownership of care is shared. “The aspect of changing roles is a particularly interesting factor in promoting participation,” he added, “because those who were once patients alter their perspective by helping others as peer educators.”

Dr. ND Niklaus Labhardt, of the Swiss Tropical Institute, introduced the role of nurse-driven care for hypertension and diabetes in rural Cameroon. Eight semi-rural districts, eight district hospitals, four peripheral physician clinics and seventy five non-physician clinics (NPCs) were included in the study. Nurses were trained for three days and equipment and initial stocks of drugs for NPC facilities were provided. The study was integrated into daily activities, with neither incentives nor additional salary. It was incorporated into the regular pharmacy of the centre. As a result of the study, facilities equipped to measure blood pressure increased from 65% to 100% and fasting plasma glucose (FPG) from 14% to 70%. A significant decrease in systolic blood pressure (SBP) was observed. The overall outcome was proven positive. Mr. Labhardt described the purpose of the study as improvement by proportionate interventions and retention of hypertensive and/or diabetic patients NPC facilities. A treatment contract plus invitation letters or incentives were used as strategies to encourage participation. The incentive group had four months of appointments and one month of treatment for free; the letter group received an invitation letter for missed appointments. He concluded that care of uncomplicated hypertension and diabetes type two can become part of the routine in nurse-led primary health care. It has proven to be feasible and therefore there is no reason for separating it. Whereas supply of drugs and blood glucose strips remains difficult, the main challenge is staff retention.

From the Non-Communicable Disease Department of the World Health Organization (WHO), Ms. Janet Voute, strongly supported the three speakers’ views. “You have all proven that by using these innovative strategies there is the need for the human capital to help treatment.” She appreciated the point made by the speakers that the issue is not only the price of medicines and admitted that this is a very important issue that needs to be communicated to the global health policy makers. Partnership is a crucial pillar of the non-communicable (NCD) action plan of the WHO. “What they do is very connected to what you talked about at regional and community level.” Finding it regrettable that the issue of non-communicable diseases does not receive sufficient attention even though they are a prevalent cause of mortality in many countries, Ms. Voute stressed the necessity of creating a network with the relevant communities as part of a development agenda.

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