Geneva Health Forum Archive

Browse and download abstracts, posters, documents and videos from past editions of the GHF

ELIPS: Multi-Dimensional Prevention Program in Switzerland after an Acute Coronary Syndrome

Author(s): Pierre-Frederic Keller1, David Carballo1, Sebastian Carballo3, François Mach1
Affiliation(s): 1Cardiology Division, Geneva University Hospitals, Geneva, Switzerland, 2Division of General Internal Medicine, Geneva, Switzerland
Name your project or intiative: ELIPS: multi-dimensional prevention program after an Acute Coronary Syndrome
1st country of focus: Switzerland
Additional countries of focus: Industrialized countries
Relevant to the conference theme: Non-communicable chronic diseases
Summary: The ELIPS program was designed to improve prescription rates by physicians and long term medication adherence by patients. Novel tools of information were specifically created for patients to improve the quality of information: a website, a DVD, a wall chart for hospitals, flyers and an application for smartphones. Moreover a specific training course in motivational interviewing dedicated to caregivers was developed including a web-platform e-learning and face-to-face training courses. Finally ELIPS network includes a discharge treatment card, a media campaign and information meetings for physicians. The media campaign in Switzerland was carried out to reinforce the deployment of the ELIPS program.
What challenges does your project address and why is it of importance?: Audits of practice reveal suboptimal control of cardiovascular risk factors and under use of evidence-based cardiovascular medications after an Acute Coronary Syndrome. Based on our systematic review of tested interventions, we developed the ELIPS program targeting patients, caregivers and healthcare system
How have you addressed these challenges? Do you see a solution?: To demonstrate the benefits of the ELIPS program on recurrence rate of cardiovascular events, the ELIPS programme has been first implemented in a Swiss healthcare network.
How do you know whether you have made a difference?: A multicenter clinical study is currently underway including prospectively a total of 2400 patients before and after the implementation of the ELIPS program with a follow-up of 12 months
Have you or the project mobilized others and if so, who, why and how?: We have mobilized all Swiss university cardiology centers. And doing so we have managed to deploy the program in all of these centers and this has involved the training of over 500 nurses in motivational interviewing, the diffusion of all informations tools (DVD, smartphone application, didactic wall chart, flyers, discharge treatment program) in 4 languages. We have also organized information meetings for referring hospitals, outpatient practionners, and rehabilitation centers and all the tools of information were also available for all caregivers treating these patients in Switzerland
When your donor funding runs out how will your idea continue to live?: Projects for future funding are currently being investigated and developed by an external consulting group. The Swiss Heart Foundation will include the ELIPS program in the catalogue of its services.

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Slowing Down Non-Communicable Chronic Diseases in Mali with Inclusive Education and Learning Nests

Author(s): Maryvette Balcou-Debussche1, Xavier Debussche2, Stéphane Besançon3
Affiliation(s): 1LCF-UMR 8143 CNRS, Université de La Réunion, Saint-Denis, La Réunion, 2CHU de La Réunion, Saint-Denis, La Réunion, 3ONG Santé Diabète, Bamako, Mali
Name your project or intiative: Slowing down the burden of non-communicable chronic diseases by developing an inclusive educational approach: the learning nests
1st country of focus: Mali
Additional countries of focus: Burundi, Reunion, Mauritius, Botswana, Mayotte, French Guiana
Relevant to the conference theme: Non-communicable chronic diseases
Summary: To face the burden of non-communicable chronic diseases efficient and feasible actions devoted to prevention and education are urgently needed. Emerging from a co-construction of expertise of social scientists and medical world, the theoretically-based learning nest approach is matched to the special characteristics of chronic diseases in plural contexts. Complete sets of educational materials can be used for small groups of learners at close quarters by trained social workers or peer educators. The first implementations in Africa and Indian Ocean have yielded results that open the way to a constructive reflection on the issues of prevention in chronic diseases.
What challenges does your project address and why is it of importance?: Most African countries are faced with contagious diseases (HIV, malaria…) but recent data show the extensive although silent burden of non-communicable diseases. This progression arises in the general context where professionals and institutions are primarily focused on curative aspects, and available drugs are costly. Moreover, human resources for health are scarce and the external resources coming via ONG and/or experts are overall characterized by the translation of questionable occidental models that cannot easily integrate actual culture, languages, literacy, and social dimensions. African countries can nevertheless mobilize major assets, such as community networks and social dynamics, in order to drive, anticipate and convey health and prevention. The present project takes into account the gaps, but also the assets that can be utilised for a sustainable approach, consistent with the localised environment. The challenge consists in changing the predominant paradigm of health care: from the focus on communicable diseases to the consideration of chronic diseases; from the curative perspective to the preventive and educative one; from the costly prevalence studies to the rapid development of actions with the harvest of relevant indicators, and consideration of actors involved in social dynamics (social workers, peers educators).
How have you addressed these challenges? Do you see a solution?: The development the learning nests aims to allow the implementation of preventive and educative actions for adults with high risk of cardiovascular diseases. The action is based on complete sets of educational material for educators and learners, which have been validated by experts from biomedical sciences and from human and social sciences. The approach is focused on the cognitive work of learners for the appropriation of knowledge in group sessions taking into account the specificity of individuals and their integrative environment, as well as conditions needed for action. Sessions take place in a comfortable and non-conflictual environment designed to encourage the emergence of new knowledge and self-esteem (hatching), self efficacy and autonomy in the social, cultural, and economic environments of persons at risk. The development of this approach relies on the identification of existing organizations and voluntary people. During a short-term pragmatic training (3 days), actors focus on the cognitive issues and on the educational approach that aims to promote a long-lasting appropriation of knowledge by the persons concerned with non-communicable diseases. In a first self-assessment session, patients work on their own clinical and biological factors that influence health maintenance (blood glucose, blood pressure, lipids, weight, waist circumference, smoking), before looking at lifestyle effects, and the specific impact of eventual changes, the focus moves to scrutinizing the feasibility of action planning and implementation in real life, taking into account all individual, social, and contextual dimensions. At the end of the session, 2 other complementary sessions are scheduled: physical activity - food and control of fat intake. Sessions are based on specific booklets, for learners and for educators, with a curriculum written protocol (EPMC booklets; Education Prévention des Maladies Chroniques), including those with literacy difficulties. In each session, patients will become aware of issues they can manage on a priority basis, taking account not only of medical dimensions (level of HbA1c, other risk factors, treatment, etc.), but also psycho-sociological, contextual, environmental, cultural and economic dimensions. This approach is possible thanks to attractive and clear supports, presented in the form of educational notebooks, a current and constant adaptation of supports for various contexts in Africa, and continuous work for more than 10 years to model an educational successful basic cycle, along with the potential fast distribution of the information and its relevance for the short and longterm. Finally, the approach integrates the possibility of working everywhere, with a single requisite equipment: supports notebooks and pencils.
How do you know whether you have made a difference?: The learning nests have been trialed from 2004 to 2011, with more than 10 000 persons exposed to cardiovascular and renal diseases, in various settings and countries (Reunion island, Mauritius, Burundi, Mali, French Guiana, Botswana, Comoros). Training sessions of educators have involved more than 500 health educators: health professionals, social workers and peer educators.  In Mali, peers educators have been trained during 3 days sessions and involved in educational sessions for persons with diabetes in Bamako and Sikasso community health centers for more than one year. A randomized control trial is being conducted, with 4 educational sessions: control of cardiovascular risk (blood pressure, waist circumference, smoking, cholesterol, glycaemia), control of Food (balance, fat, carbohydrates), physical activity management, insulin management carried out. 150 persons have been educated.  In Burundi, during the 2 months following the first training session of educators, 12 educational sessions have been held involving 109 subjects at high risk for CVD, and 7 among the ten health structures of the capital Bujumbura (hospitals, health community centers, NGO, diabetic patients associations). During the first six months a total of 60 sessions involving 567 subjetcs, and at 20 months, 2000 subjects have beneficiated from educational sessions. In Reunion, From 2004 to 2007, 394 educational sessions with a mean of 7 high risk patients have been completed : a total of 1220 patients were involved in 1 to 3 sessions (CV risk: 1009 subjects; Food regulation and fats: 837 subjects; exercise: 501 subjects).  Results in terms of intermediate health indicators (blood glucose, blood pressure, waist circumference) are positive and encouraging, as well as the evolution of the total health modifiable risk (calculated on the basis of health indicators collected during educational sessions). Trained educators continue to invest in group education for patients and evolve in education skills and practices. Presentation of this project has been chosen int the pre-selection of « Ten ideas for Africa » in 2010 by Unesco (16 pre-selected projects).
Have you or the project mobilized others and if so, who, why and how?: The Learning nests approach have been implemented in Mauritus for the structuration of diabetes education programmes (APSA Diabetes Care Centre). In Botswana, the supports booklets have been adapted and translated in English and in Setswana, and ministry of heath implemented the project in 2010-2011 for diabetes self-management education and cardiovascular risk prevention. In Mayotte (French Comoros) and in French Guiana, training of educators and health professionals has commenced. 
When your donor funding runs out how will your idea continue to live?: Funding support will help to diffuse the approach in countries who wish to halt the progression of non-communicable chronic diseases, in a long, realist, low-cost way that is adapted to local contexts. This approach is very relevant in towns where new products invade marketplaces, and sedentary lifestyles increase.   The support could take place in diverse forms:- targeting persons who are able to financially support the program.  Training, 1st round, of these ressource persons in order to initiate and implement educational sessions− Development and analysis of first actions and implementations− Training, 2nd round, of resource persons with reflections and feedback on experiences and results.− Diffusion of action and approach via these resource persons. In financial terms, donor funding would thus allow to support the costs generated by− Training− Specific equipment (documentation, internet, computers) − Impression of paper supports − Translation and adaptation to the national and\or regional languages and contexts.

Improving Type 1 Diabetes Management Through Youth Empowerment: Dominican Republic

Author(s): Merith Basey1, Molly Lepeska1
Affiliation(s): 1Ayuda, Arlington, United States,
Name your project or intiative: Improving type 1 diabetes management through youth empowerment
1st country of focus: Dominican Republic
Additional countries of focus: Ecuador
Relevant to the conference theme: Non-communicable chronic diseases
Summary: An organization run for youth by youth, AYUDA’s work is based on the idea that youth can be agents of change in diabetes communities, where a lack of education is as dangerous as a lack of insulin.  With its focus emerging from Latin America, AYUDA works with local diabetes communities in countries like the Dominican Republic and Ecuador, to develop and implement local, sustainable diabetes projects.  AYUDA’s peer learning model uses international volunteers as catalysts to empower local youth living with diabetes to form healthy habits that allow them to improve the management of their diabetes and live happier lives.
What challenges does your project address and why is it of importance?: Today 366 million people are living with diabetes; 70% of whom live in low- and middle-income countries where 80% of deaths occur as a result of non-communicable diseases (NCDs).  In Latin America and the Caribbean, NCDs and diabetes are estimated to cause as much as 60% of the mortality in the region. Approximately 20% of the total population in Latin American and the Caribbean is aged 15 and 24 with an average of 39% living in poverty. Youth is when people engage in high risk behavior and lifestyle habits are established. In the region, 25% -32% of the 12 to 24year old population is suffering the consequences of at least one kind of risky behavior. Although NCDs like diabetes affect many young people, most prevention measures are not targeted towards youth. It is young people who will bear the brunt of the economic, social and emotional burden of NCDs throughout their lives.  Adopting a healthy lifestyle is even more important for youth with diabetes because complications set in slowly and are irreversible. Extensive research demonstrates that diabetes control and health outcomes of people living with diabetes depend largely on their active involvement in managing their condition.
How have you addressed these challenges? Do you see a solution?: AYUDA has established an international volunteer program that mobilizes individuals (many of whom have diabetes themselves) - ranging from high school students to world-class medical professionals - to support diabetes leadership and empowerment programs primarily throughout Latin America and the Caribbean.  AYUDA  has been implementing sustainable low cost programs for children with type 1 diabetes in developing countries in conjunction with local partner organizations in 9 countries for over a decade. By empowering young people living with diabetes to work with and educate other youth with the same disease, AYUDA has found improved health outcomes for children when compared to alternative interventions in resource poor settings, in particular with regard to psychosocial outcomes. Since current research estimate 50% of people living with diabetes suffer from depression the psychosocial benefits from such interventions should not be overlooked from a mental health perspective. AYUDA programs are built on the fundamental idea that youth can serve as agents of change and that a lack of education is as dangerous as a lack of insulin.  As an organization, AYUDA has been recognized for its social entrepreneurship and innovation by Ashoka: Innovators for the Public, the World Bank as a 2007 Development Marketplace Finalist, and the United Nations as an NGO in Special Consultative Status with the Economic and Social Council of the UN. The socioeconomic backgrounds of the local diabetes communities AYUDA serves are diverse, although in general the children and families are from low to middle socioeconomic backgrounds.   Although today there is no cure for diabetes- the condition can be effectively managed with the appropriate tools and education,  including  peer-to –peer learning and empowerment,  which will enable young people with diabetes to live healthier, happier and more productive lives.
How do you know whether you have made a difference?: In the past decade AYUDA has expanded its support to diabetes communities by creating the AYUDA Volunteer Program that has sent more than 300 volunteers abroad to work with local partner organizations in 9 different countries.  AYUDA employs a results-based approach to implementing its strategy and programs and is committed to monitoring outputs, outcomes and impact . On the local program level, AYUDA works with its local partners to help develop logic models and measure effectiveness in order to demonstrate tangible results.  While AYUDA’s local partners are responsible for monitoring their own outcomes, AYUDA provides technical assistance in the form of volunteers and staff to help ensure effectiveness and impact are measured. In Ecuador, the country where AYUDA first began its work, the Campo Amigo program has reached approximately 80% of children and youth living with diabetes in the country.  Since 1999, over 760 Ecuadorian campers, 200 AYUDA volunteers, and 50 Ecuadorian health professionals have participated in the program. Cohort data demonstrates improvements in short-term and long-term glycemic control (HbA1c values). Campo Amigo Ecuador led to the establishment of the Fundación Juvenil de Ecuador (FDJE), which now serves as the collective voice for children and families with diabetes throughout the year. The FDJE has negotiated the lowering of prices of diabetes supplies from pharmaceutical companies, and initiated talks with the government to extend health coverage benefits to children and families with diabetes.  The FDJE now serves hundreds of families and children living with diabetes throughout the year and currently sponsors the supplies of 50 low income children with type 1 diabetes. The more recently established Dominican program supports over 150 children with type 1 diabetes in the Dominican Republic in conjunction with local partner Aprendiendo a Vivir (AAV). The program has recently integrated AYUDA’s youth leadership model and is currently sponsoring low income children with insulin and strips. It is estimated that close to 90% of low income families who have a child with type 1 diabetes reach AAV’s services via the local public children’s hospital ‘Roberto Reid Cabral’ in Santo Domingo.
Have you or the project mobilized others and if so, who, why and how?: AYUDA’s youth-to-youth empowerment model for transforming local diabetes communities has directly helped to mobilize: (a) local youth with diabetes and their families, (b) local health professionals, (c) local governments and ministries of health, and (d) AYUDA’s volunteers both with and without diabetes who will be able to apply their acquired leadership skills in different environments in the future. Having been trained to become young leaders of social change, AYUDA’s volunteers gain valuable skills and experiences that transform their lives personally, emotionally and professionally. Local youth with diabetes receive fundamental,  diabetes management education in a way that motivates them to take control of their health live happier lives.  AYUDA has worked to establish successful partnerships and relationships with a variety of institutions, including international organizations, pharmaceutical companies, diabetes camps and hospitals, and local partners. These relationships play an essential role in promoting AYUDA’s programs, fundraising, recruiting and identifying volunteers and acquiring in-kind diabetes medical supplies.  More recently, AYUDA has taken its model of youth empowerment into the greater arena of non-communicable diseases, for which diabetes is a considerable part – by becoming increasingly involved in the global policy around the High Level Meeting on  NCDs.   After co-hosting a side meeting at the summit, AYUDA is moderating a  Global Youth and NCDs working group of over 60 members from around the word, including the youth leaders from the countries in which we work, with the goal of creating a youth movement that ensures that young people,  especially those living with and working within NCDs are a meaningful part of the global NCD decision-making process. One particular partnership that AYUDA would like to highlight is with Ashoka: Innovators for the Public and Youth Venture, a world renowned leader in promoting social entrepreneurship, whom provided AYUDA with its initial seed funding. Today, AYUDA is housed within Ashoka’s global headquarters as an example of a sustainable model of youth-led social entrepreneurship.
When your donor funding runs out how will your idea continue to live?: Key elements of AYUDA program sustainability include: 1. Innovative Funding Model- AYUDA’s programs are substantially funded through an earned income stream resulting from volunteer fundraising that covers both the volunteer costs of participation and subsidizes overall program costs.  The fundraising requirement also trains volunteers in advocacy and social entrepreneurship.   AYUDA’s operation goal is to have volunteer fundraising approach 100 percent of operation costs, allowing additional revenue (ie, grants and events) to contribute to organizational development. 2.  In-Kind Donations of Medical Supplies & Equipment - Medical supplies and equipment represent a large portion of local program budgets and AYUDA works to ensure Local Partners do not have to pay for such prohibitory costs (which are usually free to diabetes camps in the US). 3.  Partnerships with Other Organizations- AYUDA has worked to establish successful partnerships with a variety of institutions, including international organizations, pharmaceutical companies, diabetes camps and hospitals.  These partnerships play an essential role in promoting AYUDA’s programs, recruiting and identifying volunteers and acquiring in-kind diabetes medical supplies.

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Sickle Cell Disease Medical Care in Sub-Saharan Africa: The Need to Decentralize the Competencies

Author(s): Dominik Schmid1, Mohamed Cherif Rahimy1
Affiliation(s): 1Médecins du Monde Suisse
Name your project or intiative: Sickle Cell Disease medical care in Sub-Saharan Africa: the need to decentralize the competencies
1st country of focus: Benin
Relevant to the conference theme: Non-communicable chronic diseases
Summary: Sub-Saharan Africa is particularly concerned by Sickle Cell Disease (SCD) for which curative treatment doesn’t exist. This disease is responsible for a mortality rate higher than 20% for pregnant women and higher than 50% for children under 5 years old. These underestimated, unknown or even ignored risk factors for this disease are never issued in statistics. Nevertheless, in 2006 the WHO recognized it as a public health problem. The first Sickle Cell Disease research, screening and care Center has been created in 1993 in Benin. The founder and director, Pr. Cherif Rahimy, is a worldwide well known hematologist and SCD specialist. He has asked Médecins du Monde Suisse to create decentralized branches of the initial Center in the country.
What challenges does your project address and why is it of importance?: According to the WHO, Sickle Cell Disease is particularly prevalent amongst the populations coming from Sub-Saharan Africa, India, Saudi Arabia and Mediterranean countries. It seems that the geographic distribution of this disease could be explained by the fact that it provides a better level of resistance to malaria but this mapping is changing because of the migratory movements. Thus, Sickle Cell Disease is today the first genetic disease in France (Bardakdjian-Michau, 2008). Although it affects 4% of the population in Benin, Sickle Cell Disease is still not well known and perceived as something shameful that has to be hidden. The lack of diagnosis and awareness of the complication caused by this disease explains the delays in care resulting in permanent consequences and a reduced life expectancy, especially for children between 0-5 years old. This statement is overwhelming considering that with a minimum of medical follow-up, a significant portion of those children affected by the Sickle Cell Disease could have a normal life.
How have you addressed these challenges? Do you see a solution?: In 2000, a national program to fight Sickle Cell Disease started which was aimed to open many decentralized branches of the Sickle Cell Disease medical care center settled in Cotonou since 1993. The Médecins du Monde Suisse project is structured in two consecutive phases: the first phase is to create branches of Sickle Cell Disease care services according to the model of the Cotonou Center and under its supervision. Concretely, the aim is to establish those branches in Department Hospital Centres and to develop the means and competencies which are needed to give medical care to the population affected by Sickle Cell Disease. Thus, the first decentralized branch, opened in Abomey in November 2010, is now offering a neighborhood service to the populations living in the Borgou’s and Alibori’s areas. The medical care of the disease can be achieved through two simple and inexpensive methods which reduce morbidity and mortality. A systematic screening of all pregnant women and infants and a follow-up program completed that strengthens families’ awareness would help achieving these reductions. The second phase would undertake to communicate the existence of these branches to the peripheral hospitals and to the health workers so that the sick pregnant women or the affected infants would benefit of these services.
How do you know whether you have made a difference?: The Pr. Cherif Rahimy is the director of the research, screening and medical care Center of the Sickle Cell Disease in Cotonou. He is a specialist of this disease and the studies he has published show that appropriate medical care of the Sickle Cell Disease gives spectacular results. He has enabled a reduction of the maternal mortality from 27% to 10% and of the infant-juvenile mortality from 50% to 2% (Rahimy and all., Blood, 2003; Rahimy and all., Blood, 2009). His work underlines the importance of pre-emptive and neonatal screening actions in the Sickle Cell Disease medical care and in the improvement in the life quality ofthose affected. Moreover, the attendance statistics of the first branch show encouraging results and the current outreach campaign should lead to a progressive increase in the number of consultations. In ten months, the branch only registered one newborn death, which tends to indicate that the outreach activities developed by the medical staff have a positive impact on the reduction of the maternal and juvenile mortality rate.
Have you or the project mobilized others and if so, who, why and how?: The project in Benin was possible thanks to the occasional and regular cooperation of diverse actors at the national, departmental and local level. In particular, the research, screening and medical care Center of the Sickle Cell Disease in Cotonou constitute the main developer acting at the national level and under the authority of the Health Department. A collaboration with the NGO « Terre des Hommes » in Abomey to disperse the knowledge to the health worker is effective. Finally, the Beninese parental association « MUFELD » (United Hands of Active Families in the fight against Sickle Cell Disease) also collaborated with the project and offer a discussion room to the families of concerned patients.
When your donor funding runs out how will your idea continue to live?: The project commenced at the request of Pr. Cherif Rahimy and is a part of an overall national strategy. All of the medical staff recruited are from Benin and an agreement has been signed with the Health Department stipulating that after 2 years the medical staff salaries will be covered by the Health Department. The Pr. Cherif Rahimy, who in charge of the project, assures medical competency of the project. The expertise of the Cotonou Center, leaded by the Pr. Cherif Rahimy, is renowned at the national and international level: doctors from neighboring countries are trained there and the dissemination of this competency through the country is assured by the creation of decentralized branches in the Department Hospital Centres. The capitalization and the modeling which took place with the implantation of the first branch in Abomey enabled a new phase, which anticipates the opening of a new branch in Parakou (center of the country) in 2013. An extension of the project in other areas of the country and other countries in the Sub-Saharan Africa is also imaginable.

School Based Intervention to Prevent Tobacco Use: Sousse, Tunisia

Author(s): Firas Chouikha1, Jihene Maatoug1, Imed Harrabi1, Wahbi Belhadj Khelifa1, Mylene Belkacem1, Sonia Hmad1, Karima Gaha2, Hassen Ghannem1
Affiliation(s): 1Department of Epidemiology, University Hospital Farhat Hached, Sousse Tunisia. 2College Khzema Ouest Sousse, Tunisia
1st country of focus: Tunisia
Relevant to the conference theme: Non-communicable chronic diseases
Summary: The Chronic Disease Prevention Research Center in Sousse Tunisia is implementing a school based intervention to prevent tobacco use among schoolchildren. It is a quasi-experimental study including two groups: a control and an intervention group. This study canvassed a pre- and a post-evaluation of knowledge, attitudes and behaviors about smoking in each group. For this we used a stratified and proportional sampling and included 4003 schoolchildren aged 11 to 16 years in the questionnaire with 1929 and 2074 respectively in intervention and control groups selected from 8 intervention and 8 control schools. Intervention began in 2010 with the training of teachers to animate standardized courses about tobacco use and consequences. We also organized training for young leaders who participated in the animation days to prevent tobacco use in their colleges. On world 'No Tobacco Day' schoolchildren leaders celebrated with the help of the project team in each of 8 intervention schools. They prepared posters which were displayed in the schoolyard. They also distributed pamphlets about consequences of tobacco use and how to prevent smoking. In other schools, schoolchildren leaders presents sketches to their collegues and their teachers. A group of leaders visited the cafeteria of the University Hospital of Sousse and tried to discuss with patients the consequences of tobacco use. They also discussed with health care professionals about their role of models and the importance to help patients quit smoking. This school based intervention is a part of a community intervention program entitled “Together in Health” targeting 3 risk factors for chronic diseases: smoking, physical inactivity and unhealthy diets in 4 settings: schools, workplace, health care setting and neighborhood. This video is to illustrate their activities.
What challenges does your project address and why is it of importance?: Tunisia is facing an epidemiologic transition and cardiovascular diseases represent the primary cause of death. Tobacco use is an important risk factor and is the first preventable cause of death.
How have you addressed these challenges? Do you see a solution?: Tobacco use begins at early age among adolescents. Once this occurs tobacco cessation is more difficult than prevention. So, we propose to implement an intervention to prevent tobacco use among schoolchildren.
How do you know whether you have made a difference?: Our project consists of a research study. It’s a quasi experimental design with intervention and control groups. We began our study by an evaluation of knowledge about smoking, attitudes and behavioral intent before the intervention.
Have you or the project mobilized others and if so, who, why and how?: To implement our project, we have different partners. The National partners are: University Hospital Farhat Hached Sousse, Department of Pediatrics, Regional Direction of Health of Sousse, Primary Health Care, School Medicine Unit, and Regional Direction of Education of Sousse  Regional Direction of Youth, Sport and Physical Education of Sousse Tunisian Heart Foundation, Tunisian Association of Life and Earth Sciences Teachers. The International partners are: National Institute of Health and welfare of Helsinki, Finland, Division of International and Humanitarian Medicine, Department of Community Medicine, Primary Care and Emergency Geneva University Hospitals
When your donor funding runs out how will your idea continue to live?: In our project, we trained teachers and schoolchildren leaders so they could participate with the project team in intervention activities. We rely on teachers and leaders to continue our actions of tobacco prevention.

State-NGO Partnership to Improve the Prevention and Management of Diabetes in Mali

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Author(s): Stéphane Besancon1, Sidibe Assa2, Ibrahim Nientao2
Affiliation(s) 1ONG Santé Diabète, Bamako, Mali, 2Service d'endocrinologie et de diabétologie, Hôpital national du Mali, Bamako, Mali
1st country of focus: Mali
Relevant to the conference theme: Non-communicable chronic diseases
Summary: Mali is one of the poorest countries in the world and has already a diabetes prevalence of 3.3% (Diabetes Atlas, 4rd edition, 2010). In Mali Diabetes is a major cause of death, the leading cause of blindness, and results in 60% of non-traumatic amputations. Despite the limited human resources to improve the care of people with diabetes, Mali has set up pilot approaches, based on close collaboration between the NGO “Santé Diabète” and the Moh of Mali, focusing on decentralization of care, access to medicines, education and prevention
What challenges does your project address and why is it of importance?: Diabetes is a chronic condition affecting more than 250 million people worldwide and kills 3.8 million people per year (Diabetes Atlas, 4rd edition, 2010). According to the International Diabetes Federation (IDF) in 2025, diabetes will affect over 380 million people, making it one of the leading causes of disability and death worldwide. Developing countries will be most concerned by the pandemic,as they will account for 76% of diabetics in the world. This epidemiological transition from “rich” countries to "poor" countries is mainly due to changes in lifestyle including increasing urbanization leading to a nutrition transition, decreased physical activity and a sharp increase in overweight. In West Africa, the alarming increase of diabetes will affect social and economic conditions as the disease affects people during their most productive years of life. The cost of diabetes care and the lack of human resources to handle the increased number of patients will be a major obstacle to the achievement of the Millennium Development Goal (MDG). Prevention of risk factors for the disease, as well as access to care, treatment, education and care of diabetes complications, is the key challenge addressed by the approach developed in Mali.
How have you addressed these challenges? Do you see a solution?: This approach is based on strengthening of the health system through 5 strategic ways:- Strengthening of human resources- Availability of drugs- Accessibility of drugs- Analysis and biological measures and Primary prevention and therapeutic education 1) Strengthening human resources for diabetes management- Ensure reference to the highest level (national hospitals). Creation of a specialization on endocrinology (4 years) and on diabetes (1 year). Establishment of postgraduate training course - Provide referral management at secondary level.  Annual program of training for referring doctors in diabetes management and its complications in regional hospitals and health centers. Annual program of training for doctors in the sanitary districts for the management of diabetes and some of its complications.  Training for other doctor and paramedics on risk factors for diabetes and diabetes screening • Analysis and biological measures- Capacity building at different levels. Hospital: technical support for further analysis in endocrinology. Regional hospitals and health centers: technical support for screening and treatment of diabetes and some complications (diabetic foot, retinopathy) Comminatory health center:  screening and management of uncomplicated diabetes. 2) Drugs - Availability: represents both the ability to develop new drugs that meet the needs but also to make them available in a given country. Work with pharmaceutical companies and generic manufacturers as well as the national pharmacy in Mali so that private wholesalers can make available the desired treatments for diabetes and its complications. 3) Accessibility: is divided into geographical and financial accessibility. The product is available for a patient throughout a given territory at a price at which the patient can buy. Work on two fronts: the negotiation of price initiative differentiated with pharmaceutical companies and work with manufacturers of generic products. Support the national pharmacy in Mali for the expression of needs and respect for the master plan of supply at different levels of the health pyramid. 4) Primary prevention. Once the system of management of diabetes is in place :• Increased knowledge of risk factors for diabetes and other NCDs common risk factors and screening (in practice diabetes and hypertension) with the referral of positive cases to the diabetes consultations. 5)  Therapeutic education- Included in the training programs for capacity building in this area. Establishment of a specific therapeutic education program in the health structures with the diabetes consultations
How do you know whether you have made a difference?: In 2004 Mali only had 2 specialized doctors (1 diabetologist and 1 endocrinologist), consulting in 3 national structures located in the capital Bamako. The problems faced were the following:  lack of adequate material (glycaemia readers, control strips…) which delayed the patients’ diagnostic and mades follow-up difficult, medication was often lacking in the central medical stores, patients provided themselves with products from private pharmacies at a much more important cost (eg: 12$ for insulin vial, 6$ for OAA, 3 $ for glycaemia controls). there was no specific program of prevention and less than 10 patients with type 1 diabetes were followed (with a life expectancy of 1 year at the testing time). The  situation of Mali at the end of 2010 is as follows:  the training of 10 doctors and 20 nurses in specialized services, training of 18 diabetes referral doctors for the different regions, training of 557 doctors and paramedical staff (nurses, midwives etc ...), consultation and management for over 3000 patients with diabetes in 7 regions of Mali and the District of Bamako. For each diabetes consultation there is availability of the testing equipment, educational materials and medicines, the cost of insulin has lowered by 48% (100UI bulb from 6200 francs CFA to 3800 FCFA),  there has been an average lowering of the prices by 10 of oral diabetes pills (20 pills from 2,500 FCFA to 250 FCFA), a specific program has been established for the management of diabetic foot and more than 500 patients with diabetic foot were managed in 2009 at the peripheral level, 95% were followed without referencing and/or amputation. There were 114 follow-up visits at the homes of patients with diabetic foot, the establishment of a therapeutic education program, the establishment of a prevention program that affected over 120 000 people in three regions of Mali as well as the establishment of a specific prevention program in schools affecting more than 4000 students.
Have you or the project mobilized others and if so, who, why and how?: This close cooperation between the state and NGOs for the implementation of actions has: Strengthened the mobilization of local authorities against diabetes, strengthened the mobilization of many donors and established an extensive network of international partners to support the fight against diabetes - France: Pr Halimi, Pr Vialettes Dr. Debussche, Prof. JJ Robert ... - World: Prof Dr Silink (Australia), Professor Delisle (Canada), Professor Jonathan Brown (United States), Pr Belhadj (Oran - Algeria). The Associations include: AFD - Luxembourg Association of Diabetes - Diabetes Association of Australia - Team Type 1 etc .
When your donor funding runs out how will your idea continue to live?: The interventions are part of the Malian national policy which allows a gradual withdrawal of actions for the Malian state

Affordable Diabetes Care: Cambodia

Author(s): Maurits van Pelt1
Affiliation(s): 1MoPoTsyo, Phnom Penh, Cambodia
Name your project or intiative: Affordable Diabetes care in Cambodia...
1st country of focus: Cambodia
Relevant to the conference theme: Communicable chronic diseases
Summary: In 2005 a mixed team of experts created a local Cambodian NGO to address the lack of information available for Cambodian diabetics to help them become successful self-managers. Over time, some of the patients became peer educators training other patients in self-management. Active screening of marginalized populations for diabetes and high blood pressure resulted in empowered communities of chronic patients with both a structure and a sense of agency. The innovative strategy remedies market failure  as the responsive services keeping price levels 3 to 5 times below the prevalent market prices. With scale-up it appears financially sustainable even in a developing country such as Cambodia.
What challenges does your project address and why is it of importance?: Most of the country’s one million people with diabetes and high blood pressure are unaware of their condition. Adequate care is unavailable or prohibitively expensive as most patients live below USD 2 a day. Premium levels for community based health insurance do not allow coverage of chronic patient routine health care costs. The problem is not just financial. Since 1993, when Cambodia’s development aid embargo was lifted, almost no attention has been given to Noncommunicable Disease. Twenty years later, Cambodia lacks the health care system and health work force able to respond to the needs of its population. Attitudes of doctors and health workers towards patients generally are top down. With chronic patients unable to get public care and vulnerable to exploitation by unscrupulous private providers, many non-poor households eventually fall into poverty when chronic disease slowly and prematurely bring down a bread winnder of the family. Mistrust in health services is so high that chronic patients only seek medical care when it is much too late. With the international priorities remaining firmly focused on “priority interventions”, there is also no intention to create a new and costly professional medical workforce to deal with the growing burden of NCD.  International public policy evidence points towards addressing NCD through primary prevention. But what can be done for Cambodia’s one million DM and High Blood Pressure patients?
How have you addressed these challenges? Do you see a solution?: In 2005, A Cambodian NGO was established to detect, register and train poor diabetes patients in urban slums how to self manage their diabetes with a focus on lifestyle improvements and self-measuring skills.  Together with the first diabetes patients, the educational self-management materials were adapted to the local context.  The NGO trained the first 2 diabetic patients to become Peer Educators. They were able to find other diabetes patients in the slums using a combination of urine glucose strips for postprandial screening and a handheld blood-glucose meter for confirmation blood glucose testing. The intervention expanded from 2 to 5 urban slums. In each of 5 urban slums a trained community-based Peer Educator resided. Equipped with regularly supplied materials he/she hosts a home weekly meeting of registered people with diabetes who gather for about an hour in the early morning before they go to work. These patients weigh themselves, measure their blood pressure and blood sugar and share their experiences and the latest news. For patients who need to see a Medical Doctor, the Peer Educator can make an appointment at the first opportunity for consultation.  The Peer Educator is someone with diabetes who has received a 5 to 6 weeks Peer Educator training and who must pass the peer educator exam organised by the NGO before being qualified. Once back in their own community with the equipment kit and after introduction at the local public health center, the peer educators start to screen the adult population of about 5,000 people. The first goal is to register 50 DM and 200 HBP patients, most of whom are unaware of their disease until their diagnosis by the peer educator. The peer educators report monthly on the activities, as gradually these patients are detected, registered, counseled and trained in self-management and remain in follow-up care. During the early years of the intervention formal medical services were being provided by foreign NGO’s operating as medical charities. The intervention initially only provided diabetes education and was merely complementary to existing clinical services in the capital Phnom Penh. However after a couple of years the charity programs ran out of funds and as the professional health staff were left to fend for themselves they began to charge unaffordable prices for basic services. At that moment, the NGO took an unusual step. Instead of demanding that more affordable services be provided, the NGO decided to train some of its peer educators so they could become diabetes care managers able to organise their primary care services in public facilities such as a self-help group charging the registered members fees for services. Shifting more and more tasks from professionals to lay health workers increased the model’s scope of services and the resulting revenue. Rewarding trained patients with a combination of immaterial and financial incentives maintains a complementary highly motivated and effective health work force without the conflict of interest. Together with other more efficient resource allocations, it reduces costs of care and prices of services 3 to 5 times.
How do you know whether you have made a difference?: Every half year, one network of Peer Educators is paid to perform an assessment of the work of another Peer Educator Network. The NGO selects a random sample of 19 diabetes patients who are being followed up by each peer educator. The visiting Peer Educator Network evaluates these patients by assessing their blood sugar, blood pressure, weight, feet, their self-management book and their knowledge of how to self-manage. The Peer Educators whose patients show to have the best outcomes in terms of knowledge and bio markers get the highest financial rewards. The elaborate questionnaires used for these re-assessments help to inform the managementabout weaknesses in the program.  Average fasting blood sugar and postprandial blood sugar of new diabetes patients is typically 200mg /dl  and 300 mg/dl when they register. However the re-assessed samples show significant reductions to 130 mg/dl and 200 mg/dl respectively on average, indicating overall improvements in blood sugar control. Also blood pressure improves : only 33% of diabetes patients have blood pressure below 130/80 mm Hg at time of registration. This normally improves to over 50% at time of re-assessments. More than 90% of patients are satisfied with their peer educator. Drop out is low. More than 80% of patients report spending less on their health than before they registered. When asked what type of food raised blood sugar and which ones do not, many patients show significantly increased knowledge that helps them lower their blood sugar naturally. Of particular importance in Cambodia is the  highly glycemic (>90) white rice variety that is commonly eaten. For this reason, the NGO encourages its members with diabetes to replace it with less polished rice richer in protective vitamins. Also more than 80% of patients report to be exercising more than before they registered. Over the years the average BMI of the membership remains stable.
Have you or the project mobilized others and if so, who, why and how?: Expansion and replication of this project has been taking place in different dimensions. Geographically and in scope of disease and scope of action; Per 25-08-2011 there are in total 3329 people with diabetes registered with MoPoTsyo patient information centre. Each patient information centre is part of a local network supervised by the Diabetes Program Manager, a supervisor who also has diabetes. The first urban network consists of 5 slum areas with a peer educator. The first rural Diabetes Network started in June 2007 in Ang Roka Operational District in Takeo province. After 18 months that experience began to be replicated to the 4 remaining Operational Districts of Takeo province.  Our aim is to cover the whole province, so we end up with a sustainable provincial network of people with diabetes. In late 2009, we received funding to set up a network in Banteay Meanchey province and in 2010 we began the intervention in Kompong Speu province. In total there are 67 such patient information centres in Cambodia where a diabetic peer educator is actively finding new patients, following up the existing ones and helping them to get access to the health services that they need.  Also, the scope of the intervention increased. Since 2009 the NGO also registers people with high blood pressure who do not have diabetes. In addition, the NGO developed its range of medical services from organising medical consultations to setting up a “revolving drug fund” that procures its generic medication abroad from international suppliers and which has its own registration and distribution system, but in close collaboration with the Ministry of Health’s own government supply. The collaboration allows the 2 systems to exist side by side complementing each other using much of the same health infrastructure with exemplary efficiency.  Since 2010 the NGO also operates a laboratory service for its members. Thanks to sharply reduced prices and the fact that the blood samples are collected in the community, the threshold for utilisation by the members is low. An international external quality assurance system (EQAS) helps monitor and inform the management about the quality of its range of biochemistry tests. This in turn increases the confidence of the prescribing medical doctors in the test results. Since 2011, the NGO has begun to collaborate with eye hospitasl to promote screening for retinopathy among its own members with more than 5 years diabetes. In 2011, active additional screening for proteinuria together with the lab results on serum creatinin are helping to inform the peer educators on who is at risk of CKD and alert the patients to consult again with prescribing doctors so they can adapt the treatment to address early signs of Chronic Kidney Disease.
When your donor funding runs out how will your idea continue to live?:  Donor funding is used as investment in order to allow the PEN’s to grow so the system reaches a break-even point at which all the expenses can be recovered from the revenue generated from the 2 main revenue sources: sale of routine medication to the contracted pharmacies and the provision of laboratory services to the members. With current levels of utilization of services by the members, this break-even point will be attained when the NGO covers 30 districts of the 77 existing ones. However, if the strategy is to make High Blood Pressure patients adhere to their medication works and external funding pays for the voucher scheme to help the poorest adhere to their prescribed medication, this break even point will be reached in a smaller number of districts. The key messages are that financial sustainability of the diabetes and high blood pressure care model is within reach and fits well with the country’s primary care system. It requires some investment to set up the Peer Educator Networks in the districts where there are none at the moment and insufficent complementary financing has not been achieved. Other questions are the long term governance of the model and how it is best linked with the 2 other main government health programs such as the Mother- and Child Health Care program and Communicable Disease program. Local health authorities and provincial authorities have spotted the potential of the model. The decentralized planning process allows them to include it into their annual operational planning for the near future.

Establishing Pre-hospital Emergency Medical System in Sri Lanka

First D.D.M.Lakruwan
Last Dassanayake
Name your project or intiative Establishment of Pre-Hospital  Emergency Medical System in North Central Sri Lanka: Gaining some thing from nothing in a resource poor setting

1st country of focus

Sri Lanka

Relevant to the conference theme

Summary By the year 2009 there wasn’t a pre-hospital Emergency Medical System in Anuradhapura. This project was designed fulfill that requirement. There were no local institutions providing training on developing, management and monitoring Pre-hospital EMS. The knowledge was gained through a training program arranged by JICA at Osaka. Establishment of pre-hospital EMS was achieved by fulfilling a set of objectives. Operations of pre-hospital EMS were monitored during first 6 months to understand the technical, logistic and legal issues. During initial 6 months they provided emergency health care to 213 patients and trained 650 population in suburbs on basic life support
What challenges does your project address and why is it of importance? Trauma has become a leading course of hospital admissions in Sri Lanka. Annually average 600,000 admitted to government sector hospitals following trauma. The contribution of the private sector is unknown. During the last 3 decades road traffic accidents have increased by 249%. Therefore an effective pre hospital EMS is essential to reduce morbidity, mortality and secondary injuries.

Rapid urbanization had disrupted the organic solidarity in many cities of Sri Lanka with in few decades, that prevailed for centuries giving minimal or no time to flourish a reasonable mechanical solidarity to compensate. Furthermore increased life expectancy and demographic transition had increased the proportion of the elderly in community who are with more non communicable chronic disorders and emergencies related to them in urban societies
In suburbs it was found on a survey the knowledge and practice of proper and safe initial care and transport of a trauma victim is less than 10% which would lead to secondary injuries even though there volunteerism is high. Furthermore on direct observation it was seen vehicles like three wheelers and motorcycles are used more and more in transporting trauma victims to hospital with little or no care regarding secondary injuries
How have you addressed these challenges? Do you see a solution? Establishment of the emergency ambulance service in the municipality of Anuradhapura

An initial survey was carried out by direct communication and site visits with the potential pre hospital care providers of the municipality of Anuradhapura. The possible institutions with the capability of generating the human resource and the infrastructure were
1. Teaching Hospital Anuradhapura
2. Municipal fire and rescue team
3. Red cross Anuradhapura
All these three institutions had the some extent of infrastructure that can be used in the pre-hospital emergency services and the man power that can be trained for that purpose. Yet the institutions were not engaged in the pre hospital emergency medical services due following reasons
1. Not adequate knowledge in pre-hospital EMS system:
2. Inadequate resources
3. No proper training
4. Different motives and working objectives
5. No interest
There were no academic institutions in Sri Lanka as per 2009 providing a formal education on Pre-hospital EMS, developing, management and monitoring Pre-hospital EMS. Required knowledge was gained by attending a relevant group training program in Pacific Resource center, Osaka, Japan and studying the EMS of Senri emergency and critical care center and the pre-hospital EMS of Osaka fire department.
Establishment of the pre-hospital emergency medical system was achieved by fulfilling a set of fine objectives which included community mobilization communication, developing community and institutional pressure groups, Public private partnership to obtain training and equipments, telecommunication, identification and strategic collaboration with the key partner institutions ( Police, Teaching Hospital Anuradhapura, Australian Sri Lanka Charitable Health fund, Medical Teams International (MTI), human resource development, infrastructure development, acquisition of equipments, formulations of standard operations plans, establishment of codes of practice and designing the EMT documentation formats, studying the possible legal implications and preventive methods through brain storming sessions with relevant expert panels.
Community training on Basic life support
This was designed under the umbrella of the pre hospital EMS of Anuradhapura to increase the chances of survival of the rural population until they are transported to the hospitals from their remote locations following medical or surgical emergencies considering the fact the high level of volunteerism of the village community and low skill levels. This program was developed to run as a collaborative program with the national blood service of Sri Lanka. The stake holders are usually the blood donors of the village community who usually having the higher tendency in volunteering in such emergencies
How do you know whether you have made a difference? During the first six months (01/06/2010 to 30/11/2010) the Pre-hospital EMS had dispatched 211 victims followed by medical and surgical emergencies. It had conducted 14 basic life support skill development programs targeting the rural communities with a participation 645 villagers. In additions it had provided emergency medical care in 4 mass population gatherings during that period

Considering the cohort of victims there was a gradual rise in the number of victims with the advancing age until the third decade of the life. There was a relative reduction in fourth and fifth decades and rise again in the sixth decade attributing to the retiring age. After that the number gradually reduces
Medical emergencies (52.5%) were slightly out numbering surgical emergencies (44.13%). Obstetric cases represented only 2.3% . Two cases were obviously dead according to the working criteria when approaching the scene which account for 0.9% of the cases. Two patients were in cardiac arrest when team reaching the incident (Acute collapse had been witnessed by the bystanders). They were brought to hospital while continuing cardiopulmonary resuscitation. One was confirmed death at the out patient department and the other admitted to Emergency treating unit and diagnosed as an acute myocardial infarction and survived in the acute phase
The majority of the surgical emergencies were road traffic accidents (32) that accounted for 34% of the total surgical emergencies. There had been significant bleeding in 32 cases representing 15% of the total victims which necessitated vigorous active measures to arrest the bleeding. Spinal stabilization was done in 54 cases representing 24.8% of the total number of victims
Considering the medical emergencies the main cause for dispatch was chest pain and difficulty in breathing (34) the key words leading to urgent cardiac or respiratory emergencies. This accounted for 30.4% of all the medical emergencies.
In three instances the advice of the doctor was requested over the phone by the EMTs in the field which is 1.5% of the total cases. Since the multiple casualties were hypothesized doctors of the unit in person attended to mass population gathering during “Pichchmal pooja” and “poson” religious ceremonies held in the municipality and directly involved in managing 16 critical cases which represent 7.5% of the cases
30 % of the cases were attended in less than 5 minutes form the call and 69.7% of the cases were attended with in 10 minutes from the call
Have you or the project mobilized others and if so, who, why and how? A strong community mobilization, formulation of a pressure group with in the institution and the community and obtaining the support of the local and the regional health administrators and the other collaborative bodies were prime objectives of this project.

Convincing the necessity of the pre-hospital EMS to municipality of Anuradhapura to the local and the regional health authorities was the key to the successful commencement and the continuity of the project. Evidence based data, national level annual data of the Ministry of health regarding the current trauma admissions and the trauma management and the health benefits in line with the health master plans that could be expected form the pre hospital EMS considering the effectiveness of the Pre- hospital EMS of the Osaka prefecture were used as the solid information. Multiple levels of health management were invited (local, regional, national) for the initial discussions to obtain the liaison and come in a collective decision in order to prevent the complexities. The initial discussions were conducted in a non directive manner as round table discussions and lectures. Director Teaching Hospital Anuradhapura, Regional Director Health Services, Anuradhapura, National Coordinator, Disaster Preparedness and Response Unit, Ministry of Healthcare and Nutrition Sri Lanka, Governor of North central Province, Mayer of Municipality of Anuradhapura were the invited participants for the initial discussions. In the discussions it was agreed that the pre-Hospital EMS is an important element missing in our health system. It was agreed Pre-Hospital EMS need to be established to cover the entire district of Anuradhapura and as a pilot project to proceed with a service to cover the municipality with a population with 70000 or an area of 5km radius from the town center.
A separate series of lectures were arranged to the hospital workers regarding the EMS in Osaka convincing them this is another area of healthcare and it can increase the chances of the survival of victims. This communication was extended to the community leaders (politicians, influential clergy), professional groups (lawyers, General Medical Officer’s association), and Business community of the municipality. It was expected to develop a pressure group for this project by this communication which ensures the continuation of the program.
When your donor funding runs out how will your idea continue to live? Since the Teaching hospital Anuradhapura was the largest health care institution of the municipality with a large human resource out numbering other small institutions it was selected as the host institution to establish the Pre-Hospital EMS. Municipality and the Fire and rescue were also evaluated as the potential hosts. Yet due to lack of man power, difficulty in establishing the monitoring methods in those two institutions and more importantly the less success in the Fire department based pre-hospital EMS in Colombo lead to select Teaching Hospital Anuradhapura as the host organization. And a separate unit was established in the hospital to carry out this function as Disaster Preparedness and Response Unit which later developed to Disaster Preparedness and Triage Unit. Nurses are working as the EMTs and the EMT level two raining was provided to them by collaboration of Medical Teams International. During that training 5 doctors in the hospital were trained as trainers who could carry out this trading in the hospital for more nurses if necessary with out external support. The Ambulance to the Unit was donated by the Australian Sri Lankan charitable health fund and it was incorporated to the regular ambulance fleet of the hospital and through that it was deployed to the unit so it is maintained as a regular ambulance in the hospital.

Even though at the beginning the project needed assistance from the donor agencies it was designed as such it can be maintained by Teaching Hospital Anuradhapura with out much external support to ensure the sustainability

RAFT: Telemedicine in Africa

The RAFT-Network provides telemedicine in African Francophone countries. The main challenge adressed is the de-isolation of care professionals working in remote areas of developing countries. The core activity of RAFT is the webcasting of interactive courses targeted to physicians and other care professionals. Courses are webcast every week, freely available, followed by hunderds of professionals who can interact directly with the teacher.

Project/Initiative Outline:

First Name
Last Name
Name of project or intiative RAFT: de-isolation of care professionals in developing countries
1st country of focus Mali
Additional countries of focus Sub-Saharan Africa and Latin America
Relevant to the conference theme Health information and technologies
Summary Continuing education of healthcare professionals and access to specialized advice are keys to improve the quality, efficiency and accessibility of health system. In developing countries, these activities are usually limited to capitals, and delocalized professionals do not have access to such opportunities, or even to didactic material adapted to their needs. This limits the interest of such professionals to remain active in the periphery, where they are most needed to implement effective strategies for prevention and first-line healthcare.

In order to address these needs, the Geneva University Hospitals have developed a telemedicine network in Africa (the RAFT, Réseau en Afrique Francophone pour la Télémédecine), first in Mali, then in Mauritania, Morocco, Cameroon, and, since 2004, in Burkina-Faso, Senegal, Tunisia, Ivory Coast, Madagascar, Niger, Burundi, Congo-Brazzaville, Algeria, Chad, Benin, Guinea and DRC.
The core activity of the RAFT is the webcasting of interactive courses targeted to physicians and other care professionals, the topics being proposed by the partners of the network. Courses are webcast every week, freely available, and followed by hundreds of professionals who can interact directly with the teacher. 70% of these courses are now produced and webcast by experts in Africa. A bandwidth of 30 kbits/second, the speed of an analog modem, is sufficient, and enables the participation from remote hospitals or even cybercafés.
Other activities of the RAFT network include medical tele-expertise, tele-ultrasonography, and collaborative development of educational on-line material.
The network is currently organized and run by more than 40 national coordinators throughout Africa, and by a coordination team based in Geneva. In each of the partner countries, the RAFT activities are supervised by the focal point, a medical authority (usually a university professor) that links the project to the national governmental bodies (ministry of health, ministry of education). A local medical coordinator (a junior physician) and a technical coordinator take care of the day-to-day operations, including communication with the care professionals, identification of training needs, technical training and support of the various sites within the country.
Key partnerships include the Université Numérique Francophone Mondiale (UNFM) and the World Health Organization (WHO). The RAFT is recognized as an official WHO collaborating center for eHealth and Telemedicine.
The current priority is the large-scale deployment of these telemedicine tools along with IT-enabled diagnostic devices such as portable echography, to the regional and district hospitals in Africa. These infrastructures could also be used to facilitate public health activities including the collection and communication of surveillance and healthcare indicators to the ministries. The usefulness of these tools to support isolated care professionals has been demonstrated, as well as the sustainability of the implementation in large hospitals who can integrate the recurring connection costs in their operational budgets. Given the high costs of satellite connections (about 500 USD per month), which are the only options in remote areas, it has been evaluated that sustainability can currently be achieved down to the district-level hospitals who usually serve populations of 50’000 to 200’000, and operate as the first level of reference for dispensaries and rural hospitals.
In parallel, the network is extending to other linguistic areas: educational sessions have been produced in English since October 2008, and are available to hospitals in English-speaking Africa and the Middle East. Since 2011, the project is being implemented in Latin America.
What challenges does your project address and why is it of importance? The main challenge addressed is the de-isolation of care professionals working in remote areas of developing countries. In most countries, remote areas are understaffed, with a suboptimal use of existing resources, while main cities retain most of the skilled professionals and have overcrowded care facilities.
How have you addressed these challenges? Do you see a solution? The RAFT network provides distance education and tele-expertise services to isolated care professionals, by establishing South-South collaborations between reference hospitals and regional/district hospitals.
How do you know whether you have made a difference? We have many anecdotes showing that these tools are effective both for professional and social de-isolation, and help maintain skilled and motivated professionals in remote areas, thus strengthening thelocal health systems.
Have you or the project mobilized others and if so, who, why and how? The RAFT network has many partnerships in order to provide quality contents and mutualize technical and organizational resources. These include WHO (HUG is a WHO collaborating center for eHealth and telemedicine), UNFM (Université Numérique Francophone Mondiale), AUF (Agence Universitaire de la Francophonie), UNESCO (University of Geneva has a UNESCO chair for distance education), Université Senghor...
When your donor funding runs out how will your idea continue to live? In most countries, the network is supported by the MoH or hospitals within two to three years of the initial deployment in that country.