Geneva Health Forum Archive

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Tackling NCDs: A Different Approach is Needed

Author(s): Jan De Maeseneer1, Sara Willems1
Affiliation(s): 1Department of Family Medicine and Primary Health Care, Ghent University, Gent, Belgium
Additional countries of focus: All Countries
Relevant to the conference theme: Non-communicable chronic diseases
Summary: The NCD Alliance proposes a vertical disease-oriented approach in order to address non-communicable diseases (NCDs). A fundamental paradigm-shift is needed from problem-oriented to goal-oriented care, and this requires a comprehensive integrated and interdisciplinary approach at the primary health care level. Horizontal primary health care provides access to the care of all health problems, thereby avoiding 'inequity by disease'
What challenges does your project address and why is it of importance?: The worldwide attention to NCDs is timely, but the NCD Alliance seems to offer a conflicted strategy. On the one hand, a vertical disease-oriented approach is recommended, such as developing a multidrug combination for people at increased risk of cardiovascular disease.  On the other hand, the NCD Alliance calls for the strengthening of health systems, particularly primary health care.  Yet their vision of primary care is limited and ambiguous.  Primary care is seen as an opportunity for “case finding” (for the disease-oriented programmes), but is overlooked as the source of comprehensive care that integrates and coordinates care for all health problems and engages individuals, families, and the community. It is here that the real added value lies for health care.
How have you addressed these challenges? Do you see a solution?: Although much has been learnt from vertical disease-oriented programmes, evidence suggests that better outcomes occur by addressing diseases through an integrated approach in a strong primary health care system.  An example is Brazil where therapeutic coverage reaches almost 100%, higher than in countries with less robust primary care.  Vertical disease-oriented programmes for HIV-AIDS, malaria, tuberculosis, and other infectious diseases create duplication, inefficient use of resources, gaps in the care of patients with multiple co-morbidities, and reduce government capacity by pulling the best health-care workers out of the public health sector to focus on single diseases. Moreover, vertical programmes cause inequity for patients who do not have the “right” disease andthere is also the internal brain-drain of health professionals. The "lessons learned" from a vertical disease-oriented approach for select infectious and neglected tropical diseases should inspire us to rethink the strategy for NCDs.  In 2009, the World Health Assembly’s Resolution WHA62.12  urged member states “to encourage that vertical programs, including disease-specific programs, are developed, integrated and implemented in the context of integrated primary health care". Horizontal primary health care provides the opportunity for integration and addresses the problem of inequity by allowing a focus on NCDs while still providing access to the care of other health problems, thereby avoiding  "inequity by disease".    Describing the rising prevalence of NCDs as a crisis makes for good drama, but misleads us into thinking that this problem is amenable to a quick fix.  NCDs represent a set of chronic conditions that will require sustained effort for many decades.   Thus, the focused "selective solution" pursued for infectious diseases must give way to a comprehensive and enduring strategy that affects and reflects the fabric of health-care services and research.  Integrated primary care is essential for tackling NCDs. Chronic conditions, much more than infectious diseases, are influenced by patients’ perceptions and behaviour.  Effective management of NCDs will require a shift from problem-oriented to goal-oriented care. The long-term management of chronic conditions requires more than "access to affordable essential drugs in primary health care”. It requires the empowerment of patients, a reduction of barriers to healthy lifestyles, and care that reflects the values of the individual patient.  There is consistent evidence of the effectiveness of primary health care in reducing hospital admissions related to NCDs; multi-morbidity among those with NCDs has been shown to be better tackled in primary health care.
How do you know whether you have made a difference?: It is not sufficient to exhort policy makers and health-care workers to promote synergies between existing programmes for NCDs and other global health priorities.  We must fundamentally rethink the way we address complexity in health problems, in both developed and developing countries.  This will require that we put people and their values at the centre of the process, rather than specific diseases.  The best answer to the challenge of NCDs is to promote people-centred care through investment in integrated primary health care, including sufficient numbers of well-trained health professionals. At least 50% of all health profession graduates should be trained for primary health care. The NCD Alliance calculates that a global commitment of about US$9 billion per year will be needed to pay for the priority interventions. Our advice is to add another $9 billion to strengthen local primary health-care services in the same countries.  As a result, millions of people will be able to have access to affordable, accessible, comprehensive, and quality primary health care that addresses all conditions, including infectious diseases and NCDs.  We are at an important moment of reflection and we should learn from previous mistakes, however well intended.  It is time to respond to the aims of Resolution WHA62.12 and to put it into practice.  We invite all stakeholders to participate in this fundamental reflection and to weave focused expertise into a broader tapestry of more effective and relevant health care and research.
Have you or the project mobilized others and if so, who, why and how?: This document has been published in The Lancet online september 6,2011. DOI:10.1016/S0140-6736(11)61135-5, signed by authors from all continents: Jan De Maeseneer, Richard G Roberts,  Marcelo Demarzo, Iona Heath, Nelson Sewankambo, Michael R Kidd, Chris van Weel, David Egilman,  Charles Boelen, Sara Willems. It has been distributed at the UN High Level meeting on NCDs in New York on 19.09.2011. It could probably stimulate a plenary debate at the Geneve Health Forum

Increasing Access to Rural Health Care through an Integrated Micro-Health Insurance Programme: Nepal

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Author(s): Biraj Karmacharya1, Chandra Yogal1, Prabin Shakya1, Roshan Mahato1
Affiliation(s): 1Dhulikhel Hospital, Kathmandu University, Hospital, Kathmandu, Nepal,
1st country of focus: Nepal
Relevant to the conference theme: Redesigning health services
Summary: One of the main challenges of rural health care in developing countries is to provide quality health service, which is sustainable. A community based health insurance program, backed up by a not-for-profit rural health partnership (with a tertiary level university hospital), coupled with strong public health program and support for livelihoods (e.g., through microfinance) can be an excellent triad in this endeavor. Our experience and research with sixty families in a community prove that there is financial sustainability, significant user satisfaction, improved health service seeking behavior and also an increased demand for such program in the rest of the community.
What challenges does your project address and why is it of importance?: In countries like Nepal, where national rural health services operate at primitive levels with totally unorganized level of care, an alternative but complementary approach to rural health care is indispensable. Private services are too expensive and also too difficult to access (because of difficult terrains, poor and expensive transportation, etc.) whereas a cheaper but quality community based approaches can provide strong technical management and long-term sustainability. Communities, if made aware, can be motivated to participate in developing a tailor-made health care program but lack the technical expertise to run such program by themselves. Whereas inability to pay does form a major barrier, equally important are the poor health service seeking behavior (because of poor health awareness) and greater community participation in organizing such a health care system. Without addressing these three issues, namely, ensuring a quality health service facility, making the people aware about the real need of health care and providing a way to financial support the health services that people seek, are absolutely inter-related and indispensable components of an alternative community based rural health care in developing countries.
How have you addressed these challenges? Do you see a solution?: We proposed a solution to this by addressing the three components. 1) Developing quality health service facility: By involving a not-for-profit tertiary level university hospital-Dhulikhel Hospital(DH).  In developing a rural primary level health center in Bahunepati, in coordination with the community, we established a center to provide quality health services to the people in the vicinity. The center is technically run by DH and also boasts of weekly visits from specialists from the central hospital as an outreach program. Consultation fees are not taken but the procedures and medicines are charged with a nominal profit margin of 6%.  The capacity for the community based learning programs of the medical and allied health sciences students to use this centre was also one of the major benefits to DH.  Incorporating public health programmes: The center was developed not just as a platform for curative health services, but was also used as the main place for training the communities through a range of community based women's health programs, school health programs and youth training programs run jointly by the students, health personnels (of hospital and the health center) and key volunteers from the community. Financial alternative: In order to make the people able to afford the health services of the center, it was vital that the people increase their capacity to improve their earnings, a part of which would be ear-marked for the health services of the women and the children. We implemented a microfinance programme for women from sixty families organized in six different groups, each member receiving a loan of about USD 100 to be paid back in three years. The loan was used for various livelihood activities and each was supposed to pay a monthly insurance premium of about 2 USD that would cover the basic health services for the woman and her children. This included round the clock health services provided by a junior doctor and assistants, access to basic medicines at the health center, access to basic surgical procedures (limited under local anesthesia), and basic obstetric and gynaecological care. Partnership with government for free obstetric care and family planning made the cost of these services almost negligible for the center. Terms and conditions were developed in coordination with the women and community members.
How do you know whether you have made a difference?: An assessment after six months revealed that about 95% of women were very satisfied with the scheme and the services. The insurance premium raised covered almost 85% of the total cost of the health services (measured in terms of medicines, surgical procedures and other use of the facility) used by the women and their children (the rest was covered by Dhulikhel Hospital). It was also encouraging to see that women visited the center for all their and their children's major health problems in the mentioned duration. The voluntary participation of the women in the health programs (mainly training and awareness) of the center was about 90%. Moreover, a survey of 50 other women in the villages who had not been included in the program revealed that 42 of them would like to join a similar program (that they came to know through their peers).  The women were also included in Cervical Cancer screening program (through PAP smear) and other health programs. A separate study also showed that they were very active in bringing other women in the health programs at the center (when 18 women were trained on the importance of cervical cancer screening, a week later the women that came for the screening was 67). Dhulikhel Hospital also found the results very encouraging as it seemed to compensate a major bulk of the running cost (mainly the consumables). The prospects of slowly taking this to a break-even point is very bright as the women are quite motivated, willing to pay more (with the time-bound increase in the profits made through the investments of microfinance program) and are not likely to overuse or underuse the facilities (because of proper trainings). Moreover, use of the health center also for the academic activities of Dhulikhel Hospital kept the running cost low, as most of the public health programs were run through a meticulously structured student program. We are expanding the program with other groups and also in five other centers. It is vital to discuss the possible challenges with the community beforehand as often the solutions suggested by them are better. In our case, the women were ready to increase the premium amount for increased scope of services.
Have you or the project mobilized others and if so, who, why and how?: Nepalimed Holland and Microcredit for Mother supported for the seed money of microfinance. Nepalimed Switzerland together with Dhulikhel Hospital supported the infrastructure and the set-up of the health center. Dhulikhel Hospital oversees the technical management of the health center and also possible financial back-up in the process of building the program to a self-sustaining level. Also for the community based learning programs of DH that use the health center makes the financial contribution by DH a low-risk investment. The academic units of the hospital meticulously prepare the programmes of the students (medical as well as allied health sciences students) which benefit, not just the students, but also benefit the communities, leading to a community based learning which is also a service-based learning. The students along with hospital and centre staff run almost all the public health programmes. The community provided land for the building and until the building was completed, they provided a modest housing for the staff and for the health center. The community coordinators volunteer (without any pay) for the activities of the health center and are actively involved in developing new strategies, following up and mobilizing other members of the community. They also participate actively in the public health programmes of the center. The center also closely works with the government health program and has managed to get reimbursed for the free services of the government, mainly in obstetric care, family planning, immunization and tuberculosis treatment. Three local schools are also involved in a range of school health programmes involving the teachers, students and the parents. Two youth clubs are involved in the adolescent health programmes of the center and work closely with the two high schools in the community. The farmer's groups are involved in occupational health programmes (mainly regarding safe use of pesticides) of the center as well. The women’s groups form the strongest partner in the community and, because of the training, act as the strongest social facilitators in matters of health. Thus a strong network of various groups of the community has been developed making the center a vibrant place of activities and a source of change in the community.
When your donor funding runs out how will your idea continue to live?: The micro-finance program has about a 98% pay-back rate and hence the money can thus be reinvested with new groups. The women (who received benefits with microfinance) were also themselves running a microcredit program for other women, but with higher interest rates. There has not been any donor money for the running cost of the program (which was basically borne by DH), and is now being planned to be covered with the expansion of this insurance program to a wider group in multiple phases. Partnership with DH makes the running costs really low (by getting students for public health programmes, easier and cheaper services from the specialist doctors, more efficient referral and teleconsultation services and by getting cost-effective training programs for the staffs of the center for maintaing quality of the services provided). The involvement of the community also significantly decreases the investment as well as running costs as the land was donated by local people and there is access to local resources, e.g. free water supply, road access, free access to stones for construction. Partnership with government is another factor in decreasing the running cost of the program. Similarly partnerships with local groups, e.g., schools, youth groups, farmers groups and women’s groups indirectly support the health center. We believe that this program has a strong possibility of being replicated in other parts of the world. The innovative approach of this program is that it seeks to address health not just as an entity, but as an outcome and hence tries to incorporate this approach in the implementation strategy of rural health services. Attempts to integrate health care with public health and livelihood support programs seem more likely to succeed in an increasingly difficult rural health services in developing countries. Partnerships with other organizations, including government, help to create a win-win and an efficient system of health care.

Merits of a New Explicit Definition of Health in India


First: Johannes
Last: Bircher
Name your project or intiative: Merits of a new explicit definition of health
1st country of focus: Global
Relevant to the conference theme: Health governance
Summary: So far no definition of health has been generally accepted. The Meikirch Model (MM, is new definition that supports an understanding of health on the basis of six explicit criteria. It is expected to assist individuals and societies to assume responsibility for health. A pilot study is planned in Orissa, India. There the MM is may result in a more coher-ent and focussed health care system. Teaching of the MM to the population from Kindergarten to old age may induce a culture of health. Thereby the control of non-communicable diseases may be strengthened with an excellent cost/benefit ratio.
What challenges does your project address and why is it of importance?: The word “health” is ambiguous, because it’s meaning changes with the context, in which it is used. The definition of health of WHO of 1946 is very idealistic and therefore of limited use in practice. Philosophical definitions of health have a level of abstraction, which makes their general use difficult. The ambiguity of the term health is unfortunate, because it facilitates subtle misunderstandings, power struggles, and moral hazard. For these reasons there is a burning need to define health unambiguously and to describe it with criteria that can be as-sessed in practice. The Meikirch Model is such a definition. Its potential for health care sys-tems goes much beyond chronic diseases. This shall be explored in Orissa, India in a pilot study together with the NYSADRI Organization in Bhubaneswar.
How have you addressed these challenges? Do you see a solution?: The Meikirch Model reads as follows: “Health is a dynamic state of wellbeing characterized by a physical, mental and social potential, which satisfies the demands of a life commensu-rate with age, culture, and personal responsibility. If the potential is insufficient to satisfy these demands the state is disease.”  The described potential consists of two components, a biologically given and a personally acquire potential. Therefore the six criteria for the assess-ment of health are the biologically given and the personally acquired potential, the demands of life, age, culture and personal responsibility. Papers will be developed that explain the Meikirch Model for all levels of the health care system. These papers will be explained in detail to relevant health care personnel and to teachers at all levels. The consequences of this interaction will be followed for one year and then evaluated. The methodological details are in progress.
How do you know whether you have made a difference?: The Meikirch Model has the potential to change health care systems in the following ways: Reduction of the ambiguity of the term “health” is expected to lead to a more coherent and more focussed health care system. General knowledge about what health is may result in the introduction of a culture of health. The Meikirch Model defines areas of responsibility for health, i.e. personal responsibility, social responsibility and overlapping responsibility. These changes are expected to be particularly useful for chronic diseases. The functioning of this concept will be monitored and investigated.
Have you or the project mobilized others and if so, who, why and how?: not as yet
When your donor funding runs out how will your idea continue to live?: If the project results in measurable improvement of health care, its contiunation will finance itself

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.