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GHF2014 – PS04 – Integrating Traditional and Alternative Medicine into Health Systems

PS04 TUESDAY, 15 APRIL 2014 ROOM: 18 ICON_Fishbowl
Integrating Traditional and Alternative Medicine into Health Systems
Dr. Edward Kelley
Director, Department of Service Delivery and Safety, World Health Organization, Switzerland
Dr. Bertrand Graz
Geneva University, ISG, Switzerland
Making Heath Care Affordable to Poorest Communities Through Acupuncture: India
Mr. Walter Fischer
Founder and Project Manager, Barefoot Acupuncturists, India
Integrating Ayurveda: Clinical Studies on the Ayurvedic Treatment of Rheumatoid Arthritis Offer New Perspectives
Mr. Olivier Talpain
Associate researcher at the University Institute of History of Medicine and Public Health in Lausanne, Switzerland
Dr. Zhang Qi Coordinator, Traditional Medicine, World Health Organization, Switzerland
Research and integration of traditional/complementary medicines into the health system. The case of malaria in Mali and diabetes in Pacific islands.
Dr. Bertrand Graz

MD, MPH, Institute of Global Health, Faculty of Medicine, University of Geneva, Switzerland
Across the world, traditional medicine (TM) is either the mainstay of health care delivery or serves as a complement to it. In some countries, traditional medicine or non-conventional medicine may be termed complementary medicine (CM).Starting from specific experience, we will discuss WHO Traditional Medicine Strategy 2014-2023, which states that:"The demand for TM/CM is increasing. Many countries now recognize the need to develop a cohesive and integrative approach to health care that allows governments, health care practitioners and, most importantly, those who use health care services, to access T&CM in a safe, respectful, cost-efficient and effective manner. A global strategy to foster its appropriate integration, regulation and supervision will be useful to countries wishing to develop a proactive policy towards this important - and often vibrant and expanding - part of health care.

Kelley_EDr. Edward Kelley

Dr. Kelley directs the Department of Service Delivery and Safety at the World Health Organization.  In this role, he leads WHO’s efforts at strengthing the safety, quality, integration and people centredness of health services globally and manages WHO’s work in a wide range of programmes, including health services integration and regulation, patient safety and quality, blood safety, injection safety, transplantation, traditional medicine, essential and safe surgery and emerging areas such as mHealth for health services and genomics.  Prior to joining WHO, he served as Director of the U.S. National Healthcare Reports for the U.S. Department of Health and Human Services in the Agency for Healthcare Research and Quality. These reports track levels and changes in the quality of care for the American health-care system at the national and state level, as well as disparities in quality and access across priority populations. Dr. Kelley also directed the 28-country Health Care Quality Improvement (HCQI) Project of the Organization of Economic Cooperation and Development. Formerly, Dr. Kelley served as a Senior Researcher and Quality Assurance Advisor for the USAID-sponsored Quality Assurance Project (QAP) and Partnerships for Health Reform Project Plus (PHRPlus). In these capacities, he worked for ten years in West and North Africa and Latin America, directing research on the Integrated Management of Childhood Illness in Niger. Prior to this, Dr. Kelley directed the international division of a large US-based hospital consulting firm, the Advisory Board Company.  His research focuses on patient safety, quality and organization of health services, metrics and measurement in health services and health systems improvement approaches and policies.

Physician and specialist in public health/international health (MPH from John Hopkins University

Dr. Bertrand Graz

Physician and specialist in public health/international health (MPH from John Hopkins University, today with Lausanne and Geneva universities), Bertrand Graz has been conducting development and research activities in Switzerland and in tropical countries, while keeping clinical activity as well. His doctoral thesis led to the validation of a non-surgical treatment for trachomatous trichiasis in Oman and China. After this, he has been leading many studies on the health effects of local traditional practices, such as  herbal treatments for malaria in Mali and diabetes in Palau, early rice feeding in Laos, Greek-Arab medicine in Mauritania, self-care for dysmenorrhoea in Switzerland. Now he aims at studying the effect of such research process in terms of optimisation of health resource's use and public health impact.

PS04_Walter_Fisher_squareMr. Walter Fischer

He has always needed to change lives and jobs whenever he knew he had hit the wall. Since early age, he chose traveling as a major mean to change and grow.  After 4 years of college, studying business and international trade, he started his professional career as export manager in a multinational. A few years later, he left and explored Asia. he went back to a (successful) business before definitely realizing that his way was elsewhere, in something hopefully more meaningful and useful to society. Studying and practicing acupuncture were a life changing experience to him. He finds it fair to share it with those most in need. He is a strong believer in the change we can bring together, with adequate tools and true intention. Humanitarian healthcare faces unlimited challenges, together with different and complementary professional approaches, situation of millions can be improved.

O_Talpain_squareMr. Olivier Talpain

As a former producer of fiction and documentary films myself, I particularly enjoy watching good documentary films. Thanks to Indian film maker Pan Nalin, I discovered Ayurveda for the first time, through his documentary film which struck me. I was impressed by the sophisticated holistic approach of the Ayurvedic system of medicine and the complexity of its medicines. Many Ayurvedic formulations are produced using tens of substances, through several long and complex processes. The testimonies of patients about unhoped-for recoveries touched me. I’ve eventually found it hard to believe that what seemed to be a remarkable blend of knowledge and know-how was kept aside and even threatened. Something didn’t make sense; I had to understand.

When I went back to university to study social sciences, I chose Ayurveda as the key issue of my research. I wrote the final dissertation of my Master in Development Studies on the recognition of Ayurveda through modern scientific research. I focused on two clinical trials on the Ayurvedic treatment of rheumatoid arthritis (1976-2012) that were funded by WHO and NIH-NCCAM. They both showed that the treatment gives positive results.

Still many questions remain. Why was the first study not published by the modern physicians in charge of it? Why is there so little research to assess Ayurveda? I am currently working on a PhD project to find some answers.

Zhang_Qi_squareDr. Zhang Qi

Dr Zhang Qi is leading the Traditional and Complementary Medicine Programme(TCM) in the Department of Service Delivery and Safety(SDS), WHO. He studied both conventional medicine and traditional medicine. He used to be a doctor, researcher and governmental official responsible for traditional medicine in China. He led the work of integration of traditional medicine services into national healthcare system in the department of healthcare services and headed the department of international cooperation, State Administration of Traditional Chinese Medicine, Ministry of Health In China. He used to lead the supervision on services, management and clinical research in the five hospitals affiliated to China Academy of Chinese Medical Science which is the national research institution for traditional Chinese medicine in China.



Certificate Course In Evidence Based Diabetes Management: Capacity Building of Primary Care Physicians in Diabetes Care, India.

Author(s) Shivangi Vats1, K Srinath Reddy2, V Mohan3, Sandeep Bhalla 4
Affiliation(s) 1Training, PHFI, Delhi, India, 2PHFI, PHFI, New Delhi, India, 3Dr Mohan’s Diabetes Specialities Centre, Dr Mohan’s Diabetes Specialities Centre, Chennai, India, 4CCEBDM, PHFI, New Delhi, India.
Country - ies of focus India
Relevant to the conference tracks Education and Research
Summary CCEBDM is a pan India program for the capacity building of primary care physicians in the field of diabetes. As the country is becoming the diabetic capital with a lack of trained physicians in this field this program is launched in 2010. An evaluation was done to assess the short impact of the program and it was found that the program was effective and the skills of the physicians improved after attending the training program.
Background Diabetes is considered one of the major contributors to the global burden of disease. It exemplifies management challenges because of long latency, chronicity, multi-organ involvement and long term care. In India, health system is constrained in term of trained manpower and limited institutional capacities for diabetes management. A balanced approach to equip primary care physicians with advanced and newer evidence based knowledge for better diabetes management is fundamental.
Objectives This article/paper is aimed to assess the impact and effectiveness of PAN INDIA Certificate Course in Evidence Based Diabetes Management (CCEBDM).
Methodology CCEBDM is an evidence based diabetes management course with the objective of improving the treatment outcomes for patients by serving as an evidence based guidance for clinical decision making in risk assessment, diagnosis, prognosis and management of diabetes. Improvement in knowledge of physicians was assessed by quantitative and qualitative methods. For quantitative analysis pre and post test scores were used and for qualitative analysis, end-line evaluation as a cross-sectional survey was conducted with 100 and 125 randomly selected physicians from CCEBDM Cycle-I and cycle-II respectively using pre tested scheduled questionnaires two months after completion of cycles.
Results Pre-post test scores of 2776 physicians were assessed for the knowledge improvement and it was found that there is significant improvement (P value < 0.05) in knowledge regarding basics of diabetes, pharmacological treatment, acute and chronic complications with management. Once the course was completed the frequency of treating diabetic patient/physician/month increased (38% 501 to 1,500 patients per month and 44% stated that they treated about 101 to 500 patients per month), and the confidence level of physician increased in the field of diabetes diagnoses and management. Frequency of physicians who were confident to manage diabetic complications like hypoglycaemia (73%), peripheral neuropathy (94%), skin complication (82%), sexual dysfunction (78%), diabetic foot (74%) and nephropathy (71%) increased. 90% were confident about managing patients on insulin independently.
While assessing the clinic structure it was found that 66% of physicians had provision for laboratory facilities routine blood screenings, 53% had on-site dieticians who help the diabetic patients, 35% had a counsellor to guide the patients, 49% were using DBMS, 79% had full time nurses on duty, and 76% used various forms of Patient Education Resources to elicit awareness about diabetes. The majority of the physicians agreed that the course contributed significantly to their knowledge of diabetes management and added value to their treatment skills. All agreed that curriculum was up-to-date with latest advances and guidelines and faculty’s personal clinical experience added to their teaching were very useful as now they can consult the diabetic experts anytime for references.
Conclusion CCEBDM is an evidence based course and uses recent clinical findings in developing clinical guidelines for better management of diabetic patients and is very effective in improving the knowledge of physicians and clinical practices in diabetes management. Also by building the capacity of primary care physicians in diabetes management, it seems to be a solution to control the increasing burden of diabetes and to improve the productivity of people who are living with diabetes.

Eldercare in Cameroon: attendance of a proximity hospital in Yaoundé.

Author(s) Jossy Eyenga-Oli1, Armelle-Lucrèce Ngougni-Kana2, Marcel Azabji-Kenfack3, Eddie-Karistan Lakoudjeu 4, Nkodo Mendimi 5
Affiliation(s) 1Direction, Hôpital de District de la Cité Verte, Yaoundé, Cameroon, 2DESSAF, DESSAF, Yaoundé, Cameroon, 3Department of Physiological Sciences, Faculty of MEdicine and Biomedical Sciences, Yaoundé, Cameroon, 4Social Affairs, DESSAF, Yaounde, Cameroon, 5Direction, Hôpital de district de la Cité Verte, Yaoundé, Cameroon.
Country - ies of focus Cameroon
Relevant to the conference tracks Health Systems
Summary Cameroon is entering a demographic transition era, as elsewhere in Subsaharan Africa, with more old persons in proportion to the general population. But, our hospitals are not prepared for elderly care in terms of attendance, since there are no baseline data. This study examined the attendance of a proximity district urban hospital, and gives the basic statistics of hypertension, diabetes and elderly admission in a 3-months period. We underlined the neccessity of planning a policy in terms of capacity building for elderly.
Background In recent years, several studies have reported that African countries are facing an era of demographic transition, with a marked increase in the proportion of elderly people. In Cameroon, recent statistics reported approximately 6% of older people in the general population.
Because our health services are not fully prepared specifically for the care of the elderly, it is essential to establish a statistical observatory hospital attendance by the elderly. This is in order to build better care policies for this population group. For this purpose, we have conducted this pilot study to provide baseline data in terms of attendance.
Objectives To describe the attendance and basic epidemiological patterns of elderly patients (≥60 years old) admitted to outpatient departments during a 3-months period, monitoring routine activities related to chronic health problems, hypertension and diabetes mellitus.
Methodology It was a cross sectional retrospective study conducted from June to August 2012. Data were collected from medical records, including age, sex, social status, medical history and type of treatment. Incomplete records were excluded from the study. Ageing was defined as follows: Group-A= “Younger patients”, aged 65 years. Statistical analysis was performed using MS Excel 2003.
Results At the outpatients department, we recruited consecutively from the registers a total of 1714 patients during the study period. The mean age of the whole attendance in adult consultations diabetes/hypertension unit was 39.5 years (21-87 years) and the sex ratio (male:female) of 1.08. We recorded 47,8%, 30,7% and 21,5% respectively for Group-A, Group-B and Group-C. Among them, 447 were definitely admitted for Diabetes and 171 for complicated hypertension. The diabetic patients were divided into 18,3% for Group-A, 48,3% in Group-B and 33,3% in Group-C. Hypertension patients were divided into 31,0% for Group-A, 41,5% in Group-B, and 27,5% in Group-C. The main comorbidities associated were chronic kidney disease (25.4% of the total attendance) and chronic heart disease (15,3%).
Conclusion These data show that, both in the outpatient department and admission wards, the proportion of older people varies between 20% and 45% of our health care activities, which is huge compared to the proportion of 6% the age in Cameroon. This pioneer work is an urgent plea to establish a more detailed preliminary for a plan that is dedicated to elderly care in district hospitals statistical observatory. A phase of capacity building of staff in aged care is also a conducive form of retraining.

Take a Step for Diabetes

Author(s) Beatriz Yáñez1, Martijn Pakker2, Marie-Hélène Charles3, Lorenzo Piemonte 4, Leonor Guariguata 5, Aneta Tyszkiewicz6.
Affiliation(s) 1Programmes and Policy, International Diabetes Federation, Brussels, Belgium, 2Programmes and Policy, International Diabetes Federation, Brussels, Belgium, 3External Relations, International Diabetes Federation, Brussels, Belgium, 4External Relations, International Diabetes Federation, Brussels, Belgium, 5Programmes and Policy, International Diabetes Federation, Brussels, Belgium, 6Programmes and Policy, International Diabetes Federation, Brussels, Belgium.
Country - ies of focus Belgium
Relevant to the conference tracks Advocacy and Communication
Summary Diabetes is a global epidemic that has traditionally lacked proper attention, a situation the International Diabetes Federation (IDF) is working to revert through integrated advocacy and communication efforts. IDF pushed for a UN High-Level Meeting on Non-communicable Diseases, held in 2011 and resulted in a Political Declaration on NCD prevention and control, placing diabetes high on the global health agenda. IDF also implements campaigns such as “Take a Step for Diabetes” to raise awareness on diabetes to an increasingly broader audience thanks to social media. The combined advocacy and communications efforts result in campaigns to help reduce risk factors and raise awareness on diabetes.
Background Diabetes and Noncommunicable Diseases (NCDs) are the leading cause of death and disability worldwide - accounting for 34.5 million of the 52.8 million global deaths in 2010 (65%). They exact a heavy and growing toll on physical health, economic security and human development.A global epidemic at crisis levels, diabetes affected 371 million people in 2012 and the number is due to increase to 552 million in 2030.The United Nations Political Declaration on NCD Prevention and Control raised diabetes/NCDs to the top of the international agenda and led to the adoption by the 66th World Health Assembly (WHA) of the Global Monitoring Framework (GMF). This sets out 25 indicators to monitor progress towards the achievement of nine voluntary global targets by 2025 – including halting the rise in diabetes and obesity.

Therefore, advocating for health strategies and promoting social mobilisation to decrease NCD risk factors is vital. This can be achieved through awareness-raising communications that will have a positive effect on improving both diabetes/NCDs management and preventing the rise of new cases of diabetes and NCDs.

Objectives Despite its consequences, diabetes continues to lack proper attention: half of all people with diabetes in 2012 – a shocking 186 million – were undiagnosed and type 2 diabetes is increasing worldwide at an alarming rate. Raising awareness of the risk factors and promoting healthier lifestyles have the double impact of improving diabetes management and halting its rise.
The International Diabetes Federation (IDF) – whose mission is to promote diabetes care, prevention and a cure worldwide – has two objectives to revert the present situation: advocate for political commitments and increase public awareness.INFLUENCING POLICY
In 2009 IDF, the Union for International Cancer Control, the World Heart Federation and the International Union Against Tuberculosis and Lung Disease formed the NCD Alliance (NCDA), a highly influential civil society force focused on placing non-communicable diseases (NCDs) on the political agenda.
IDF and NCDA have engaged in high-level advocacy to achieve this effect. IDF and NCDA campaigned for a UN High-Level Meeting on NCDs, held in September 2011 which was a major milestone in the history of diabetes and other NCDs. During the Summit IDF and NCDA influenced political negotiations to secure strong outcomes for diabetes and NCDs. The unanimously adopted Political Declaration on NCD Prevention and Control, opened the door for further advocacy efforts towards a Global Monitoring Framework (GMF). This was finally endorsed by the World Health Assembly in 2013. The GMF has 25 indicators to monitor progress to the achievement of nine voluntary global targets by 2025 – including halting the rise in diabetes and obesity.
IDF and NCDA’s work does not finish with the adoption of these global targets. IDF, its Member Associations and NCDA continue to work to monitor the progress governments make on their promises and to press the case for including NCDs in a global development framework post-2015.SOCIAL MOBILISATION
Despite the political will to stop the current diabetes epidemic that is reflected in the adoption of these nine voluntary global targets, there must be more advances. There will be no change unless both people with diabetes, and those at risk of developing the condition, are aware of the risk factors and willing to adopt healthier lifestyles. With that objective IDF has set in motion the social mobilisation campaign “Take a step for diabetes”, as part of the 5-year World Diabetes Day theme “Diabetes: education and prevention”.
Methodology Over the last four years World Diabetes Day has focused on raising awareness of the warning signs and risk factors of diabetes, highlighting the serious global threat that it poses, promoting simple and cost-effective measures to prevent the further rise of type 2 diabetes and the importance of diabetes education from a young age.With the goal of keeping the global commitments on diabetes made during the 2011 UN Summit on NCDs on the global health agenda, IDF launched the 2013 campaign “Take a Step for Diabetes” in March 2013, marking the final year of the “Diabetes: education and prevention” campaign.Conceived as a new way of raising awareness, inspiring local communities and promoting membership “Take a Step for Diabetes” has been designing as an innovating, engaging programme. It encourages people to make a symbolic donation of steps accrued through activities that help promote diabetes awareness, improve the lives of people with diabetes, promote healthy lifestyles or reduce one’s individual risk of developing diabetes. A total of 32 activities – ranging from wearing blue to running a marathon – can be done repeatedly. The aim is to reach 371 million steps – one for each person with diabetes in the world.

The main target groups are IDF member associations, other diabetes-related organisations, young leaders in diabetes, health professionals and community groups promoting healthy nutrition and physical activity. However, everyone – individuals and groups - is invited to register on the campaign website ( and submit steps, providing a short description of the activities performed. The steps are collected on an online platform that displays the total number of steps submitted and the gap to the 371 million target.

This campaign is widely promoted through all IDF communication channels: website, social media (Facebook, Twitter, YouTube), newsletters (IDF, World Diabetes Day, World Diabetes Congress) and events where IDF has a stand. Specific communication materials have also been developed for the campaign including web banners, promotional videos, posters promoting key messages, a smartphone application, merchandise and an online toolkit providing information and resources on diabetes.

The “Take a Step for Diabetes” campaign will be widely promoted in the run up to and on World Diabetes Day – November 14 – and will officially end at the World Diabetes Congress Melbourne 2013 – 2-6 December.

Results The IDF campaign “Take a Step for Diabetes” has been designed to reach not only people and organisations strongly connected with diabetes – IDF regions and member associations, other diabetes-related organisations, community groups active in promoting healthy lifestyles, young leaders in diabetes, health professionals – but everyone who is interested in promoting the diabetes cause and furthering IDF’s mission.One of the campaign’s goals is to involve as many people as possible. The use of social media – mainly Facebook and Twitter – is essential in reaching a broad audience and engaging new publics in constructive dialogue. With more than 21.000 fans on Facebook and 13.000 followers in Twitter informed daily about the campaign, “Take a Step for Diabetes” has proven to be a powerful instrument for social mobilisation.More traditional means of drawing attention to the campaign are also used: the WDD newsletter had over 25.000 subscribers in September 2013 and, since the launch of the campaign in March the WDD website had achieved more than 100.000 views.

By the end of September 2013 over 450 individuals and groups had registered on the campaign online platform and performed around 8000 activities, accruing more than 332 million steps. The achievement of 90% of the target, 371 million steps by December 2013 which is 3 months in advance of the deadline, reflects the campaign’s impact and success.

However, as IDF is encouraging its member associations and other organisations and groups to organise WDD awareness activities – particularly during the month of November and WDD (November 14), a significant hike in the submitted number of steps is expected around those dates. Considering that the initial 371 million steps target will possibly be achieved before then (October), and the campaign does not end officially until the World Diabetes Congress 2013 in December, it is likely that IDF may increase the current steps to make the goal more ambitious.

Once the target is achieved and the campaign is over, IDF will send an open letter to the United Nations Secretary General Ban Ki-Moon on behalf the “Take a Step for Diabetes” participants. The great social mobilisation achieved through this campaign will be used to advocate for the global commitments on diabetes made during the 2011 UN Summit on NCDs to be kept on the global health agenda.

Conclusion Diabetes is a massive global burden with brutal health and socio-economic consequences. Although type 2 diabetes – which accounts for the vast majority of the cases worldwide – is largely preventable, the number of affected people is increasing in every single country. Tackling the current situation is a health priority for which interdisciplinary collaboration is imperative.Advocacy and communication are two inextricably linked working areas with the common objective of raising awareness. While advocacy is focused on influencing governments and key authorities to develop more comprehensive policies and strategies, communication promotes dialogue by delivering a series of messages to the general public. Both of them have a big role to play in overcoming the diabetes epidemic.The foundation of the NCD Alliance, of which IDF is founding member, was a clear advocacy milestone in combatting the NCDs and diabetes outbreak. As a network of more than 2,000 organisations, the NCDA is using its powerful voice to press governments into giving urgent response to NCDs as was shown by the UN High Level Meeting in 2011. The adoption of the GMF with its nine voluntary global targets to achieve by 2015 is another NCDA victory.

Political commitments on diabetes and NCDs are of great importance but would have little impact if the population is not aware of the risk factors to which we all are exposed. Communication campaigns such as “Take a Step on Diabetes” are perfect tools to promote healthy lifestyles and raise awareness on those risk factors. Social media has meant a revolution in this discipline, as now it is possible to reach a much broader audience than previously. In addition, an engaged population is another influential force for holding governments accountable for their political commitments.

Advocacy and communication are continuously interacting and frequently the outcome of one discipline can be used as a tool by the other. On the occasion of the achievement of the “Take a Step for Diabetes” campaign target a letter will be sent to the UN Secretary General Ban Ki-Moon, to continue advocacy efforts on keeping diabetes and the NCDs high on the political agenda. The constant feedback between advocacy and communication is a mechanism that needs to be continuously strengthened, to ensure the best outcomes in the fight against diabetes and NCDs.

Analysis of Medicine Entitlement Programs for NCDs in the Philippines.

Author(s) Raoul Bermejo1, Beverly Lorraine Ho2, Wim Van Damme3
Affiliation(s) 1Department of Public Health, Institute of Tropical Medicine -Antwerp, Manila, Philippines, 2Health Unit, Philippine Institute of Development Studies, Manila, Philippines, 3Department of Public Health, Institute of Tropical Medicine -Antwerp, Antwerp, Belgium.
Country - ies of focus Philippines
Relevant to the conference tracks Governance and Policies
Summary In response to rising non-communicable disease prevalence and access to medicines challenges for the worst-off, the national government has launched three medicines access programs. Data were collected from informant interviews, site visits and document reviews. These were analyzed by first creating a chronology of events. Then, using a health policy framework, strategies and actions used along with the results were examined. Findings revealed that the rapid roll out of the NCD access programs exhibited strong political commitment towards UHC. However, weak policy processes have failed to ensure equitable access to quality and cost-effective medicines and implementation success.
Background As more Filipinos continue to be exposed to non-communicable disease risk factors such as tobacco and alcohol use, unhealthy diets and physical inactivity, prevalence for hypertension and diabetes mellitus have risen to 21% and 7.7 % respectively in 2008, and are expected to increase further. Cardiovascular disease and diabetes, along with cancer and chronic respiratory disease account for 57% of total deaths during the same year. According to the National Health Accounts, 52.7% of health expenditures are out-of-pocket. Of these, pharmaceuticals – accounting for 65.75% of household spending – are the single largest item of health care expenditures for households. Republic Act 9502, a law providing for cheaper and quality medicines was enacted in 2009.The Department of Health’s National Center for Pharmaceutical Access and Management launched three medicine access programs, namely DOH Complete Treatment Pack (ComPack), Valsartan (VAP) and Insulin Access Programs (IAP). ComPack provides complete (monthly) treatment regimens at no cost to the poorest families identified under the NHTS who are diagnosed to have diabetes and hypertension. VAP and IAP make available patent-protected Valsartan and Insulin at 60% lower cost than market prices.
Objectives The paper aims to document the policy process of three NCD medicine acces programs in the Philippines using a health policy analytical framework. Specifically, the paper seeks to understand the interaction of strategies that were employed and the factors that contributed greatly to policy advancement.
Methodology A qualitative, case study methodology using an in-depth longitudinal, prospective examination of events was employed for each of the three programs. Primary and secondary data were collected from (1) interviews with key policy and programme stakeholders; (2) visits to programme implementation sites; and (3) review of government documents, development partner reports, meeting records, conference proceedings and media clips. Representatives from government, academic institutions, nongovernment organizations, multilateral and bilateral agencies were interviewed. The interview guide reflected the three themes of emergence, formulation and implementation as described in the analytical framework by Lemieux (2002). A chronology of events was developed and process tracing was conducted. Triangulation of multiple data sources and discussion/verification with key actors supported interpretation and minimized bias.
Results Emergence: Our analysis shows that the following were critical in moving the access programs forward: (1) political commitment to achieve Universal Health Coverage by 2016, (2) availability of national health budget, (3) strong NCD policy community and access to medicines alliances, (4) increasing focus for the worst-off population and (5) strong industry lobbying.Formulation: The policy unit responsible for the programs was operational for less than 3 years when the policies were conceptualized and launched, and did not receive full technical support as was required. A relatively participative process was undertaken to define the contents but there was minimal integration into the health system.Implementation: Full subsidy of $15 million/annum and $400,000 are allocated for the ComPack and VAP. IAP has no subsidy since it is procured on a supply now-pay later (or consignment scheme). Information activities, implementation and evaluation support were constrained for all three programs largely due to funding limitations. The non-uniformity of information across health workers and patients resulted in a varied application of the policy in different implementation sites. Implementation was compromised by immediate national roll-out and devolved set-up for ComPack and the limited access sites for IAP and VAP. Availability of an efficient means for monitoring and responding to stock-outs remained a major challenge. To date, no plans for program evaluation have been articulated. IAP and VAP were also unable to address access challenges especially for the worst-off.
Conclusion The rapid roll out of the NCD access programs exhibit strong political commitment towards UHC. However, weak policy processes have failed to ensure equitable access to quality and cost-effective medicines and implementation success. Findings indicate that that rapid rollout of access to medicines programs is possible only if strategies employed are purposeful and contextually sensitive. Favorable conditions for the emergence of a policy may not always exist but can be created.

Understanding Policy Development of an NCD Benefit Package: Philippines

Author(s) Raoul Bermejo1, Pura Angela Wee2, Wim Van Damme3.
Affiliation(s) 1Department of Public Health, Institute of Tropical Medicine -Antwerp, Manila, Philippines, 2Zuellig Center for Asian Business Transformation, Asian Institute of Management, Manila, Philippines, 3Department of Public Health, Institute of Tropical Medicine -Antwerp, Antwerp, Belgium.
Country - ies of focus Philippines
Relevant to the conference tracks Governance and Policies
Summary There is increasing global attention on Non-Communicable Diseases (NCDs). In the Philippines, the burden of NCDs is growing but government response remains weak. The study is a policy research that looks at the development of a new benefit package for non-communicable diseases within the Philippine social health insurance program (Philhealth). We investigated how the interaction between the context, actors and processes contributed in shaping the policy. The push for Universal Healthcare, the increasing fiscal space, the growing burden of NCDs, and the increasing demand for access to quality medicines are important contextual discourses that help push the development of the benefit.
Background There has been increasing attention to non-communicable disease (NCDs) globally since the run-up to the high-level summit at the United Nations in September 2011 (Beaglehole 2011). In the Philippines, the burden of NCDs is growing (Shaw 2010). Although the government has started to develop policies and programs to address NCDs, there is still poor financing especially for prevention activities and comprehensive primary care services, lack of health human resource and weak political support (Higuchi 2010; Dans 2011). At the community level, the implementation of NCD programs, comprising mainly of healthy lifestyle clubs and occasional screening activities, remain weak (Lorenzo 2011). Overall, there is an inadequate response considering increasing burden of disease (Bermejo 2011; Van Olmen 2011).The improvement of the health financing mechanisms and particularly of the national health insurance agency, PhilHealth, is seen as a key in decreasing inequities and improving access (Romualdez 2011). One of the new Philhealth benefit packages that is ready to be piloted is the “Outpatient Medicines Benefit Package For Hypertension, Diabetes And Dyslipidemia” also known as the "Primary Care Benefit 2" (PCB2).
Objectives The study is essentially a policy research which looks at the development of a new benefit package for non-communicable diseases within the Philippines social health insurance program (Philhealth). We investigated how the interaction between the context, actors and processes contributed to shaping the policy. The study will also identify different streams in the discourse around PCB2 and analyze how and why this specific policy window emerged.Philhealth is emerging to be one of largest purchasers of healthcare services in the Philippines. It is an agency attached to the Department of Health and is increasingly seen as one of the institutions that shape the healthcare landscape in the country. This research will help to gain insight into its policy making processes, what and who these affect and how these are influenced. This study will help us identify opportunities for improvement of the policy processes at Philhealth and develop recommendations to inform current health policy.
Methodology Study design
A case study methodology was done using both qualitative and quantitative methodologies. Documents and issuances related to the development of PCB2 including Administrative Orders, Philhealth Circulars, other legal issuances, and reports of key meetings and events were reviewed. Key informant interviews were conducted among an initial list of actors involved in the development of this new benefit package to gain insight into the key decision made, why these decisions were made and how such decisions were arrived at. The snowballing technique was employed to identify other potential interviewees. The study aimed for theoretical saturation. A trend analysis on quantitative data from the Philhealth database on inpatient claims for NCDs was performed to enrich the contextual description of the case.Sampling
A total of 28 key informant Interviews were conducted with actors involved in the development of PCB2, including:
1. Philhealth decision-makers (e.g. the former and current president of Philhealth, technical personnel within the Primary Care Benefit Team);
2. Program managers and decision-makers at the Department of Health specifically those who are concerned with primary care, NCDs, access to medicines and local health systems development;
3. Members of the academe and researchers consulted on PCB2;
4. Representatives of advocacy groups on Universal Health Care and NCDs;
5. Health officers and representatives of local governments selected as pilot sites;
6. Representatives of the private pharmaceutical sector in the Philippines.Analysis
The policy triangle (Walt and Gilson 1994) and Kingdon’s policy window theory (Kingdon 1995; Guldbrandsson 2009) was applied to analyze the case. The researchers reconstructed the story of the development of PCB2 and identified key strategic decision-making points in the development process. We analyzed how the policy was shaped by the interaction between the context, actors and process. We enriched the contextual description with the time trend analyses of Philhealth population coverage, NCD-related inpatient claims, and reserve funds. The study also identified different streams in the discourse around PCB2, including the discussions on Universal Health Care, NCDs, primary care, strengthening local health systems, and analysed how and why this specific policy window emerged. The research approach was iterative. Each set of data analyzed were used to construct and test the theory.
Results We identified four key elements in the new outpatient benefit package of Philhealth: 1) only for sponsored program members or the bottom poor enrolled into the program by the national and local governments, 2) use of the WHO Package of Essential Noncommunicable (PEN) Disease Intervention guidelines for screening and risk scoring, 3) access to full monthly regiments of 8 firstline NCD medications which were 4) made available through contracted private pharmacies.The focus on the bottom poor is consistent with the overall poverty reduction strategy of the government. The strategy is to concentrate poverty alleviation interventions (e.g. Conditional Cash Transfers, enrolment in social health insurance) among the bottom poor (20% of the population) identified through a national household targeting system for poverty reduction.The use of the PEN guideline for screening and risk scoring was a result of consultation with the World Health Organization (WHO) and with the health managers of the City of Pateros where the guidelines were being piloted. Setting risk scores was seen by the insurance managers as a good way to have control over the cost exposure of Philhealth on this new benefit package. This was further validated by expert consultants in Medicine.The first line generic medications included in the list covered by the benefit package was arrived at with the technical team validating the evidence around NCD drugs included in the Philippine National Drug Formulary. By law, all government agencies, including Philhealth, can only pay or procure medicines that are included in the formulary. The position of Philhalth is to promote rational drug use and is directed at the common practice of many physicians who prefer originator drugs. Representatives of pharmaceutical companies, public health centers and specialist doctors actively raised the issue of the "very limited" list of medicines covered by the package.

The decision to make the NCD medicines available through contracted pharmacies is to be consistent with the Pharmacy Law but also largely depoliticizes access to drugs and link it as a clear benefit of being a Philhealth member. Access to medcines made available through public primary care facilities are often politicized.

The push for Universal Healthcare, the increasing fiscal space, the growing burden of NCDs, and the increasing demand for access to quality medicines are important contextual discourses that help push the development of the benefit.

Conclusion Health policies, programs and and agendas do not exist in separate silos from each other. PhilHealth’s “Outpatient Medicines Benefit Package For Hypertension, Diabetes And Dyslipidemia" or "Primary Care Benefit Package 2" (PCB2) is one such policy whose development was shaped by policy development processes, actors pushing for their specific agenda and by the context. The actual policy is a product of the dynamic interplay of these factors.

The Use of Traditional Medicine: A study in Bangladesh.

Author(s) Rumana Huque1
Affiliation(s) 1Department of Economics, University of Dhaka, Dhaka, Bangladesh.
Country - ies of focus Bangladesh
Relevant to the conference tracks Advocacy and Communication
Summary The present study aimed to examine the determinants of using traditional medicine by different socio-economic groups of people, assess the marketing strategies of providers of traditional medicines, and look at the existing policies that regulate the production, marketing and supply of traditional medicines. Household survey, exit client survey and key informants interview were employed to collect data. The findings suggest that though traditional medicine is popular in both rural and urban areas, inadequate monitoring and poor implementation leads to improper preparation of medicine with low quality or even the manufacturing of such medicines without legal permission.
Background Traditional medicine is the sum total of knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures that are used to maintain health, as well as to prevent, diagnose, improve or treat physical and mental illnesses. In Bangladesh, traditional health care providers (ayurvedic, homeopathic, unanie/kabiraji and others) are common and popular in rural areas leading to low utilisation of public facilities. It is evident that the non-availability of drugs and commodities, poor access to services by the poor, imposition of unofficial fees, lack of trained providers, a rural-urban imbalance in health providers’ distribution, weak referral mechanisms and unfavourable opening hours are contributing to low use of public facilities in Bangladesh. This indicates that though the health care seeking behaviour is partly associated with the socio-economic status of the population, the supply side problems existing within the health system also influence service utilization. In this context, the present study aimed to examine the determinants of using traditional medicine, assess the marketing strategies of providers of traditional medicines and to look at the existing policies to regulate traditional medicine.
Objectives The present study aimed to examine the determinants of using traditional medicine by different socio-economic groups of people and assess the marketing strategies of providers of traditional medicines. The specific objectives are to:• Assess the perception of people about safety, efficacy and quality of traditional medicine
• Identify the reasons for preferring traditional medicines by their types and by different socio-economic groups of people, and the types of services received
• Explore the level of satisfaction of users by socio- economic category, age, and gender
• Investigate the marketing strategies of providers for selling traditional medicines
• Identify the national policy and existing regulatory mechanisms for traditional medicines
Methodology The study followed a cross sectional survey approach where both quantitative and qualitative data was collected from exit clients, providers and at the household level at a single point of time. The study was carried out in two districts: Tangail and Munshiganj. Two upazilas from each district had been chosen randomly. Household surveys were carried out to assess the extent to which people from different socio-economic groups prefer traditional medicine and the reasons for preferring traditional medicine. Household surveys gave an overall understanding of the preference for traditional medicine among the population. A total of 800 households were surveyed from the four upazilas, taking 200 from each upazila. Among the households, 400 households were selected from rural poor areas and 400 from urban/peri urban non-poor areas to include samples from different socio-economic groups. A multi-stage stratified systematic random sampling approach was adopted. Wards were selected as Primary Sampling Units (PSU) through a systematic random sampling procedure from the list of wards as documented in Community Series Population Census 2001, published by Bangladesh Bureau of Statistics. After selecting the sample wards as the PSUs, we again adopted a systematic random sampling technique to draw sample households from the wards. We followed a cluster randomization approach for selecting the households within the sample frame. A semi-structured questionnaire was used for the household survey. Randomly selected 20 exit clients of each type of traditional medicine users (160 clients from eight facilities/providers) were interviewed to assess their knowledge, attitude and practice regarding traditional medicine usage, and their level of satisfaction. This contributed to the gathering of a more specific understanding of the preference for traditional medicine among the users. A semi-structured questionnaire was used to collect data. We interviewed three policy makers within the Directorate General of Health Services and one academic. A total of 18 traditional medicine providers were also interviewed for the study. The quantitative data were analyzed by using both descriptive and analytical statistics. Transcribed qualitative data were analyzed with respect to context, process, and outcomes.
Results Traditional medicine was popular among households in study areas. Overall, 48% of the households sought treatment from traditional providers in the recent past for themselves or for any one of their family members in the study areas, while the proportion was relatively higher in Tangail (54%) as compared to Munshigonj (42.5%). It was also found that the proportion of households who used traditional medicines were higher in Sadar upazilas (51%) as compared to the remote upazilas (45%). It was evident that 47% of households who had sought treatment from traditional providers were poor defined as those whose monthly household income was less than 10,000 Taka. Households sought treatment from traditional providers generally for women and children, who suffered from fever, pain, common colds and general ailments such as anemia, helminthiasis and nutrition, eye infection, common dental diseases and ear problems. The percentage of households inclined to take treatment from traditional providers for the elderly was relatively low in both areas (15% in Tangail and 11% in Munshigonj), and a few of them sought treatment for non – communicable diseases such as diabetes, cardio-vascular disease, hypertension, heart diseases and hypertrophy of the heart. The major reasons for seeking care from traditional providers were low cost, no side effects, prompt services and most importantly the close location of the service centre which makes the service easily accessible. It was found that illiterate and little learned persons were the main clients of traditional medicine. A considerable number of exit clients were found to be familiar with traditional medicine and had been using it for quite a long period. Therefore, from the view point of effectiveness, the clients were satisfied with traditional medicine. Most of the clients of both districts claimed that they never had any side effect for using traditional medicine. Providers also distributed leaflets in popular public places, did promotion on TV through cable operators and made miking and wall paintings to attract less-educated and middle income group people. It was evident that though there exists law and policy regarding production and practice of traditional medicine in Bangladesh, the poor implementation of the law and inadequate monitoring leads to improper preparation of medicine with low quality or even the manufacturing of medicines without legal permission due to the unavailability of proper medicine testing laboratories for traditional medicines.
Conclusion Traditional medicines are believed to be made of natural products and therefore are safe and have no side effects. However, traditional medicines and practices can be harmful if the medicines are inappropriately prepared and consumed. For mainstreaming the traditional medicine into the public health system, the followings measures need to be adopted:• A proper regulatory framework is required for the quality production and safe use of traditional medicine in Bangladesh. Given the heterogeneity of the service provision by the traditional providers, a monitoring and regulation mechanism needs to be developed to ensure quality of service provision. Governments should take the necessary measures to strengthen drug administration to ensure the quality of traditional medicine.• An appropriate medicine testing laboratories service must be introduced to ensure the quality of Unani, Ayurbedic and Homeopathic medicine.• Government needs to establish training centres for service providers and manufacturers of traditional medicine.

• Initiative should be taken by government and NGOs to increase awareness among the population about the service variety and quality of traditional medicine.

• Further research should be done on the cost-effectiveness of traditional medicines, pharmacology of natural products, characterization of natural products, synthesis of natural products, product development and possibility of commercialization of traditional medicine.

Integrating artistic programs in diabetes education and self management in Madagascar.

Author(s) Tojosoa Rajaonarison1, Haja Ramamonjisoa2, Tiziana Assal3, Jean-Philippe Assal4, Georges Ramahandridona5.
Affiliation(s) 1Art-therapy, Madagascar Diabetes Association, Antananarivo, Madagascar, 2Therapeutic Education, Madagascar Diabetes Association, Antananarivo, Madagascar, 3Art-therapy, Foundation for Research and Training in Patient Education, Geneva, Switzerland, 4Therapeutic Education, Foundation for Research and Training in Patient Education, Geneva,Switzerland, 5Medical, Madagascar Diabetes Association, Antananarivo, Madagascar.
Country - ies of focus Madagascar
Relevant to the conference tracks Chronic Diseases
Summary The Malagasy perception of diabetes is negative. Patient with diabetes often do not accept their treatment and their family members reject them. Heath caregivers need to be closer to patients and to promote a good collaboration with them.
Our Diabetic Association has organized up to 12 painting workshops from 2010 to 2013 with 141 patients. They are centered on patients’ problems and needs. Each workshop provides painting exercises associated with specific moments: blood sugar measurements, diet discussion, and hypoglycaemia. Health caregivers provide flashes of therapeutic education during this time. Workshops also provide psychological and social balance enabling patients to be more responsible for their health
What challenges does your project address and why is it of importance? Painting workshops are a tool to promote therapeutic patient education for all types of diabetics. Organized by A.MA.DIA. (Association Malgache contre le Diabète à Antananarivo), they have brought many changes in our participants’ lives: patients are finally able to express themselves more freely, they discover their personal creativity, they are more involved in social activity, they feel less isolated. This process has a strong effect on the coping ability of each patient. Adherence of treatment increases, medical appointments are better respected and the doctor–patient relationship improves. As a consequence, there is a general improvement of patients and care providers’ attitudes. They all feel more empowered in their daily activities. After the workshops patients feel that their family members understand them better.
How have you addressed these challenges? Do you see a solution? The A.MA.DIA has faced many problems over the years including crowded outpatient clinics, lack of enough fully trained personnel, difficulties in continuing education as well as being faced with false copies of medication: diabetic oral agent, antihypertensive drugs, and antibiotics. This situation has forced us to develop specific courses to teach patients to detect the copies of false drugs that patients may have bought cheaply at a local market.
Hypoglymia in children and young adults is another serious problem.
During the workshops with children, the blood sugar is tested and explanations are given about corrective snacks.
Another aspect is the timidity of patients in the presence of the care providers. The consequence is that patients suffer from a lack of psychological support.
Painting workshops reinforce continuing education as well as the self-reliability of patients.
They develop self-confidence and autonomy.
How do you know whether you have made a difference? The various activities we described, linked to therapeutic education, did not exist 4 years ago. Since their creation and development, there is an increasing demand for participation among patients as well as their families.
There is a weekly connection through skype between A.M.A.DIA and the Geneva center, and a monthly video sessions with the participation of experts who are at the disposal of the team of l’AMADIA Hospital. Those meetings allow joint discussions, lectures, supervision, continuing evaluation and support.
The experts have writen some observations about our workshops of Art-Therapy : “The thing that strikes all those who have observed the AMADIA workshops is the extraordinary enthusiasm and commitment of the caregivers and patients. Caregivers experiment continuously new ways of helping patients using art, working with different groups of participants: families, young diabetics, aged people as well as mixed groups."
The example of AMADIA shows that art can be integrated in a global system of care where emotional expression and medical care can be simultaneously present.
Have you or the project mobilized others and if so, who, why and how? Among the various approaches we have developed, we obtained help from the World Diabetes Foundation and the order of St. Jean France and Switzerland. This allowed the improvement of our Hospital AMADIA and the widening of detection campaigns throughout the country. We also have the benefit of monthly Video sessions with Geneva with the help Orange Madagascar and the Foundation for Research and Training for Patient Education in Geneva.
When your donor funding runs out how will your idea continue to live? We think that financial support from donors is of vital importance for the continuity of the painting workshops. Madagascar is a very low income country and so are the majority of our patients. Many people cannot even afford the cost of their daily pills.
However, psychological support is necessary for people living with diabetes. It is fully recognized that painting equipment colors, paper, brushes are expensive. This is why this type of practice should be supported.

Improving Elderly Autonomy Through Serious Gaming and Social Networking.

Author(s) Emilie Pasche1, Rolf Wipfli2, Christian Lovis3
Affiliation(s) 1Division of Medical Information Sciences, University Hospitals and University of Geneva, Geneva, Switzerland, 2Division of Medical Information Sciences, University Hospitals and University of Geneva, Geneva, Switzerland, 3Division of Medical Information Sciences, University Hospitals and University of Geneva, Geneva, Switzerland.
Country - ies of focus Global
Relevant to the conference tracks Innovation and Technologies
Summary In fifteen years, the number of octogenarians will have increased by 80%. With the ageing of the population, chronic diseases are expected to double by 2050. Healthcare systems may collapse under the weight of the demand. In this context, the MobilityMotivator project aims to provide elderly people with a tool to help them age well by improving their mobility and preventing social isolation. This project follows a four-step plan: a specification phase, a prototype development phase, an evaluation phase and a dissemination phase. The conclusion of this project will enable us to determine the impact of such an approach on the mobility of elderly people and the socio-economic impact.
What challenges does your project address and why is it of importance? Only a minority of elderly people perform a sufficient amount of physical exercises. A study performed in England reported that only 17% of men and 13% of women aged 65-74 reach the recommended levels of physical activity. There are many reasons why elderly do not feel they can or should engage in physical activity (e.g. fear of injury, physical limitations, etc.) which leads to a lack of motivation. The consequences of this lack of activity directly results in the decrease of the quality of life of elderly people, with the increased risk of developing chronic diseases (coronary heart diseases, diabetes, etc.) and increased social isolation. Moreover, because of the growing proportion of older adults, this represents an increasing public health problem.
The challenge of this project is to motivate elderly people to remain engaged in physical activities so that they stay connected with their peers. This challenge is of major importance to both the individuals and the society. For the individual, it is essential to age well in order to have a satisfactory quality of life and autonomy. For the society, active ageing will reduce the health costs and also ensure that the healthcare system is able to manage the demand.
How have you addressed these challenges? Do you see a solution? The MobilityMotivator project proposes an approach based on the development of a serious gaming environment to motivate elderly to remain involved in physical activity and social interaction. The approach proposes two modes: a telemonitoring mode and a gaming mode.
The telemonitoring mode is dedicated to the healthcare provider and enables them to supervise and encourage their patients to undergo physical activities, but also to remain active and engaged within the urban environment. The patient performs exercise at home in front of his television and the healthcare provider is provided with monitoring mechanisms to assess cognitive and physical performances of his patient through the Mobility Motivator platform. It also enables the healthcare provider to define the level of challenges for their patient according to the patient's abilities.
The gaming mode is dedicated to elderly people. The game relies on two elderly people playing together: the outdoor player and the indoor player. Initially, both players get in touch through the platform and start a game. The choice of challenges is based on an intelligent engine that customises the game according to the individual’s assessment for mobility and cognitive capacities. The outdoor player, who is provided with a smartphone, faces a mission such as making his way to the museum in the centre of the town. He moves through the game and performs tasks associated with the mission. At some points, the outdoor player interacts with the indoor player, thus receiving feedback and encouragement. During the time, the indoor player is challenged with a cognitive enigma, such as solving simple orientation problems in a given time, or with indoor physical activities such as chair exercises. The end of the game will be achieved when players reach the final destination. The players can repeat the game process at a later date by switching roles. Over time, the game builds a record of progress, which can be analysed by the healthcare providers when evaluating each patient’s mobility and cognitive abilities.
Although health e-games generally provide health literacy, physical fitness, cognitive fitness, skills development and condition management, these are mainly designed for mainstream consumers rather than the over 65 not familiar with technology like the MobilityMotivator. In addition, no other health e-game incorporates telemonitoring functionalities to enable feedback provided by healthcare providers.
How do you know whether you have made a difference? The development of the solution will be based on a rigorous assessment and monitoring of user needs and interests and will be tested through three user representative organisations in three European countries.
The impact evaluation in real living and working environments will aim to assess the usability of the MobilityMotivator environment under real living and working conditions, using key indicators applicable to indoor and outdoor situations. This evaluation will also enable to determine the impact on mobility, autonomy and socio-economic parameters in comparison to a parallel control group experiencing conventional living and working conditions. A number of qualitative and quantitative indicators for success will be identified. Methods for collecting these indicators in an unbiased way will be defined. Data collection will be designed and planned with the support of statistics experts in the design and analysis of clinical trials.
Have you or the project mobilized others and if so, who, why and how? The project is a European research project which is composed of a consortium of nine partners distributed in six countries: Laboratory of Engineering Systems of Versailles (France), Institute für Arbeit & Technik (Germany), Audemat (France), Inventya (England), E-Seniors (France), University Hospitals of Geneva (Switzerland), German Red Cross (Germany), Studio 345 (Luxemburg) and La Mosca (Belgium). The consortium has been designed with careful consideration to the following key requisites. First, the portfolio of complementary skills necessary to ensure project objectives is met. Second, the consortium comprises a balance between industrial SMEs, research community, user involvement and market expertise. Finally, geographical spread aims to facilitate initial establishment in three European countries (Switzerland, France and Germany) as a foundation for future growth and expansion.
When your donor funding runs out how will your idea continue to live? The market for MobilityMotivator has great potential since it is still largely untapped. A study conducted by Empirica found that a mixed market for technologies, which promote active ageing and other telecare related ICT-products, is emerging. Older people from some countries are starting to privately purchase such products and services in order to age well. Healthcare providers may also be interested to improve the quality of care and supervision provided. Moreover, a modest investment in devices that encourage mobility that could improve the ageing process has the potential to save several billions per year in Europe. Dissemination activities need to be focused on all these actors to convince them of the value of having access to the MobilityMotivator environment. There are signs that, with sufficient support, the market for technology for the elderly can be accessed.
European-wide exploitability of the MobilityMotivator is considered from the very start of the project. The consortium partners plan to launch a Joint Venture in order to implement exploitation strategies and business plans following project completion. This is expected to be achieved within the 2 years of project completion. The potential return on investment will be further investigated following the development of the business model in the research phase.

Barriers for Care and Medicines in Diabetes and Hypertension: A pilot study in Lima-Peru.

Author(s) MARIA KATHIA CARDENAS1, Dulce Morán2, Jaime Miranda3, David Beran4
Affiliation(s) 1CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru, 2CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru, 3CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru, 4Division of International and Humanitarian Medicine at the Faculty of Medicine, University of Geneva, Geneva, Switzerland.
Country - ies of focus Peru
Relevant to the conference tracks Health Systems
Summary The aim of this study is to pilot test the implementation, for the first time in Peru, of World Health Organization manual to identify barriers to access to medicines and care in patients with non-communicable diseases (NCD). As part of an active stakeholder engagement in the process, this study aims to promote a policy response. Tools were prepared to collect quantitative and qualitative data. In total, 141 interviews and meetings were conducted in four levels . This study identifies existing bottlenecks in the access to care and management of patients with diabetes and hypertension. This system-level analysis elicits current challenges and opportunities to improve care for NCDs in Peru.
What challenges does your project address and why is it of importance? Non-communicable diseases (NCDs) have been recognized by the global community as a major public health challenge. World Health Organization's (WHO) response includes the development of a Global Action Plan for the Prevention and Control of NCDs for years 2013-2020 and a Research Agenda with focus on the prevention and control of NCDs in low- and middle-income countries (LMICs) such as Peru. The importance of the challenge posed by NCDs in the context of Peruvian health system was also highlighted by the Peruvian Ambassador during the 43rd Session of the Commission on Population and Development. For Peru, WHO estimates a NCD burden that represents 60% of mortality in Peru, which highlights the relevance of chronic diseases for our health system. According to Nolte and McKee the management of chronic NCDs is one of the largest challenges that health systems throughout the world currently face and each system needs to find locally-adapted solutions. These solutions require a clear understanding of the barriers within the health system to access to NCDs care and medicines, from higher policy-level to the individual patient-care experience. Our projects precisely address this challenge.
How have you addressed these challenges? Do you see a solution? We have addressed this challenge by contributing to the limited available body of evidence concerning NCDs and health systems in Peru. Specifically, our study determined barriers for the access to medicines and health care for diabetes and hypertension using a novel tool for health system assessment that was adapted for the Peruvian health sector context. The tool applied was based on the Rapid Assessment Protocol for Insulin Access (RAPIA), a tool that has previously been implemented in six countries (representing four WHO Regions) with the support of the International Insulin Federation: Kyrgyzstan, Mali, Mozambique, Zambia, Nicaragua and Vietnam. Previous implementations of the RAPIA have resulted in improvements in access to medicines like insulin (Mali, Mozambique and Zambia), development of NCD policies (Mozambique and Zambia), inclusion of recommendations in government policies and programmes (Kyrgyzstan, Mali, Mozambique, Nicaragua and Viet Nam), improvement and increase in the visibility of Diabetes Associations (Mali, Mozambique, Nicaragua and Zambia), inclusion of recommendations in projects and programmes of national NGOs (Mali and Nicaragua), external funding and support for diabetes programmes (Mozambique, Zambia and Vietnam) and the use of RAPIA for monitoring and evaluation (Mozambique).At the health system level, the introduction of this tool for the assessment of NCDs will also be helpful for developing future research agendas in the field. This tool can also serve as a field guide to assist researchers in collection, analysis and presentation of data to evaluate and inform the development of health-care services and policies for specific NCDs or groups of diseases.Policy makers can also benefit from these assessments as it can inform them about ongoing challenges or bottlenecks in NCDs-related health care provision. It is expected that the engagement in the planning phases of the study will provide windows of opportunity and knowledge translation that will likely directly translate in policy changes aimed to improve NCD care.
How do you know whether you have made a difference? The results from this study will contribute to a better understanding of the current situation of the management of diabetes and hypertension in the context of the Peruvian health system, in order to formulate appropriate recommendations for the policy decision makers. However, we know that it is premature to attribute any change to this study. In the context of almost non-existing systematic assessments of health systems in the Peruvian health sector, in particular around NCDs, we expect this research to set the grounds for future policy recommendations. Our results show that NCDs are not yet a priority for policy-makers in Peru, at least not in the practice. There are some initiatives that have not yet reached the expected results such as the basic regulation to protect patients with diabetes and a policy to promote reduction of anti-diabetic drug prices. Presently there is only a national guideline for hypertension attention at the primary health level but no guideline approved for diabetes as well as a National Strategy for NCDs without a current Strategic Plan. The universal health coverage in Peru includes a list of essential treatments for each disease covered by any insurance, but it is partially implemented due to the lack of clinical guidelines and the lack of awareness on this topic by the health professionals. At an intermediate and local level we found problems facilitating the demand for medication and laboratory consumables.General practitioners in the lower-level of management provide care mostly to those patients with no complications. Patients with complicated disease are referred to Hospitals, where patients must wait long periods to obtain an appointment. Even those patients with public health insurance often buy their medication at private pharmacies, due to the lack of stock in pharmacy facilities of public sectors. The high price of medicine in private pharmacies is one of the main reasons for treatment cessation by the patient.In order to strive towards achieving a difference we will perform a follow-up on the following activities. As part of the implementation study, a list of recommendations will be shared with the stakeholders before the end of year 2013 and a follow-up of activities will be performed starting the year 2014. During year 2014, every 4-6 months, a member of the research team will contact the stakeholders by e-mail, telephone or by person in order to monitor the implementation of the recommendations.
Have you or the project mobilized others and if so, who, why and how? Since the beginning of the project we participated in different meeting with stakeholders from different sectors in order to establish initial contacts. The purpose of the meetings was to provide information about the project, to listen to different perspectives, and finally, a last activity will be developed before the end of the year to jointly discuss potential recommendations and to define an action plan towards policy changes that are pragmatic and feasible in the current local context. We have developed a presentation of the study to stakeholders, in which we invited them to a workshop session in order to receive feedback of the study. At this workshop we explained the past experience with RAPIA as well as the background and methodology of the present study. The stakeholders gave suggestions and confirmed their support and interest. Among the participants was a high officer of Ministry of Health (MoH), as well as members of different areas of Peruvian MoH, social Security, public health insurance, health organizations, acadaemia, among others.Members of our CRONICAS research team also participated in meetings with the Experts Committee in NCDs, a coordination unit of the MoH. We participated in one of the activities of this Committee which was the discussion of the National Strategic Plan for Prevention and Control of NCD 2014-2021, as well as the meeting for discussing the National Guidelines for Diabetes Management, which has not yet been approved. Additionally, regarding to the Social Security, we also contributed to the Health Services Portfolio, which is a technical guideline for the effective interventions for specific chronic diseases during the patient's lifespan. CRONICAS contribution was cited in the technical document.
When your donor funding runs out how will your idea continue to live? CRONICAS Center of Excellence in Chronic Diseases has as part of its goals "to contribute to research development on NCD in Peru (Goal 1)" and "to participate actively with public health policy-makers and study population (Goal 2)". Therefore, when funding runs out we will still remain in communication with stakeholders. Most of policy makers and stakeholders find our evidence-generation group an ally for policy-related interactions and a source of technical expertise in the generation of future health policies. Whilst being a research-based institution, our group strives towards contributing to the transition from research to action for the improvement of health care in patients with diabetes and hypertension. We also plan to obtain funding in order to develop the study in other regions in Peru which are less-urban and poorer, and have different epidemiological profiles and, obviously, different health-system needs.