During the last Technical Working Group meeting at the Provincial Health Department in Takeo province, MoPoTsyo staff presented results of the 5 Peer Educator Networks (PEN) in Takeo's 5 Operational Districts. These include performance results of each of the networks but also results on adherence to treatment and cost data.
The Khmer language version of these presentations can be downloaded here in pdf. As each of the 5 OD's has its own PEN and some started earlier than others, each network performs differently, based on the standardised re-assessment method and indicators. The reward levels vary according to individual performance of every peer educator. The annual cost per patient per OD is not the same. Thanks to strong support from Cambodia's Ministry of Health for the Peer Educator Networks, MoPoTsyo has begun to involve the OD Offices in the supervision and in the re-assessments of the Peer Educator Network activities to as one of the priorities in public health care.
In Phnom Penh, Cambodia, from May 2nd to 4th and under the title “Regional Forum on Health Care Financing”, an international conference was held. It was organized & funded by the following institutions: Cambodia’s Ministry of Health, USAID, URC, the French AFD, the Australian Nossal Institute for Global Health, the Belgian BTC-CTB and LuxDev from Luxembourg. The 150 participating experts, mostly health economists and many from 7 countries in the region, came together. What made this conference particularly interesting is that Financing for chronic NCD was among the topics (Day 3). For decades the traditional view of experts has been that there was insufficient evidence to encourage Governments in Low Income Countries to allocate resources for secondary prevention of chronic NCD. As a result of long neglect by public policy, failing markets dominate in the area of chronic NCD and play nowadays a destructive role in health system development in those countries.
Alarmingly, recent studies found that NCD slow down progress towards the Millennium Development Goals( (2010) Drivers of Inequality in Millennium Development Goal Progress: A Statistical Analysis. PLoS Med 7(3): e1000241. doi:10.1371/journal.pmed.1000241) and even economic growth measured by GDP. Recently, Chronic NCD’s have been getting more attention from health policy makers but there is still a lack of robust data on costs of effective care in developing countries. The long term neglect also means that there is a knowledge gap where it comes to advising on practical implementation and delivery of cost effective secondary prevention in developing countries. There is no large pot of global money available to begin to do something similar to what was done a decade ago in order to address HIV-AIDS, TB and Malaria. As political pressure has been mounting to do something, there is a great need for studies and scientific debates on evidence and better understanding of which responses are in the best interest of the populations in developing countries.
On the Forum’s Day 3, Prof James LoGerfo from the University of Washington (Seattle, USA) moderated a session consisting of 3 parts: First, researcher anthropologist Chean Men, PhD cand., interviewed 5 Cambodian diabetic patients on stage, as the experts on how they have been financing their diabetes care. They gave their answers frankly and live in front of the audience, that listened to simultaneous translation into English. Every one of these patients had been coping for more than 5 years with diabetes. While 2 of them had been finding their own way during all those years, 3 others had been member of Peer Educator Networks and were therefore experienced in a different way. The diabetic patients answered his questions on how they take care of themselves. The recordings of these live interviews will be analyzed. Chean Men's recently published article about inequitable access to services for people with Diabetes called " I wish I had AIDS" features on the WHO Alliance for Health Policy and Systems Research's front page and can be accessed here. The second part of the session consisted of 5 slide presentations. Prof LoGerfo provided a general introduction, followed by MoPoTsyo staff's 4 slide presentations which were essentially excerpts from 4 new posters produced for the forum and all about aspects of financing of secondary prevention of chronic NCD in Cambodia.
Heang Hen (Monitoring Officer): Poster 1: Paying for performance in chronic NCD
Suy Vannak (Fin-Admin): Poster 2: Costs of Care: introducing the 14 products
Mao Ngeav (Pharm.): Poster 3: Costs & Service Revenue
Mao Ngeav (Pharm.): Poster 4: Vouchers to help the most vulnerable patients access their prescription medication: (a first experience with this social health protection tool, financed by Health Equity Fund)
The last slide of each presentation raised a number of issues for debate. These were discussed during part 3 of the session: Group discussions! The results were reported back to the plenary. The background reader which had been distributed for the topic can be downloaded here. From the group discussions it emerged that "Secondary Prevention is Possible" and that many of the activities which these Peer Educator Networks have been undertaking over the past 7 years in the operational districts (screening, promoting early diagnosis, training in disease self-management, helping to organize the priority medical services in the public facilities, monitoring and building a follow-up system) are useful from a public health perspective and that they should be integrated as part of public policy for chronic NCD.
The Forum provided an opportunity for the participants - and many are not clinicians – to learn from a cost-effective example of chronic NCD patient-centred care in the low resource setting. The need for more research and action-research remains large. If Cambodia can meet the primary care needs of these chronic patients, perhaps other developing countries in the region can too....? Technical agencies and donors please take note...!
Other important things that happened recently and worthwhile to highlight are:
In Switzerland, the Geneva Health Forum (http://www.ghf12.org/) was held from 18 to 20 April 2012. This time, the forum was entirely dedicated to Chronic Disease as this year’s title indicated: A critical shift to chronic conditions: learning from the frontliners. There was a wealth of interesting examples from practice. Among them experiences with MoPoTsyo’s Peer Educator Networks, shared through videos
(see http://www.ghf12.org/?p=2953) and (http://www.ghf12.org/?p=1541)
plus a short presentation in the session on “Therapeutic Education”.
The interested Endocrinologist-Anthropologist Dr Yehuda Kovesh Shaheb has visited several times the Peer Educators in the rural areas and slums. Please read his blog:
(40.000 views). He has picked up many valuable lessons for other contexts.
A new intervention area: In January, the health authorities from Baray Santuk OD in Kompong Thom province, traveled to Kong Pisey OD in Kompong Speu province in order to see for themselves a functioning Peer Educator Network (funded by AUSAID). Since then, the written agreements to establish a network in Kong Pisey OD have been signed. Eleven candidate Peer Educators from the operational district Baray Santuk in Kompong Thom province are being trained.
The first 4 peer educators passed their exam at the end of May, so they can begin to organize the community-based self screening for diabetes and set up the network in Baray Santuk OD, the 9th Operational District in Cambodia with a PEN. These activities are mostly funded by the Belgian Government through Louvain Coopération au Développement (LD), but matching funding has to be found next year. There is a Mental Health intervention in same area, managed by LD and TPO. We will try to create functional links between the Peer Educator Network for the lifestyle related chronic diseases and the mental health intervention. There is also a food security intervention which may also provide opportunities for certain linkages. Below is a picture of the first Peer Educator for Baray Santuk (right), Mr Saem Savath. He is the head of a primary school with 250 pupils, a school which he had helped to set up a few years ago. On the left Dr Bun Socheath, trainer of Peer Educators.
Early this year, on Sunday morning January 29 2012, at MoPoTsyo’s office, staff was given opportunity to present data from ongoing research to our Board members and regular visitor and adviser Prof. of Internal Medicine at the University of Washington Dr James LoGerfo. Although board membership is unpaid, MoPoTsyo's board has grown which is a good sign of interest in the role of our NGO in Cambodian society.
After passing the “due diligence process” of Global Giving, MoPoTsyo made web pages to raise funds for the most vulnerable among our members with diabetes in the urban slums. There are currently 56 members with diabetes in the urban slums who receive vouchers to help them pay their routine prescription medication. We hope to increase their number to 250 such urban slum patients with diabetes over time.
Please take a look at http://www.globalgiving.org/projects/help-250-cambodian-diabetics-phnompenh-city-slums/ For USA citizens the donations are already tax deductible. In The Netherlands, the so called ANBI status has been applied for which will hopefully result there also in tax deductibility.
The World Diabetes Foundation approved the audit carried out in 2012 by Price Water House Cooper of the WDF Grant 09-463. This grant finances partly the expansion of our peer educator networks in Takeo province, from 1 OD to 5 OD's.
Beginning 2012, CSC and MoPoTsyo began to collaborate in organizing screening among Diabetics for presence of Diabetic Retinopathy or other eye problems among its members with diabetes in the urban slums. If a treatable problem is found, including laser, the treatment is free including cataracts and other eye problems, even if surgery is required. Since the start in February 2012 more than 100 MoPoTsyo members with more than 5 years Diabetes were screened. More than 30 were found with early stages of Diabetic Retinopathy. This complication can cause blindness unless it is early diagnosed and well managed. The early stages are asymptomatic but patients often present with multiple other eye problems which bother them and therefore more important to them. The first 100 beneficiaries came forward spontaneously, many with eye-problems, so the proportion 30 out of 100 is not representative for our whole membership and should not be used to calculate prevalence. Much of the challenge will lie in creating an effective follow-up system for Diabetic Retinopathy. For this we have adapted our database. Follow up will only be effective if the patients understand the threat to their vision from DR, separating this issue from their other eye-problems. In clarifying this the Peer Educators can play a key role, with extra training. Although the screening, the transport and the treatments for the screened patients is all free of charge, MoPoTsyo uses a voucher system that is distributed by the Peer Educator because the voucher, with its explicit wordings in Khmer language and the name and ID of the beneficiary, strengthens the perception of entitlement by the beneficiary and that may help overcome some of the barriers. Barriers are not only financial but also social. See below for an example of the voucher.
At the end May 2012, MoPoTyo and CARITAS Takeo Eye Clinic signed a similar screening agreement for diabetic members of MoPoTsyo in Takeo and Kompong Speu. There also, the transport, screening and treatment of Diabetic Retinopathy is free, but not treatment for the other eye problems. CARITAS Eye clinic has a means test to decide which patient is poor and qualifies for a certain discount. It will be useful to compare the outcomes of the two programs over time in terms of effectivenes of the screening and of the follow up. If patients have to pay for treatment of other eye-problems, it may prove more difficult to motivate them to go for screening in the first place and to return to the clinic for follow-up. Time will tell...! CTEC will train MoPoTsyo's Peer Educators on diabetic retinopathy so they can explain it to the patients and convince them to join the screening.
Every year, Cambodia’s Ministry of Health meets with its Development Partners to prepare for the Joint Annual Performance Review. This year’s Pre-JAPR was held in Kampot. Like in 2011, the Ministry of Health and Development Partners decided again in 2012 to include Peer Educator Networks among the priorities in meeting the challenges from NCD. The later held JAPR confirmed what had been prepared.