Fresh supplies of Insulin and medicines arrived in January. We received the bulk of this Insulin from Insulin For Life Australia, which will help our more than 100 insulin requiring members through the year 2011. The medicines are generics purchased in Europe.
We have excellent support from the Ministry of Health with regards to the custom clearance procedures, all based on the new agreements that were signed recently between MoH and MoPoTsyo creating the official framework for the revolving drug fund for more than 5000 registered members with chronic noncommunicable disease Diabetes and or high blood pressure.
Primary Prevention Results: In Takeo province, in Ang Roka OD, a team of Peer Educators has been carrying out primary prevention activities in communes and in schools. The aim is improving awareness of risk factors for chronic NCD. The target groups are commune leaders and school teachers. The whole OD will be covered. The opportunity is used also to explain the role of the community based peer educators with regards to “secondary prevention”, the prevention of complications due to uncontrolled risk factors. During these primary prevention sessions there are hardly any new diabetes cases found based on the fasting blood glucose test because 98% of the adults in the Ang Roka OD had already self-screened for diabetes in 2007 and 2008 having learned at that time how to use a urine glucose strip. Almost 60% of all people with diabetes in Ang Roka OD are member of MoPoTsyo, if we base diabetes prevalence on the latest STEP Survey of 2010. Normally less than 1 in 3 people is aware of diabetes in rural Cambodia. The experience shows that this self-screening method with urine glucose strip (of course combined with Blood Glucose confirmation) is both cheap and good in a low resource setting. It suggests that technical arguments about the urine glucose strip’s lack of sensitivity, the elevated renal threshold and the most of all of course the need of professional health workers for diabetes screening should not be used in a socio-economic context like Cambodia where you either can do this type of comprehensive intervention encompassing both primary and secondary prevention with patients as low cost actors, or nothing at all. As a result, Ang Roka OD is the only OD in Cambodia which can now boast that 60% of all its resident with diabetes are aware of their diabetes and properly registered. Early detection and care are both helpful in the reducing and delaying secondary complications.
Eye care collaboration with CARITAS: In Ang Roka OD in Takeo province, the Takeo Eye Clinic and MoPoTsyo worked together to get diabetes patients to do an eye check. Yearly eye checks are essential to identify and treat people who are at risk of becoming blind. Among the first 65 Diabetes patients with a history of more than 5 years diabetes there were 4 who needed laser treatment. For some it is too late. But even if it is too late to restore the eye-sight, people can still join in the peer educator groups and participate. We targeted the patients with a history of more than 5 years diabetes.
Use of simple technology: For many years we have been struggling with poor quality scales that quickly break down and are often inaccurate. In fact Cambodians have very reliable scales that they use and which they can repair themselves. Recently we switched…and it is not fancy, it is not modern, it is not high tech or electronic but it so much more adapted to what we need at the moment in the countryside.
Revolving Drug Fund: We are at a cross roads with our Revolving Drug Fund. We have been contracting private pharmacies to sell the medicines to the members, but could we sell them through one or more public health centers to our members? After discussing with the Ministry of Health, we are going to conduct a pilot experiment trying this. Staff attitude, motivation, reporting, mistakes, payments.... It will be interesting and of great value to study this experience !
Laboratory: We have conducted 1826 laboratory tests in 2010 of which 1340 in the communes and 486 at our HQ. External assessments show that the quality is good enough, within the allowable ranges. The prices are at around 30% of market prices. Besides, our members can stay where they are and do not have to travel to town, do not lose time (the technical term is “opportunity cost”) because blood is drawn between 6 and 8 AM in their own community, and last but least, they get an explanation from their peer educator on what their results means for them. It is a great service for the patients and very much appreciated, including by the Medical Doctor who has to decide on treatment. We are preparing introduction of proteinuria or albuminuria testing among the range of tests that we offer at community level. The program will be studied in May and June of this year by a volunteer who is both anthropologist and biochemist.
Policy & Advocacy:
Research Report by CAS
Center for Advanced Studies published the report of its research into the immediate effects on people with diabetes when the join the organization as member and start to benefit from the Peer Educator Network intervention. The full report can be downloaded here.
GIZ (formerly GTZ) published a report of the study on the social health protection of older persons and persons with disabilities and on how to integrate their needs into the Cambodian social health protection scheme that is being designed. The report is based on field research in Kampot and Kampong Thom, provinces where MoPoTsyo does not have a Peer Educator Network, so the needs of older people with diabetes and high blood pressure that emerge from the report are tremendous. The report strongly supports the establishment of peer educator networks such as MoPoTsyo’s to help protect these people. The full report can be downloaded here.
MEDICAM NCD Task Force Position Paper
In a series of meetings the NCD Task Force prepared a position paper for MEDICAM which can be downloaded here. The group struggled to find appropriate words for describing the risk that chronic patients could become the new cash cows of the public health services. With privatization there is a risk that the health system becomes too dominated by medical facilities relying on user fees from the service users. Chronic patients are most vulnerable and their interests are increasingly at stake. There is no protection foreseen in the health system for near poor or middle class. The disease related expenses of pre identified poor and community based health insurance clients are simply not covered unless the clients are hospitalized. The problem asks for an appropriate vision and the NCD Task Force lists the principles underlying such a vision. It all seems feasible, but will these principles be adopted and respected ? The future will tell us !
Joint Annual Performance Review organized by the Ministry of Health: During the preparation of the JAPR the wordings of the annual operational planning were slightly modified in order to incorporate the future collaboration between Ministry of Health and Development Partners with programs or interventions on Noncommunicable Diseases. That includes NGO's like MoPoTsyo, in particular with a view on Goal number 4 of the National Strategy on Noncommunicable Diseases. This is an important step for the future so Cambodia will be able to invest in expansion of Peer Educator Networks to other areas in the country which are presently not covered. The total cost is an estimated USD 2 to USD 2.50 per capita as a one time investment to get the system into place. Once the system is in place, the poor patients can be assisted with targeted subsidies, so they will have equal opportunity to benefit from the new system.
ICIUM conference Alexandria : the ICIUM conference planned for April 2011 in Alexandria (Egypt) has been delayed with a couple of months. MoPoTsyo had prepared 2 abstracts on access to routine medication for patients with diabetes and high blood pressure.
WDF: Emily Kirstein of the World Diabetes Foundation came to visit the WDF09-463 project in Takeo province. She met patients, peer educators, a Village High Blood Pressure Group leader and MoPoTsyo staff. During two busy days she visited field locations, health facilities and spent time to discuss at Head Quarter. She saw primary prevention activities, a medical consultation session at a referral hospital and peer educator conducting a group session.
ICCO KIA came to Cambodia in order to announce that they will withdraw in one year the financial support to their health program. The background reason is of course the financial crisis and cuts in the Dutch government’s budget for development aid. Unfortunately this will affect us seriously because ICCO KIA is our donor for the project in Thmar Pouk OD. We had engaged with him for “the long term’ and are preparing for a second phase to the Thmar Pouk OD project. Without donor money this is impossible. We, and our partners CAAFW and CAS, need to find another donor. ICCO KIA is helping us to approach other donors.
Bridges Funding: The International Diabetes Federation funds translational research proposals for the 3rd time in Round 3. The idea is generate reliable evidence about what works in the real world, instead of the artificial world of laboratories and not sustainable demo projects. Together with diabetes service providing organisations in Democratic Republic of Congo and in Philippines, and with technical support from Antwerp Tropical Institute, MoPoTsyo is partner in a proposal to pilot the use of mobile phones to help improve diabetes patient outcomes in those 3 countries. The research is set up in such a way that the results of the 3 countries can be compared and combined. The Ministry of Health supports our funding application (download Letter of Endorsement). At the moment, we wait for the IDF decision whether the research will be funded or not. After that we have to get ethical approval. Only 20% of our members have a mobile phone in Cambodia and their proportion is increasing over time. Would it make a difference if patients receive a mobile phone or not..?
Friends For Life (The Netherlands) is a foundation in the Netherlands which supports the activities of MoPoTsyo. This year the foundation’s President, Willem van de Put, came to visit the urban slum project in Sras Chork early morning during the gathering of people with diabetes. Friends for Life is our main supporting organization based in The Netherlands. It helps us to raise funds in The Netherlands. We have been able to obtain funding from private donors in the Netherlands, including the Diabetes Association Netherlands (DVN) which was subsequently doubled by Impulsis.
Louvain Développement's, General Director Bernard Hanin came to Cambodia to visit the ongoing Louvain projects in Kompong Thom province with regards to Mental Health. Louvain (a.k.a. LD) and MoPoTsyo have agreed to start to work together in 2011 to find out if and how we can link the Peer Educator Network for Diabetes and High Blood Pressure with a Mental Health intervention. That will provide new lessons for health policy on chronic NCD in low income countries. LD is closely linked with the University of Louvain in Belgium. On the picture Bernard Hanin visits a Diabetes Peer Educator session in the urban slum of Sras Chork near the Boeungkak Lake in downtown Phnom Penh where this diabetes group has been running since 2005, managed by patients themselves and financially sustainable.
Center of Hopeand MoPoTsyo have a longstanding collaboration. In early March Dr Thai Sopheak and Dr Johan van Griensven visited the Diabetes Peer Educator peer support group in the slum area of Sras Chork. Together we are thinking about ways to help people living with AIDS who develop chronic NCD. It is time to integrate our interventions with a view on sustainability. Not easy.
Men Rithy Chean of the Center for Advanced Studies published the report on his investigation into the early effects of the Peer Educator Network in Thmar Pouk OD in Banteay Meanchey. Both the presentation and the report can be downloaded here.
Integration into the public health care system: With their positive impacts on the population becoming more evident, the Peer Educator Networks gradually integrate into the public health care system at lower levels, although their role has not yet been subject of detailed healthy policy. They are part of the National Strategy but in terms of implementation there are no detailed regulations or policies. There is growing interest from the side of the Cambodian health authorities in the intervention. The review of the achievements of 2010 in Takeo was done in an event held at the Provincial Health Department with representatives of the Operational Districts present. A similar review of the Peer Educator Networks activities for the diabetic and high blood pressure members in the urban slum areas was held for the first time inside the Municipal Health Department involving the Operational Districts West and North. At both occasions there were discussions on how we can strengthen collaboration and planning, in particular for 2012 when the Annual Operational Plan will allow the intervention to be included for the first time.
In 2010, MoPoTsyo became member of the WHO's Alliance for Health Policy and Systems Research. This research unit based within WHO commissioned MoPoTsyo to start documenting its intervention. The work consists of 3 outputs. The first deliverable is a international literature review which can be downloaded here.
Peer Education and its benefits in low income countries require more study in how it functions in different contexts. Peers for Progress is regularly publishing a newsletter with the latest developments.
In Thmar Pouk OD, there are now 7 Peer Educators. Their local supervisor is Mr Seak Sarun. He is our Diabetes Program Manager in charge of the whole network with 259 diabetes patients (25 Jan 2011) and 106 high blood pressure patients (25 Jan 2011). He traveled to Phnom Penh in February for reporting but also to join in the selection and purchase of the motorbike that he will use to perform his official duties. There are now 4 private pharmacies contracted in this area to dispense the medicines to the members. In the near future, we will collaborate with RACHA in Thmar Pouk OD to pilot the dispensing of medicines to our members through one of the Health Centers. RACHA has excellent technical expertise with the medicine distribution logistics of the Central Medical Store, so they are an important technical partner to ensure good the design and monitoring of this innovation. In December 2010, the members had the opportunity to get laboratory examinations for the first time.
After completing 5 years of adventurous growth, we thought it would be a good idea to have an external management review. The person who did the review is an experienced hospital manager from the UK, currently working as VSO volunteer in Thmar Pouk OD advising the Hospital Management there. His findings are laid down in the report that can be downloaded here. It is an independent review and we did not pay the reviewer, as he had agreed to volunteer and do it for free. Thanks Oly Shipp and thanks to VSO.