- Thursday, 21 February 2013
MoPoTsyo patient information centre helps Cambodians with diabetes to get themselves organised. This is done through the following activities:
How do Peer Educators help to reach people who need chronic care?
Per mid 2016, there are more than 160 Health Center coverage areas with a trained diabetes peer educators in 16 OD’s in Takeo, Banteay Meanchey, Kampong Speu, Kampong Thom, Kampot, Kampong Cham, Svay Rieng and Phnom Penh. More than 700,000 adults have used a urine glucose strip to screen themselves for diabetes. In 2015, more than 15,000 registered patients wer actively using the medical services facilitated by the networks.
To find other diabetic people: In order to reduce the relatively high cost of Blood Glucose (BG) strips, PE identify the Diabetes patients in 2 steps: 1st, by distributing free Urine Glucose strips among the whole adult population residing in the same health center coverage area as where they live themselves. If people see that their (after meal within three hours) urine shows positive for urine glucose, their PE offers the 2nd step with a hand-held Glucometer that uses the 10 x more expensive BG-strip test in order to measure the actual level of BG to decide if someone in fact has Diabetes or not. Combining the 2 steps reduces the cost of screening for Diabetes but unfortunately leaves many adults undetected because the urine glucose strip is not sensitive enough. Any adult who pays for the more sensitive blood glucose test can also enroll later. With the PE permanently based inside the community, remaining active and available for patients, people can approach the PE anytime when they recognize symptoms and hear positive experiences from other patients. With low-cost supplies and covering all villages the whole adult population that resides in one Health Center coverage area can be reached within a period of one to two years at a cost of only USD 0.10 per screened individual adult.
For High Blood Pressure: For detecting and follow up people with High Blood Pressure, the PE set up a Village High Blood Pressure Group where the group uses an automated Blood Pressure device which runs on batteries.
Lifestyle: PE help newly registered patients by explaining them how their disease symptoms relate to their lifestyle and welcoming them into a group. They give them educational materials and counseling about lifestyle changes. Gradually, they can share their disease self-management skills and - knowledge with them. Once they have registered, every new patient gets an ID code and a self-management booklet. This note-book has the ID on the front plus an individual barcode that allows to track use of medical services. This includes monitoring of adherence to treatment that is prescribed by a qualified Physician. As the PE collects both baseline data and follow-up data over time, disease progress and control can be monitored as long as the patient stays member of the Peer Educator Network and continues to use the various services facilitated by the network.
The involvement of Peer Educators in facilitating access to professional Medical Services:
Laboratory Diagnostics: The PE also facilitate access to low-cost outreach blood- and serum collection. This is done through mobile sessions organized by the Peer Educator Network early morning at a Health Center according to schedules known ahead of time. The HC nurse draws blood (venipuncture) . Teams of trained peer educators prepare the samples on ice for dispatching to MoPoTsyo’s laboratory in Phnom Penh. When the results arrive back from the lab to the rural area, every Peer Educator explains these to the patients who live in their area. The system provides screening for Dyslipidemia and Chronic Kidney Disease among registered patients. In some areas, screening and treatment for Diabetic Retinopathy among diabetics has begun as well. The laboratory results are made available for the Doctor during the medical examination to inform and support the Doctor’s treatment decision. Besides helping the Doctor decide on treatment, the laboratory parameters, once they are understood by the patient, can also help motivate him or her to adapt lifestyle and adhere to treatment.
Medical Consultation: When a patient appears not well under control, the PE facilitates for this person their access to a Medical Consultation session at their local Referral Hospital. These sessions are organized at least monthly by the Peer Educator Network on a morning or an afternoon when a sufficiently large (>30 people) group of members from that area can gather to meet the visiting Specialized Physician. This Medical Doctor is contracted and paid for the occasion by the Peer Educator Network from a sum that has been pre-paid by the members. The session itself is run by the trained Peer Educators but it always takes place at the Public Hospital.
In particular in rural Cambodia, there are not enough Medical Doctors with sufficient knowledge and experience to treat Diabetes and High Blood Pressure and provide adequate maintenance treatments. Therefore, during the session this qualified physician also trains his local counterpart – if available - at the Referral Hospital besides doing the examinations of patients who are member and writing prescriptions for routine medication in the patient’s self-management book. These prescription data are also electronically entered into the Patient Database Management system, a software application that tracks content and use of all the medical services organized by the Peer Educator Network. In 2015, doctors from 14 hospitals and 2 health centers received 3 weeks of refresher trainings, organized by Ministry of Health, Sihanouk Centre of Hope and MoPoTsyo, on care for these chronic conditions.
Medicines: The PE’s guide their patients to find the place where to buy their prescription drugs. Since 2006, these are supplied at low and fixed published prices from the Revolving Drug Fund, owned by MoPoTsyo Patient Information Centre. As a not-for-profit Cambodian NGO with formal agreements with the Ministry of Health we import these medicines in bulk and take care of distribution through more than 30 contracted pharmacy outlets, the majority of which are in public hospitals. Selected contracted PE take on various roles also in this aspect of their chronic care system: Revenue collection from the Pharmacy Outlets, stock control, re-supply, monitoring and other aspects of the organization of their Revolving Drug Fund. As the patients are paying the full cost of their medication well below the in-country retail market prices, the RDF is already financially sustainable but it cannot meet the new needs from natural disease evolution as patients need more drugs over time as they can avoid premature death and live longer with good control of their conditions. The RDF is entirely based on pre-financed procurement of medicines and cannot by itself finance expansion to new areas.
Official recognition of Peer Educator Networks and integration with the public system
In April 2014, the Ministry of Health disseminated its National Strategic Plan for Prevention and Control of Non Communicable Diseases 2013-2020. In this plan, the Peer Educator Networks for Diabetes and High Blood Pressure are placed formally under the responsibility of the Operational Districts (OD), the health authority in charge of supervising the local referral hospital and health centers. The national plan also calls for continuation of the existing PEN and their expansion to all OD’s in Cambodia.
Together with their patients, all (usually there 10 to 20) PE in one Operational District (OD) form one Peer Educator Network (PEN). In 2016, there are 16 such PEN in Cambodia. Each PEN reports to the OD Director - the local health authority - about its activities on the 25th of every month based on standard indicators. With the data being collected and entered into the Patient Management Database, the OD Office staff can analyze the extent to which areas with registered patients are using the services sufficiently. They can observe patterns in blood pressure and blood glucose control and try to identify what causes these. In turn, this can help to provide clues to improve services and reward performance. By repeating the 2010 STEP Survey every five years, the MoH can update a denominator against which every Operational District Office will be able to measure its progress with regards to the control of chronic NCD with an acceptable margin of error in their own OD and compare to other OD’s.