Transcript No Slide Title

How to Approach
CKD Prevention in Large Country
SK Agarwal
Outline
 Introduction
 Preventive program in other countries
 Proposed prevention program in India
 Healthcare set-up in India
 Government approach to Non-communicable diseases
 Where we need help at present
 Summary
Summary
Incidence of ESRD
260 / pmp
RT
3 / pmp
CAPD
1 / pmp
Govt. spend
8$/capita/yr
What to rest
254 pmp ?
HD
2 / pmp
RRT /person /yr
750-3000 $
Death
Prevention is only solution
Preventive Program for Chronic Illness
Issues involved:
 Is the disease prevalent in the country
Yes
 Are the effects serious to warrant prevention?
Yes
 Is the disease/causes of disease easy to detect?
Yes
 Can disease be easily prevented?
Yes
 Is the cost of prevention less than the treatment? Yes
 Can the preventable program sustainable?
???
Major Causes of Chronic Kidney Disease
60
50
AIIMS, New Delhi
Apollo, Chennai
PGI, Chandigarh
40
30
20
10
0
Diabetes
Ht
Parenchymal
(CGN+TID)
Etiology of CKD in India
Hospital based studies
Agarwal
et al (2000)
Mittal et al
(1997)
Field study
Sakuja et al Mani MK
(1994)
(1993)
Mean
Agarwal et
al ( 2002 )
No of
Cases
7072
835
453
2028 10388
37
DN
28.4
23.2
23.8
26.7
25
41
Ht
5.7
4.1
13.5
10
8.3
22
GMn
48.5
28.6
36.6
18.2
32.9
16
TID
7.5
16.5
14.3
27.8
16.5
5.4
PKD
1.9
2
3.5
2
2.3
0
Prevention Program in Other Countries
Can Causes and CKD easily detectable?
Parameters
KEEP Ivor Sylvia
Hoy WE
(USA) (SA) (Singapore) (Australia)
History of Diabetes & Ht




Questionnaires




Ht & Wt
Urine for Sugar & Protein








Spot urine Alb/Cr




SCr, Blood Sugar, HBA1c

mcg Albuminuria ?


X

X

X
Risk of CKD in Relatives of High Risk Group
Familial aggregation of CKD is high





Hypertension
Diabetes mellitus
IgA Nephropathy
FSGS
Systemic lupus
Brown WW et al Am J Kid Dis 2003;42:22-35
Approaches for Prevention Programs for CKD
Selected
Community
High Risk
Group
Australian
Program
 KEEP
 South Africa
Whole
Population
NKF
Singapore
Proposed Prevention Program in India
Possible Prevention Program in India
Selected
Community
High Risk
Group
• Diabetics
• Ht
• 10 Relatives of
• CKD
• Diabetics
• Ht
Whole
Country
Multiple Level Approach
Awareness of CKD in Community
Both Medical, Paramedics, Non-medical
Start making a
base
For community
Level screening
as part of existing
Infrastructure
Start
early detection
program Of CKD
in “High Risk
Group”
Top 10 Specific Causes of Death in India, 1998
Causes
No in
thousands
%
India / World
CAD
1471
15.8
19.9
Acute LRT Inf.
969
10.4
28.1
Diarrhoeal Dis
711
7.6
32.1
CVA
557
6.0
10.9
TB
421
4.5
28.1
ESRD
250
???
???
RT Accidents
217
2.3
18.5
Measles
190
2.0
21.4
HIV/AIDS
179
1.9
7.8
Tetanus
165
1.8
40.3
COPD
153
1.6
6.8
Total Deaths
9337
100
17.3
982223
100
16.7
Total Population
Possible Prevention Program in India
Start program with a network in Urban area initially
• Diabetes and HT more common
• It will be easy to educate
• It will be easy to organise & implement
• Some networking is existing
• Positive results are likely in short period
• Impact of program will be faster
Make a base in rural area utilizing existing infrastructure
Possible Prevention Program in India
Central Coordinating Team
Nephrologist
 Community Medicine person
 Biostatistician
 Administrator / Ministry

Nephrologist
 Community Medicine
 Administrator

Zonal
Coordinator
Zonal
Member
(15)
Nephrologist / Internist
 Nurse / Other paramedics

Medical Colleges / Private Hospital / Pvt. Clinics
Chandi
Z-1
Punj
HP
Zone-3
Uttar
Z-5
Sikkim
UP
Rajas
A P
Z-2
Z-13
Z-15
MP
Gujrat
Z-6
Jhar
Z-7
Maha
Z-8
Z-14
Mani
WB
Megha
Z-4
Mizo
AP
Z-10
Z-11
Z-12
Naga
Trip
Z-9
Goa
Assam
Bihar
TN
Pond
Possible Prevention Program in India
In addition to screening high-risk group

Multicentric study for prevalence of CKD and its
etiology in community

Education program for CKD in community

Audio-visual aid

Information booklets

Posters

Interactive session with healthcare team

PEP (Patient-educates-patient)
How to run the program?
Health Care Set-up in India,
its changes with time
Government Priorities and Policies
Transition of Indian Health System
• Demographic
High mortality
High fertility
Low mortality
Low fertility
• Epidemiological Malnutrition
Communicable Dis.
Chronic Non Communicable Dis.
• Social
Low knowledge
Low expectations
High knowledge
High expectations
Public sector
Private sector
Low cost / event
• Diarrhea
High cost / event
• MI
• Economical
Indian Health Care System
RURAL
Community Health Center
CHC
By State Govt.
Primary Health Center
PHC
By State Govt.
Sub-Center
SC
By Central Govt.
URBAN
Dispensaries






Hospitals
CGHS
Railways
ESI
MCD
NDMC
Many others
Indian Health Care in Rural Area: Infrastructure
SC
Number
1,37,311
PHC
( 6 SC)
22,842
Population
Covered
Villages Covered
5400
(5000)
4.5
32,469
(30,000)
27.8
2,40,000
(1,20,000)
201
Beds
No
4-6
30
• 1 Medical Officer
• 1 Technician
• 14 Paramedics
• 4 Medical Officer
• 7 Nurses
• Pharmacist
• Lab tech
• Radiographer
Personnel
• 1 MPW (M)
• 1 MPW (F)
• 1 Voluntary
CHC
(7.5 PHC) (4)
3043
Rural Health Statistics in India 2002, Govt. of India
Current Health Policy & Problems in India
Cont….
• Unplanned increase in urban population
• 35% population is illiterate, thus  education
• Public funding, central and state funding less
• Research utilization only 1.4% of 80,000 Crores (98-99)
• Only “Vertical” implementation of health programs
• Programs NOT having vertical implementation ??
• Absence of disease surveillance network
• Absence of scientific health statistics database
Rural Health Statistics in India 2002, Govt. of India
Demographic Changes in India (1951-2000)
160
140
Life Exp.
Crude Birth Rt.
Crude Death Rt.
IMR
120
100
80
60
40
20
0
1951
1981
2000
Goal for 2000
National Health Policy 1983, Registrar General of India
Impact of Public Health Expenditure
% Population
with income <
1$/day
IMR /1000
% Health
expenditure
of GDP
% Public
expenditure
of total
Health
budget
India
44.2
70
5.2
17.3
China
18.5
31
2.7
24.9
Sri Lanka
6.6
16
3
45.4
UK
6
5.8
96.9
USA
7
13.7
44.1
Indicator
Rural Health Statistics in India 2002, Govt. of India
National Health Policy 2002 in India
OBJECTIVES
 To achieve acceptable standard of good health for all
 Establishing new infrastructure in deficient area
 Upgrading infrastructure in existing area
 More equitable health service across the country
 Increasing the contribution by central government
 Contribution of private sector in health to be enhanced
 Prevention & first line curative service at PHC level
 Other traditional system of Indian medicine to be utilised
Rural Health Statistics in India 2002, Govt. of India
National Health Policy 2002 in India
key Points
 55% / 35% & 10% public health budget in Primary,
secondary and tertiary care
 Health programs should be under single field administration
 Autonomous bodies involvement should be more
 Exclusive staff for individual program + common staff
 Common staff should be trained appropriately
 More in-service training for staff
 Establish a baseline estimates for NCD
Rural Health Statistics in India 2002, Govt. of India
Goal to be achieved in India by 2015
Eradicate Polio & Yaws, Leprosy
2005
Eliminate Kala Azar
2010
Eliminate Lymphatic Filaria
2015
Achieve zero level growth of HIV
2007
 Mortality by 50% due to TB, Malaria, water borne
2010
 Prevalence of blindness to 0.5%
2010
 IMR to 30/1000 & MMR 100/Lakh
2010
 Use of Public Health Facility from <20% to > 75%
2010
 Govt. health expenditure from 0.9% to 2%
2010
 Central Govt. share to at least 25%
2010
 State health expenditure from 5.5% to 7% / 8%
Establish integrated system of surveillance & statistics
2005 / 2010
2005
Rural Health Statistics in India 2002, Govt. of India
WHO statement on Non-communicable diseases 2001
The increasing burden of noncommunicable diseases
(NCD), particularly in developing countries, threatens
to overwhelm already-stretched health services. The
factors underlying the major NCDs (heart disease,
stroke, diabetes, cancer and respiratory
conditions) are well documented. Primary prevention
based on comprehensive population-based programes
is the most cost-effective approach to contain this
emerging epidemic.
WHO statement on Non-communicable diseases 2001
In 2000, the 53rd World Health Assembly passed a
resolution on the prevention and control of non-
communicable diseases with the goal of supporting
Member States in their efforts to reduce the toll of
morbidity, disability and premature mortality related
to NCDs.
WHO Stepwise Approach to NCD Surveillance
NCD
Step-1
Step-2
Step-3
Death
(The past)
Death rate by age
& sex
Disease
(The present)
Hospital / clinic
admission by age
& sex
Rate & principle
conditions in
three groups;
Communicable,
NCD & Injury
Cause specific
disease incidence
& prevalence
Questionare
based report on
key risk factors
Questionare plus
physical
examination
Questionare plus
physical
examination &
biochemical
reports
Risk factors
(The future)
Death rate by age,
Death rate by
sex and cause of
age, sex and
death
cause of death
(Verbal autopsy) (Death certificate)
Risk factors Common to Major NCD
CVS
Cancer
Smoking


Alcohol

Nutrition


Physical
Inactivity
Obesity

Risk Factor
Diabetes Respiratory
Diseases
CKD
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


Hypertension


Diabetes



Hyperlipidemia
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Where we need help?
Where we need help?
From WHO
 Recognize CKD importance
 Include CKD in thrust areas of NCDs
 Training in public health issues
Where we need help?
From ISN
A. Include AIIMS as center of excellence
 Govt. recognizes it as center of excellence
 It is strategically placed
 Our group is interested
 We have done work in this field
B. Help organising prevention conference in Delhi
 Initiate enthusiasm in local peoples
 Stress CKD importance in local leaders
Where we need help?
From ISN
A. Help in funding for attending preventive
conferences in world for key peoples
 Keep enthusiasm alive
 Help in building partnership
B. Expertise & funding for
 Research in key areas of local importance
 Help in establishing registries
Summary
 CKD is a public health problem in India
 Diabetes and Hypertension are common causes
 Risk factors for CKD & CKD itself is easy to detect
 Prevention program is the only way to handle CKD
 Education for CKD is urgently needed
 Initially the program can be started in urban areas
 Ultimately it has to go to primary health center level
 A networking approach is correct approach
 International funding is required for this program