Transcript International Aid and Medical Practice in the less

International Aid and
Medical Practice in the
less-developed world:
Doing it right !
Dr. Ivor Katz
Dumisani Mzamane African Institute
of Kidney Disease
University of the Witwatersrand
Soweto
South Africa
Talk Outline
• 1st part - General issues of Medical
International Aid Organisations (MIAOs)
• 2nd part - International Aid in Nephrology,
focussing on Kidney Disease Prevention
• The last part - Practical aspects of
establishing a Kidney Disease Research
and Prevention Program (KDRP)
The challenge of chronic conditions:
WHO responds
BMJ 2001;323:947-948
International aid and medical practice in the
less-developed world: doing it right
‘Less developed nations need and deserve the
help of industrialised countries for the transfer of
technology, the development of markets, the
exchange of perceptions and ideas, and the
fostering of research.’
‘The obligation of wealthier states toward the poor
derives not from some pathological sense of
guilt, but from the fact that the sustained welfare
of any nation cannot be separated from the
welfare of the poorest nations’
Essay -E M Einterz Lancet 2001; 357: 1524–25 Extrême-Nord, Cameroon
Background Issues
• ‘..international aid organisations whose first
mandate is to further their own profit, their own
fame, or the glory of a sponsoring government
play a dangerous game by consuming precious
funds and goodwill.’
• ‘…they should work together, adhering to
uniformly high standards of integrity, and they
must not be content to measure success with
paper achievements.’
Ellen M Einterz Lancet 2001; 357: 1524–25
Background Issues
• ‘..aid organisations should also resist
temptation to conspire with corrupt
bureaucratic gatekeepers, however worthy
the goal, and they should be patient and
willing to fail if it happens that success can
only be had at so high a price.’
Ellen M Einterz Lancet 2001; 357: 1524–25
International Aid and
Medical Practice in the
less-developed world:
Doing it right !
International Aid Organisations
Examples of IAOs
World Health Organisation
The World Health Organization, the
United Nations specialized agency for
health, was established on 7 April
1948. WHO's objective, as set out in
its Constitution, is the attainment by
all peoples of the highest possible
level of health.
WHO Core Functions
In carrying out its activities, WHO's secretariat
focuses its work on the following six core
functions:
• Articulating evidence-based policy
• Managing information and stimulating research and
development
• Catalysing change through technical and policy
support, to build sustainable national and inter-country
capacity
WHO Core Functions
In carrying out its activities, WHO's secretariat focuses its work
on the following six core functions:
• Negotiating and sustaining national and global
partnerships
• Setting, validating, monitoring and pursuing the proper
implementation of norms and standards
• Stimulating the development and testing of new
technologies, tools and guidelines for disease control,
risk reduction, health care management, and service
delivery
Central Objectives
Correcting the 10/90 gap
focus on


Research
Collaboration between
partners in both the public
and private sectors.
Strategies
 Organizing annual
meetings.
 Helping develop prioritysetting methodologies.
Supporting networks in
priority health research
areas
IC-Health (funding by World Bank and
other partners) was born in 1999 as a
joint program of the Global Forum for
Health Research (GFHR) and the WHO
Aims
promote and prioritize resource-sensitive and
context specific research
address the growing burden of cardiovascular
diseases in the developing countries.
Secretariat for the Initiative in New Delhi, India.
Priorities
Research on sustainable models of disease
prevention through primary health care in resourcepoor settings.
Effective and safe prevention is known, BUT how to
deliver these reliably and affordably in developing
world still needs to be developed
Large scale cost effective programs in low- and
middle-income countries
Cardiovascular Disease & Diabetes Control in
Thailand
Prevention program targeting diabetes and others with high risk of
cardiovascular diseases in Primary Care setting
Prevention of Cardiovascular Disease & Management
of Diabetes in India (Andhra Pradesh province)
115 villages from rural and semi-urban areas
 First phase - mortality surveillance system and survey of
cardiovascular disease, diabetes and other risk factors
 Second phase - evaluation of an intervention program
Capacity
Building
&
Institutional
Strengthening
• Capacity development and institutional strengthening
• Short courses in epidemiology, biostatistics and data management
and other fellowships
Macroeconomic Consequences Of Cardiovascular
Diseases & Diabetes
• Developed with Earth Institute at Columbia University, New York.
• Assess the macroeconomic consequences of cardiovascular
diseases and diabetes in low- and middle-income countries.
Médecins Sans Frontières (MSF)
• Since 1970, Médecins
Sans Frontières (MSF)
has been providing
medical care to
vulnerable populations
• At the moment, MSF is
working on approximately
400 projects in 80
countries.
MSF Activities
Emergency interventions

Natural disasters, epidemics, and armed conflicts
Protocols for managing complex diseases like
HIV/AIDS


populations that have neither the means nor the technical
knowledge to deal with these health calamities.
Simplified antiretroviral treatment protocols to treat AIDS in
resource-poor areas in South Africa.
Epidemiological programmes

Ebola.
International Aid Organisations
and Chronic Disease
Analyses of IAOs and initiatives
Medical IAOs priorities
 Not substitute formal health structures
Provoke change and be a catalyst
Aims to pass on knowledge and skills
Is this possible?
International Aid in the Medical Arena
MSF, WHO, IC Health
 complement formal health sectors
BUT.. moral dilemma in providing health
care to vulnerable populations!
 Dependence
on external assistance and
minimise governments responsibility
 Projects can be manipulated by existing
governments & mask the real problems
International Aid in the Medical Arena
Difficulties which exist for people establishing
programs
• Accessing existing resources and projects
• Establishing contact
• Accessing the funds and management of these
funds
• Planning and sustaining projects
• Research as a means of accessing resources
and of managing the project – skills required!
International Aid Organisations
Problems
Making these ‘intellectual resources’ available
 ‘Making good management ideas travel’ (WHO)
 Ensuring medication and technical advances =
Quality of life improvement
 Shifting from an acute, reactive, and episodic
model of care - the “Find it and fix it“ model
 Organizing and simplifying the use of guidelines

International Aid Organisations
Problems

Converting ‘Action Plans’ and intentions to
real success!

Reducing the ‘plausible reasons’ explaining
failure e.g. inflation, no stability, lack of political
will, time and logistics, mismanagement,
corruption and theft by managers
Ellen M Einterz Lancet 2001; 357: 1524–25
World Health
Organisation
Improving prevention and management
Recognizing the disease continuum
• Focus - whole population at risk, then the individual
• Primary prevention then Secondary prevention, and
lastly Treatment of Disease
Interventions
1. Government Services, Private Health and NGOs
2. Global corporate involvement e.g. Pharmaceuticals,
Foundations, Grant Funding, Business
R. Bengoa World Congress of Nephrology Berlin 2003
This logic is not appropriate for chronic
disease
High Mortality Developing Countries
Deaths in 2001 attributable to 15 leading causes
Cardiovascular diseases
HIV/AIDS
Respiratory infections
Injuries
Perinatal conditions
Diarrhoeal diseases
Malignant neoplasms
Childhood diseases
90% of all deaths
attributable to
15 leading causes
Malaria
Respiratory diseases
Tuberculosis
Digestive diseases
Maternal conditions
Neuropsychiatric disorders
Nutritional deficiencies
0
1000
2000
3000
4000
Number of deaths (000s)
World Health Organization
5000
6000
World
Deaths in 2000 attributable to selected leading risk factors
Blood pressure
Tobacco
Cholesterol
Underweight
Unsafe sex
Fruit and vegetable intake
High Body Mass Index
High Mortality Developing Countries
Physical inactivity
Low Mortality Developing Countries
Alcohol
Developed Countries
Unsafe water, sanitation, and hygiene
Indoor smoke from solid fuels
Iron deficiency
Urban air pollution
Zinc deficiency
Vitamin A deficiency
Unsafe health care injections
0
1000
2000
3000
4000
5000
Number of deaths (000s)
World Health Organization
6000
7000
8000
Towards a framework for Surveillance of major
NCD risk factors
 Hierarchical framework to unify surveillance activities
 Flexible across a range of risks, conditions, ages, areas
 Standard methods and tools adaptable to local settings
 Common core: expanded and optional extras
 Basic sentinel surveillance sites
 Add on to existing systems
 Guiding principles: KISS!
Dr Ruth Bonita, Director, NCD Surveillance
Non-Communicable Diseases and Mental
Health, WHO Geneva
World Health Organization
The WHO STEPS – Risk Factors
Different levels of assessment
 Behaviours
 Physical measurements
 Blood samples
Three modules per risk factor:
 Core
 Expanded core …and
 Optional.
World Health Organization
The WHO STEPS Framework
Step1: Behaviours
 Tobacco and alcohol use
 Intake fruit and vegetables
 Physical inactivity
Step 2: Physical measures
 Height, weight, waist
 Blood pressure
 Pulse rate
Step 3: Blood samples
 Cholesterol
 Blood glucose
World Health Organization
Positives
• Research based projects / solid science (?negative)
• Development of partnerships
• Primary care setting and qualitative components
• Solid approach core issues and long term outlook
Negatives
• Funding and donor shortages
• ?Sustainable
• ?Access to these funds and selection of project
• Grant funding requires significant skills and
resources
MSF
Positives
• Volunteers spend an extended time in the country
• Program are well planned
• Evaluate problems in the country together with
local NGOs or government structures
Negatives
• Significant funding to support volunteers (positive?)
• Significant funding and organisation behind MSF
• ?Sustainability – HIV projects are new
International Aid Organisations
Ideal IAO Programs & Mx of Chronic Disease
1. Support from Government, local community,
health workers and patients
2. Brigding assistance - MIAOs
3. Productive interaction between pt and practice
team developed in above milieu
4. Organized programs vs. standard programs
(shown better outcomes)
5. Primary Health Care focus with the PHC Nurse
Barbara P Yawn West J Med. 2000 Feb;172(2):77-8
Nephrology and International Aid
The second part looking at nephrology and
international aid
Nephrology and International Aid in
Developing World
. “Prevention of renal
diseases in the emerging
world:
Toward global health
equity”
ISN COMGAN



Support from Foundations
Support of Developed Country Institutions
Support from Pharmaceutical Industry
? Sustainable and continuous
Establishing KDRPs
The practical development and
establishment of a Kidney Disease
Renoprotection Programs
Components of Australian and South
African Chronic Outreach Programs
Work together with communities to
o
o
o
o
o
Engage community interest
Assess needs
Develop an agreement
Help local staff implement the program
Ensure sustainability
o Evaluate processes and outcomes
KDRP
38
Chronic Outreach
Program Model
Educational material,
guidelines, algorithms for
testing and treatment
Doctor
RN/PHCN
Physician
least important!
 Nurse
coordinators &
program
managers
PHCN or
Community volunteer
(α resources)
PHCN, Health worker or educator, most
important
(e.g. Volunteers, church groups or paid workers)
Kidney Disease Renoprotection
Programmes
Tx
Dialysis
ESRD
Preparing people
Prevent Progression
KDRP Programmes
Where to
Start ?
Initiator / Injury
Protein leakage, Proteinuria
Locate People at risk
Diabetes, Hypertension, Elderly, HIV
Screening General or High Risk Population
Existing KDRPs
Focus on current programs in nephrology
programs
‘A Nephrological Program in
Benin and Togo’ (West Africa)
G.B Fogazzi et al KI 63:s56
Hospital based screening and treatment ‘program’
Success
Raised awareness of renal disease
Problems
Small numbers of patients, hospital based
Lack of basic diagnostic and therapeutic resources
Not focused on prevention or early detection in
community (Treating those already with disease “Find it
and fix it“ model )
Kidney Help Trust rural project –
India
Muthu K. Mani KI 63 S83 pp S86-89
Primary care run by local community
Screening component and treatment component
Successes
• Simplicity. "We keep it simple".
• Cheap mass screening and early detection
• PHCN used to detect disease and give basic treatment
under supervision
Problems
• No long term quantitative data unable to evaluate impact
• Only 8% took ongoing treatment and only able to visit
homes every 18 months
THE BOLIVIAN RENAL DISEASE
PROJECT Lancet 2002 Plata, Remuzzi et al
In 2002 a program was started with support of Bergamo
Institute and ISN-COMGAN
Screening program with referral to a hospital
BOLIVIA
PERU’
Beni
BRASILE
La Paz
Cochabamba
CILE
PARAGUAY
ARGENTINA
THE BOLIVIAN RENAL DISEASE
PROJECT Lancet 2002 Plata, Remuzzi et al
• Educational campaign
• Dipsticks screening and referral to secondary center.
• Determined main problems  UTI , haematuria and TB
Successes
• Basic screening - good understanding of local problems
• Cost effective?
Possible Problems
• Currently more a ‘Find it and fix it model’ but is
developing?
• Not sustained primary care based program, although
screening is in primary care setting
Chronic Disease Outreach Program in Australia
Tiwi Islands
KDRP Australia
Wadeye
Naiuyu
Broome
Borroloola
Woorabinda
Bega, Kalgoorlie
Cherbourg
Prof. Wendy Hoy – Menzies University Darwin &
University of Queensland, Brisbane - Australia
Australian Chronic Disease Outreach
Program Hoy et al KI 2003 KI vol 63 s83 pp s86-73
Started in Tiwi Islands and extended to other Aboriginal areas in
Australia
Screening of entire community for high risks groups
Initiation of treatment and follow up for few years
Successes
• Showed definite improvement from baseline and reduction in kidney
and cardiovascular disease and all cause mortality
• Influenced protocols, Govt lobby group and galvanized NGOs
Possible Problems
• Not sustained by community with no support from authorities in
some areas, although this appears to be changing
• Despite successes, slow to change and influence day to day
practice throughout Australia
• Aboriginal peolpe margenilised minority relying on ‘paternalism’
South African Experience
Evaluation of personal experiences in trying to
establish a ‘successful aid’ program in South
Africa.
South African Chronic Disease
Outreach Program
Johannesburg
& Soweto
Wits Health
Region A
Gauteng Health
Dept
(South Western
Township )
Transitional
Community of
3 million people
Study by GHD Internal audit June 2000
Dr. ES Mohamed at Soweto Clinics before PPP
Number of patients achieving a BP target of < 140/90
50% of the readings < 140/90
4.20%
95.80%
80% of the readings < 140/90
0.90%
Controlled
Uncontrolled
99.10%
Controlled
Uncontrolled
Study by GHD Internal audit June 2000
Dr. ES Mohamed at Soweto Clinics before PPP
Number of patients with serum blood glucose <8mmol/L
50% and all the readings <8mmol/L
1.80%
6.80%
93.20%
80% and all the readings <8mmol/L
Controlled
Uncontrolled
98.20%
Controlled
Uncontrolled
Outline of Primary Prevention SA Outreach
Program
DMAIKD & Gauteng Health Dept monitor outcomes
via a central computer & Australian collaboration & support
History &Examination
•BP
•Urine dipstick
Entry data
•BG
Admission
Into PPP
End Points
Achieve Targets
Hypertension
Diabetes
Proteinuria
Health Promoter / PHCN
ESRD
Stroke
CCF
Death
Lost to F/up
3-5 year follow up
Simplicity of Targets
BP
120/70
Targets
Proteinuria
<1g or less
Blood
Glucose
<8
Reduction
in strokes,
CCF, death
etc.
Systolic Blood Pressure Control
S
y
s
to
licb
lo
o
dp
re
s
s
u
re
M
e
d
ia
n
;B
o
x
:2
5
%
,7
5
%
;W
h
is
k
e
rs
:n
o
no
u
tlie
rm
ina
n
dm
a
x
2
4
0
2
2
0
2
0
0
1
8
0
Systolicbloodpresure(mmHg)
1
6
0
1
4
0
1
2
0
1
0
0
8
0
T
re
a
tm
e
n
t
p < 0.00001
C
o
n
tro
l
p = 0.8
Abstract ISHIB Meeting SARS 2002/3 unpubished
Treatment Group
Macroalbuminuria and >3month follow up
30
25
No. of Patients.
• 45 of 75 patients
showed remission
or regression
• 60% showed
benefit from ACEi
and PPP (i.e. early
ACEi and
education)
Regression Remission Progression Graph
35
20
15
10
5
0
Regression
Remission
Progression
Category
Abstract ISHIB Meeting SARS 2002/3 unpubished
Criticisms
• Poor planning in phase 1 of
program
• Too many people placed on
program – inadequate
resources
• Funding Shortages especially
drugs and infrastructure
• Data capture quality and
efficiency
• Inadequate long term follow
up and evaluation of end
points in phase 1
• Only focused on quantitative
data and not qualitative data
evaluating service
Positive
• Strong support from
Australian Outreach
Program
• Despite problems still seeing
a benefit
• Developing sustainability as
we are using existing staff
and infrastructure and govt is
now sponsoring and
providing staff for program
• Link between primary and
tertiary
• Education staff and
(patients)
• Stamina ‘staying power’
SA PPP Outreach KDRP
Phase 1
Phase 2
•
•
•
•
•
• Developed from phase 1
problems
• Broader focus kidney and
cardiovascular
• Now quantitative and
qualitative components
• Broadening international
support
Assess baseline status
Pilot project
Focus on kidney
Quantitative only
Showed treatment
success
• Not able to assess end
points
Practical Issues in Doing it Right!
The last part!
Fundamentals of IAO medical projects.
Phases of establishing a project
Managing chronic diseases in
less developed countries
• Healthy team working and patient
partnership is as important as adequate
funding
• Focus not only on the technical aspects of
but on supporting or caring for staff.
• The paradox  continuing care delivered
by a well functioning team is the basis on
which control of chronic disease must rest
Epping-Jordan J The challenge of
chronic conditions: WHO responds. BMJ 2001; 323: 947-948
What's chicken got
To do with Prevention
Of CKD and CVD?
It’s the 11 herbs
and spices!
Prevention is a blend of 11 herbs and spices
Developed by a loyal following
Of ISN members and experts
with a successful business and service approach!!
Common Practical Principles for
Doing it Right – ‘Kentucky Fried Chicken
& Big Mac Principle’
1.
2.
3.
4.
5.
6.
7.
8.
9.
Project Planning
Collaboration with MIAOs
Funding of projects and developing sustainability
Resources and support to source and manage funding
Development of a data base to evaluate the project
Data Collection (established 1st World principles)
Establishments of systems to run the program
Primary Health Focus & Qualitative evaluation
Development of clinical algorithms (SIMPLIFIED!) e.g.
WHO principles of Core, Expanded Core and Optional
10. Development of local teams and structures and
coordinators
11. Persistent hard work – stamina!
Concluding Remarks
• We know KDRPs save kidneys and lives BUT can we
convince funders and governments?
• Can we plan them well using existing models and
evidence based research?
• Primary prevention, early detection, secondary prevention
and disease management go hand in hand (this is seen
with HIV)
• Research or studies must be ‘politically appropriate’
carry the economic argument and show clinical benefit
and have qualitative component to evaluate the model
Concluding Remarks
• Not just focus on renal disease but on chronic diseases
i.e. kidney and cardiovascular disease “Integrated
Approach”
• For HIV the concerns have been safety and economic and
this has caused action… What is the key for action in
CKD and CVD primary prevention and management
• Can we achieve the same for Kidney and
Cardiovascular Disease Prevention and convince
developing world governments and communities of
this fact!
Good Planning
 Govt
Experts
Community
Regional, National and
International adaptation
Efficiency and
sustainability
Doing
It
Right!
Pilot Project
Expert support and
assistance
Assess burden and
community knowledge
Thank You!