International Aid and Medical Practice in the less-developed world:

Doing it right !

Dr. Ivor KatzDumisani Mzamane African Institute

of Kidney DiseaseUniversity 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 International aid and medical practice in the less-developed world: doing it rightless-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 policyArticulating evidence-based policy

• Managing information and stimulating research and Managing information and stimulating research and development development

• Catalysing change through technical and policy support, Catalysing change through technical and policy support, to build sustainable national and inter-country capacityto 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 ObjectivesCentral ObjectivesCorrecting the 10/90 gap

focus on

Research Collaboration between

partners in both the public and private sectors.

StrategiesStrategies   Organizing annual Organizing annual

meetings.meetings.

  Helping develop priority-Helping develop priority-setting methodologies.setting methodologies.    

Supporting networks in Supporting networks in priority health researchpriority health research  areas  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

AimsAimspromote 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 resource-poor 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 Organisationsand 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 Difficulties which exist for people establishing programsprograms

• 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

World Health Organization

0 1000 2000 3000 4000 5000 6000

Nutritional deficiencies

Neuropsychiatric disorders

Maternal conditions

Digestive diseases

Tuberculosis

Respiratory diseases

Malaria

Childhood diseases

Malignant neoplasms

Diarrhoeal diseases

Perinatal conditions

Injuries

Respiratory infections

HIV/AIDS

Cardiovascular diseases

High Mortality Developing CountriesDeaths in 2001 attributable to 15 leading causes

Number of deaths (000s)

90% of all deathsattributable to

15 leading causes

World Health Organization

0 1000 2000 3000 4000 5000 6000 7000 8000

Unsafe health care injections

Vitamin A deficiency

Zinc deficiency

Urban air pollution

Iron deficiency

Indoor smoke from solid fuels

Unsafe water, sanitation, and hygiene

Alcohol

Physical inactivity

High Body Mass Index

Fruit and vegetable intake

Unsafe sex

Underweight

Cholesterol

Tobacco

Blood pressure

High Mortality Developing Countries

Low Mortality Developing Countries

Developed Countries

WorldDeaths in 2000 attributable to selected leading risk factors

Number of deaths (000s)

World Health Organization

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 SurveillanceNon-Communicable Diseases and Mental Health, WHO Geneva

World Health Organization

Different levels of assessment

Behaviours Physical measurements Blood samples

Three modules per risk factor:

Core Expanded core …and Optional.

The WHO STEPS – Risk Factors

World Health Organization

Step1: BehavioursStep1: Behaviours Tobacco and alcohol use Intake fruit and vegetables Physical inactivity

Step 2: Physical measuresStep 2: Physical measures Height, weight, waist Blood pressure Pulse rate

Step 3: Blood samplesStep 3: Blood samples Cholesterol Blood glucose

The WHO STEPS Framework

Positives• Research based projects / solid science (?negative)• Development of partnerships• Primary care setting and qualitative components• Solid approach core issues and long term outlookNegatives• 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

KDRP 38

Components of Australian and South African Chronic Outreach Programs

o Engage community interest o Assess needso Develop an agreemento Help local staff implement the programo Ensure sustainability

o Evaluate processes and outcomes

Work together with communities to

Chronic Outreach Chronic Outreach Program Model Program Model

Educational material, guidelines, algorithms for testing and treatment

Physician least

important!

Nurse coordinators &

program managers

PHCN, Health worker or educator, most important

(e.g. Volunteers, church groups or paid workers)

Doctor

RN/PHCN

PHCN or

Community volunteer (α resources)

Kidney Disease Renoprotection Programmes

Locate People at risk Diabetes, Hypertension, Elderly, HIV Screening General or High Risk Population

Initiator / InjuryProtein leakage, Proteinuria

Prevent ProgressionKDRP Programmes

ESRDPreparing people

TxDialysis

Where to Start ?

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’

SuccessRaised awareness of renal disease

ProblemsSmall numbers of patients, hospital basedLack of basic diagnostic and therapeutic resourcesNot 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 supervisionProblems• No long term quantitative data unable to evaluate impact• Only 8% took ongoing treatment and only able to visit

homes every 18 months

In 2002 a program was started with support of Bergamo Institute and ISN-COMGAN

Screening program with referral to a hospital

THE BOLIVIAN RENAL DISEASE PROJECT Lancet 2002 Plata, Remuzzi et al

BOLIVIA

PERU’

La Paz

CILE

PARAGUAY

BRASILE

ARGENTINA

Beni

Cochabamba

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

Borroloola

Wadeye Naiuyu

Tiwi Islands

Chronic Disease Outreach Program in AustraliaKDRP AustraliaKDRP Australia

Prof. Wendy Hoy – Menzies University Darwin &University of Queensland, Brisbane - Australia

Woorabinda

Cherbourg

Bega, Kalgoorlie

Broome

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& SowetoWits Health Region AGauteng HealthDept(South Western Township )TransitionalCommunity of3 million people

0.90%

99.10% Controlled

Uncontrolled

95.80%

4.20%

Controlled

Uncontrolled

Number of patients achieving a BP target of < 140/90

Study by GHDStudy by GHD Internal audit June 2000Internal audit June 2000

Dr. ES Mohamed at Soweto Clinics before PPPDr. ES Mohamed at Soweto Clinics before PPP

50% of the readings < 140/90 80% of the readings < 140/90

93.20%

6.80%

Controlled

Uncontrolled

1.80%

98.20% Controlled

Uncontrolled

Number of patients with serum blood glucose <8mmol/L

50% and all the readings <8mmol/L80% and all the readings <8mmol/L

Study by GHDStudy by GHD Internal audit June 2000Internal audit June 2000

Dr. ES Mohamed at Soweto Clinics before PPPDr. ES Mohamed at Soweto Clinics before PPP

Outline of Primary Prevention SA Outreach Program

AdmissionInto PPP

HypertensionDiabetesProteinuria

ESRDStrokeCCF Death Lost to F/up

Achieve Targets

History &Examination•BP•Urine dipstick•BG

End Points

DMAIKD & Gauteng Health Dept monitor outcomes via a central computer & Australian collaboration & support

Entry data

3-5 year follow upHealth Promoter / PHCN

Simplicity of Targets

Targets

Blood Glucose

<8

Reduction in strokes, CCF, death

etc.Proteinuria <1g or less

BP 120/70

Systolic blood pressure

Median; Box: 25%, 75%; Whiskers: non outlier min and max

Sys

tolic

blo

od

pre

ssu

re (

mm

Hg

)

80

100

120

140

160

180

200

220

240

Treatment Control

p < 0.00001 p = 0.8

Systolic Blood Pressure Control

Abstract ISHIB Meeting SARS 2002/3 unpubished

Treatment Group Macroalbuminuria and >3month follow up

• 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

Regression Remission Progression

Category

0

5

10

15

20

25

30

35

No

. o

f P

atie

nts

.

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

• 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’

Positive

SA PPP Outreach KDRP

Phase 1

• Assess baseline status• Pilot project• Focus on kidney• Quantitative only• Showed treatment

success• Not able to assess end

points

Phase 2

• Developed from phase 1 problems

• Broader focus kidney and cardiovascular

• Now quantitative and qualitative components

• Broadening international support

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

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!!

It’s the 11 herbs and spices!

What's chicken gotTo do with PreventionOf CKD and CVD?

Common Practical Principles for Doing it Right – ‘Kentucky Fried Chicken

& Big Mac Principle’1. Project Planning2. Collaboration with MIAOs3. Funding of projects and developing sustainability4. Resources and support to source and manage funding5. Development of a data base to evaluate the project6. Data Collection (established 1st World principles)7. Establishments of systems to run the program8. Primary Health Focus & Qualitative evaluation9. Development of clinical algorithms (SIMPLIFIED!) e.g.

WHO principles of Core, Expanded Core and Optional10.Development of local teams and structures and

coordinators11.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

ExpertsCommunity

Pilot Project

Assess burden andcommunity knowledge

Expert support and assistance

Efficiency andsustainability

Regional, National andInternational adaptation Doing

It Right!

Thank You!