International Aid and Medical Practice in the less-developed world: Doing it right !

1. 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

2. 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)

3. The challenge of chronic conditions: WHO responds BMJ 2001;323:947-948

4. 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

5. 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

6. 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

7. International Aid and Medical Practice in the less-developed world: Doing it right !

8. International Aid Organisations Examples of IAOs

9. 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.

10. 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

11. 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

12. Central Objectives Correcting the 10/90 gap focus on Research Collaborationbetween partners in both the public and private sectors. Strategies Organizing annual meetings.  Helping develop priority-setting methodologies. Supporting networks in priority health research  areas

13. 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.

14. 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

15. 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

16. 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.

17. 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.

18. 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.

19. International Aid Organisationsand Chronic Disease Analyses of IAOs and initiatives

20. Medical IAOs priorities • Not substitute formal health structures • Provoke change and be a catalyst • Aims to pass on knowledge and skills Is this possible?

21. 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

22. 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!

23. 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

24. 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

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 • Government Services, Private Health and NGOs • Global corporate involvement e.g. Pharmaceuticals, Foundations, Grant Funding, Business R. Bengoa World Congress of Nephrology Berlin 2003

26. This logic is not appropriate for chronic disease

27. High Mortality Developing Countries Deaths in 2001 attributable to 15 leading causes 90% of all deaths attributable to 15 leading causes Number of deaths (000s)

28. World Deaths in 2000 attributable to selected leading risk factors Number of deaths (000s)

29. 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

30. The WHO STEPS – Risk Factors • Different levels of assessment • Behaviours • Physical measurements • Blood samples • Three modules per risk factor: • Core • Expanded core …and • Optional.

31. 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

32. 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

33. 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

34. International Aid Organisations Ideal IAO Programs & Mx of Chronic Disease • Support from Government, local community, health workers and patients • Brigding assistance - MIAOs • Productive interaction between pt and practice team developed in above milieu • Organized programs vs. standard programs (shown better outcomes) • Primary Health Care focus with the PHC Nurse Barbara P YawnWest J Med. 2000 Feb;172(2):77-8

35. Nephrology and International Aid The second partlooking at nephrology and international aid

36. 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

37. Establishing KDRPs The practical development and establishment of a Kidney Disease Renoprotection Programs

38. Components of Australian and South African Chronic Outreach Programs Work together with communities to • Engage community interest • Assess needs • Develop an agreement • Help local staff implement the program • Ensure sustainability • Evaluate processes and outcomes KDRP

39. Physician least important! Chronic Outreach Program Model Educational material, guidelines, algorithms for testing and treatment Doctor • Nurse coordinators& program managers RN/PHCN PHCN or Community volunteer (α resources) PHCN, Health worker or educator, most important (e.g. Volunteers, church groups or paid workers)

40. Tx Dialysis ESRD Preparing people Prevent Progression KDRP Programmes Initiator / Injury Protein leakage, Proteinuria Locate People at risk Diabetes, Hypertension, Elderly, HIV Screening General or High Risk Population Kidney Disease Renoprotection Programmes Where to Start ?

41. Existing KDRPs Focus on current programs in nephrology programs

42. ‘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 )

43. Kidney Help Trust rural project – IndiaMuthu 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

44. THE BOLIVIAN RENAL DISEASE PROJECTLancet 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

45. THE BOLIVIAN RENAL DISEASE PROJECTLancet 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

46. Chronic Disease Outreach Program in Australia KDRP Australia Tiwi Islands Naiuyu Wadeye Broome Borroloola Woorabinda Bega, Kalgoorlie Cherbourg Prof. Wendy Hoy – Menzies University Darwin & University of Queensland, Brisbane - Australia

47. Australian Chronic Disease Outreach ProgramHoy 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’

48. South African Experience Evaluation of personal experiences in trying to establish a ‘successful aid’ program in South Africa.

49. South African Chronic Disease Outreach Program Johannesburg & Soweto Wits Health Region A Gauteng Health Dept (South Western Township ) Transitional Community of 3 million people

50. Study by GHDInternal 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 80% of the readings < 140/90