Cambodia
Diabetes self-help groups
MoPoTsyo
Patient Information Centre
Maurits van Pelt
Our Main Message
Diabetes Peer Educator networks
should be integrated in
the primary health care system
But most Health Policy makers say
“Chronic Disease interventions are not
cost effective”
“Chronic Diseases are a black hole,
especially for secondary prevention
among patients……..”
Cambodia Health Sector Donors
.
External assistance focus by programs budgets only 1% for
Non Communicable Diseases (NCD) although they cause
more than half of disease and death
P1 –
Mgt&Admin
P2 – MCH
P3 – CDC
P4 – NCD
P5 – Serv Del
We say:
This lack of policies….breeds poverty!
Markets move fast to grab opportunities;
Markets create confusing information;
Product safety concerns increase Willingness-to-Pay
Biggest spender on product promotion wins
Consumers do not know what would be their best choice
The market’s natural response is supply side centred;
All factors combined: It leaves many unmet needs…
Premature disability replaces productivity
Elements of the Diabetes context
Lack of trained Doctors and Nurses;
After training, they are severely underpaid;
Public health system is only for acute cases;
Chronic patients supplement health staff income…;
A profitable patient is an ignorant one…;
Question: If formal health staff has no incentive to
transfer knowledge + skills to chronic patients……then
who has ?
Diabetics are: Rich.. ? Overweight.. ? Old.. ?
Too low educated to self-manage?
We often assume that we
understand the problems
We set priorities for low
income countries….
This can be terrifying..
Proposed thesis :
“Diabetes Peer Educator Networks are a
worthwhile investment for Low Income
Countries in Asia like Cambodia”
Demand side organisation in NCD
A Diabetes Peer Educator Network in an
Operational District (a.k.a. zône de santé) led by
a manager (a.k.a. DPM) in charge of community
based Diabetes Peer Educators
The Diabetes Peer Educator
Is a self-managing Diabetes patient who may have
any profession except health service provider &
 Is Literate
 Is Volunteer
 Was trained 6 weeks in Diabetes Peer Education
 Has passed the Peer Educator exam
What do DM patients actually need ?
A) Understand how they can keep their blood glucose
and blood pressure always within the safe margins:
•
lifestyle (type of food, exercise, kg)
•
right medication
•
self-measuring
B) Understand how they can keep this affordable;
Benefit 1: Earlier Detection
Immediate Effects:
 Distribute urine glucose
strips for self - testing:
one per adult;
 Detect DM earlier (70%
did not know it)
 Increase reservoir of
aware DM from 30% to
41% in Yr 1 (Yr 2 > 50%)
Peer Educator Assesses:
 Presence of Urine glucose
 Fasting Blood Glucose
 Blood Pressure
 Heart rate
 BMI
 Waist circumference
 Feet inspection, nerve d. etc.
…..reports to her/his DPM
Benefit 2: Transfers Knowledge + skills
DM patients self-testing urine during last month
15%
1%
Did not do urine self test
Did 1 or 2 urine self tests
84%
Did more than 2 urine self
tests
Benefit 3: Lifestyle changes <12 months
BMI Changes in rural program
23%
11%
66%
weight improved
becoming too skinny / even skinnier
becoming too fat / even fatter
Benefit 4: No stress on health services
BenefitRural
4: Program: the number of diabetes Dr consultations
during the first 15 months in the first 388 registered diabetics
nr of medical consultations
•
Avoiding early medicalisation
728 Medical Consultations in 15 months
Average 1.8 consult per patient,
160 DM did not yet meet with the Doctor
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
0%
10%
20%
30%
40%
50%
Benefit 5:
Cost Containment
1 million patients: 350.000 DM + 700.000 High BP
Annual drug bill remains too high if supply side controls while the
demand side pays (USD 250 million).
Annual drug bill can be low, if demand side controls AND pays
(USD 40 million, is mostly affordable…);
There will still be a role for targeted subsidies for new poor DM;
Benefit 6:
Quality of Life
DM Patients feel better because they:
-
Regain control over their health
Spend less than before on health care
Can get health information that they need
Benefit 7:
Biological outcomes
133 randomly selected DM patients
more than 3 months registered in Rural Program
Fasting Blood Glucose (norm is FBG<126 mg/dl)
FBG > 200
5%
FBG 126 - 200
43%
FBG < 126
52%
Benefit 7:
Overall lower BG
Ang Roka OD HbA1c result July 2008
(124 DM patients randomized)
17%
HbA1c < 7.5%
7.5 < HbA1c < 9%
16%
HbA1c >9%
67%
Benefit 7: Blood Pressure among DM
Rural Diabetics Blood Pressure after 6 months (N=133)
50.0%
30.0%
10.0%
-10.0%
Syst≤130 or
Diast≤75
Syst≤140
Diast.≤90
Syst>140 or
Diast>90
baseline
45.1%
36.1%
18.7%
after 6 months
45.1%
37.3%
17.6%
Example Ang Roka OD
133.000 inhabitants

Example Ang Roka OD
133.000 inhabitants
Peer Educator network running costs
USD 6700 per year for 665 (2nd year-) diabetics
USD 10 per diabetic per year at current levels
A Peer A Day Keeps the Doctor Away!
www.mopotsyo.org