Peer educator networks for diabetes and hypertension

in Cambodia

Health literacy, ICT & empowerment

If there are access-to-chronic-care problems such as…

• costly distance• unreliable drug

supply• unresponsive

services• long waiting

times• over-loaded medical

staff

• exclusion

• lack of certain services

• lack of referral to other specialisations

• over-pricing (cf. reference)

• unnecessary services

• inappropriate information

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….this opens a market for involvement of chronic patients

“Unmet needs” create opportunities… Chronic patients meet at the

home of the community-based Peer Educator

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Tasks of a Diabetic Peer Educator PE core tasks: 1. Organize screening Diabetes, High Blood Pressure & CKD & DBR +++2. Counsel, assess new patient, register: create a record (=EMR)3. Train patients in self-management4. Be intermediary: Make appointments on behalf of patient with Dr5. Follow-up by outreach to patient’s home if necessary;6. Set up Village HBP Groups in each village, maintain monthly visits7. Report monthly to ODPM (OD Peer Network Manager (salaried);

Selected PE extra tasks:1. Some help organize 2x/yr the blood collection for lab service (at Public HC)2. Some help in Medical Consultation sessions (OPD only at Public Hospital)3. Some help supervise & run Revolving Drug Fund (Public + Private)4. Some join in Primary prevention activities

Distribute voucher to the poor patients for 70% discount on medicines (Revolving Drug Fund)

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From 2005 until October 2013: 15,539 members

11 sub-networks in 13 health districts (OD’s)AREAS:

o Phnom Penh (3 OD’s) : 5 poor areas (1 OPD)

o Takeo province: all 5 OD (6 OPD’s)o Banteay Meanchey : 1 OD (1 OPD)o Kompong Speu : 2 OD‘s (2 OPD’s)o Kompong Thom : 2 OD’s (2 OPD’s)SERVICE INFRASTRUCTURE:o 22 Contracted pharmacies (4 public)o 12 OPD’s in Public Referral Hospitalso 129 Peer Educator (129 HC areas)o 553 Village HBP Groups BENEFICIARIES per October 2013:o 537,883 adults self-screened (UG

strip)o 8,369 DM patients registered

338 DM self-injecting Insulino 7,170 HBP patients (non-diabetic)

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Health Literacy in Outputs & Outcome Re-assessments + Rewards (yearly..?)

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1. Physical Outcomes (15)

2. Patient Book filled (3)3. Nutrition habits (7)4. Physical activity (4)5. Medical care (6)6. Knowledge of disease

(3)7. Feeling well (5) Total = 43 indicators

ICT for empowerment of: 1. Groups & 2. Individual Patients

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Database

“internet”

Registration data (1st

assessment by PE) createsE.M.R.

Laboratory

Profiles

Medical Consultation + Prescribed Medication Retail

Pharmacy invoice

data

Self -Management data (via PE follow-

up)

Integration TYPES of data: 1. Clinical + 2: Self-Management + 3. Medicine Supply + 4. Use

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Use Database as a tool… :• Calculate supply needs Revolving

Drug Fund • Measure % adherence to prescribed

medication• Measure performance by main

actors by area– Patients themselves– PE’s (degree of patients under control) – Doctors’ prescribing– Pharmacists dispensing

• Determine financial rewards for the main actors

• Long term cohort records• Measure use of special

subsidies/discounts

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Example 1: ICT for group power

Generates data for financial reward : (A + B)/2 * C A) % of Satisfaction among patients who used public pharmacy at least 2 times (PE-routine-survey);

B) % of Adherence to prescribed medication over past 12 months

C) multiplied by 15% of the value of dispensed medication to chronic patients over the same period;

Reward was SHARED as Payment for Performance among:Provincial Health Department, 1%Operational District Office, 3%User Fees of the Public Hospital, 36% Pharmacist of the Public Hospital 60%

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Example 2: ICT for individual power

Laboratory profile :

• In Khmer Language• Result Trend over

time• PE trained to

explain and counsel• Lab profile offered

at 30% of market prices

• External Quality Assurance System11

final slide ! Sustainability & AcceptabilityActivity 4 new

market(s)Policy Status

ICT-role

Peer Educator Networks

Financially sustainable from RDF-mark up. Alternative via local governments ?

National MoH Policy (07.11.2013)

Database holds it all together ; barcodes;*PE Smartphone

Revolving Drug Fund (RDF)

Financially sustainable. Below market prices.It can also handle complementary Gvt supply

T. B. D.No alternative that works well.

Transparent system;POS-Automation Software applicationsInternet

Public Hospital OPD’s

Financially sustainable, perhaps under-minable;

T.B.D. Not yet tried

Laboratory Service

Financially sustainable. At 30% of market price, no competitor is interested…

Continue as not-for-profit provider

DatabasePotential for more*PE smartphone

Re-assessments & Rewards

Financial sustainable but depends on RDF (ideal?)

TBD How adaptable is our database?

Supervision by local Gvts

Interested and open to take on a new role

OD is supervisor of Peer Educator Netw.

Database to be installed at OD

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