This presentation was given at the 'Beyond Scaling Up: Pathways to Universal Access' workshop which was held at the Institute of Development Studies, Brighton on the 24-25 May, 2010. This event was co-sponsored by the Future Health Systems Research Programme Consortium and the STEPS Centre. Van Pelt presented on the self management of diabetes in Cambodia through the mopotsyo network.

1. A Peer Educator Network
“P.E.N.” for chronic NCD
care + prevention
Self management by People With Diabetes
(PWD)
www.mopotsyo.org 1

2. Cambodia’s Transition
Double Disease Burden : CD + Chronic NCD
Low Income Country
13,500,000 population
>1,000,000 chronic NCD
> 255,000 People With Diabetes
90% of PWD get no care
72% of PWD are unaware
International consensus on
LIC health priorities
excludes care for chronic
NCD (spooky WB 2007 report )
www.mopotsyo.org 2

3. Universal Access to what ?
Scale-up only for CD, not NCD
Allocation of resources to selected needs;
Chronic NCD are left to markets: Market Failure
Annual Health Donor Millions USD
$0.8 $6.3
$9.3
Admin
MCH
Comm.Dis.
$43.7
Non Comm Dis.
www.mopotsyo.org 3

4. Result of neglect of NCD:
Severe LIC Health System failures
1. Weak agency on behalf of chronic NCD patients.....
2. No one tells them what they need to know
3. Patients bear the full costs of their disease O.O.P.
4. No chronic care, no realistic model except the current
veterinary model (biological patient)
5. Incentives favor disease/cure instead of health & self-help;
6. Standard care package is unaffordable for average citizen;
7. Prescription has been mostly “captured”
8. Not enough trained health professionals
www.mopotsyo.org 4

5. But, in fact….
plenty of opportunities in LIC !
1. If you purchase Out-Of-Pocket…you decide
2. Costs can be slashed, real value can be improved.
3. Enough “patients” who are eager to learn
4. Slow disease means enough life-time left to learn
5. Lay people (non-medical) have less conflict of interest
than medical staff in sharing knowledge;
6. Lay people are inter-sectoral
7. Lower cost favors adherence by PWD/chronic patients
8. Set cost to patient at <10% of GNI per capita
9. Lay people are cheap;
10. Task shift to lay people reduces health system stress
www.mopotsyo.org 5

6. Real Public Policy challenge from NCD in LIC =
to push & favor optimal mixes of these opportunities
4 different levels of self management
Patients become People Affordability to patient becomes a key
who get their act
together, take initiative Agency
of
and involve in design, Chronic
patients
management & Peer Educator in
governance of their Public Health Role
problems and Peer Educator in relation
to fellow Patients
solutions….as part of
the overall health
Patient Self-Management
system
www.mopotsyo.org 6

7. Pyramid’s Ground Floor:
Self-Management by PWD
1. Joining in 6 group lessons at home of PE
2. Get >monthly blood glucose at PE
3. Self-Measuring urine glucose (multiple ways)
4. Result Recording in own patient book
Patient Self-Management
5. Healthy eating (follow food pyramids)
6. Sufficient physical activity
7. Improving maintaining weight
8. Buying medicines monthly + adherence to prescription
9. Not smoking, not heavy drinking
10. Joining in 6-monthly assessments
11. Join in monitoring, community actions
12. ….if HBP, peer educating on HBP…..eventually hosting
www.mopotsyo.org 7

8. Low mid-level: Peer Educator as Expert PWD
in relation to other PWD
1. Sharing & Counseling,
2. Registering & Assessing
Peer Educator in relation
3. Informing & training, to other Patients
4. Hosting at home
5. Monitoring-service providing-supplying-selling
6. Guiding to professional health services
7. Welcoming & helping to navigate the hospital
8. Confronting…..coaching...blaming…abandoning ..?
www.mopotsyo.org 8

9. High-Mid level: Peer Educator as
Public Health Expert Peer Educator in
Public Health Role
1. Organising Screening chronic NCD
2. Health Promotion on Risk Factor Control
3. Actual facilitator of access to services
4. Local Eyes & Ears: Monitoring and reporting
5. Mobilising members when necessary
www.mopotsyo.org 9

10. Pyramid’s Top Agency
Chronic
patients
Self-Management at Agency level
1. Patient representation at health policy level
2. Purchasing public health services (health promotion,
screening, getting better deals, bringing costs down)
3. Revolving Drug Funds (at least governance)
4. (e.g. Laboratory) Services
www.mopotsyo.org 10

11. Potential Risks/Weaknesses
1. Weak peer : weak patients 7. Timely referral
2. Narrow view of health 8. Multiple roles: counseling,
3. What is right balance sharing, informing, service
between under- and over providing, explaining,
incentivising; guiding, welcoming at
4. Compete with professionals hospital, blaming…?
5. Co-morbidities
6. Credibility in diabetes • Standards of
means local credibility on care…...whose?
more diseases • Agency Governance /
capture
www.mopotsyo.org 11

12. In summary: public policy challenge with regards to
care for chronic NCD in Low Income Countries
1. End the “defaitism” on care for chronic NCD.
Yes, it can be a black hole but not if…
2. We help chronic patients in LIC get
themselves organised instead of letting them
down as we do now……....………....No?
www.mopotsyo.org 12

13. Acknowledgements
support from
www.mopotsyo.org 13