strengthening health research capacity in developing countries for equity in esrd prevention
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Strengthening Health Research Capacity in Developing Countries for Equity in ESRD Prevention. Chitr Sitthi-amorn, MD PhD Institute of Health Research February 2004. Health Research Needs for Equity in ESRD?. Quantify Magnitude of the Problems Predictable, Preventable - PowerPoint PPT PresentationTRANSCRIPT
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Strengthening Health Research Capacity in Developing
Countries for Equity in ESRD Prevention
Chitr Sitthi-amorn, MD PhDInstitute of Health Research
February 2004
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Health Research Needs Health Research Needs for Equity in ESRD?for Equity in ESRD?
• Quantify Magnitude of the Problems– Predictable, Preventable– Equity of access to care by social
groups• Tap Unprecedented opportunities
– Screening & early treatment for DM, HT• Coping with widening disparities of
access to care by the disadvantages (available, affordable, acceptable).
• Dealing with capacity constraints
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ESRD in Asian-Pacific Regions
• Prevalence of ESRD linked to funding of dialysis (prevalence = 4.2 to 17.3% between 1998 to 2000).
• PD = 3.9 to 81% of dialysis population.
• Transplantation rate: 3.1 per million to 32 per million
Semin Nephrol. 2003; 23: 107-14)
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Objectives of HR for ESRDObjectives of HR for ESRD
• Improve health & quality of life.• Promote evidence based actions to
improve equity of access to prevention, early treatment, rehabilitation
• Efficacy, Effectiveness, Efficiency.
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Key Challenges
• Value of Health Systems and Health Research System:– Access: equity or ability to pay
• Country Focus & Regional/Foreign support: – Local Trust: Actors, Issues, Settings.
• Key Research Areas: Capacity, Facilities, Commodities, Knowledge
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1. Value: Equity & Ability to Pay
Goal Basic HFA Ability to Pay Ownership Collective
Central Plan Private Market
Allocation Budget Price Demand/Supply D>S or S>D Equilibrium Deficit Soft budget Profit
Efficiency Poor Good in fair market
Quality Poor Good in fair market
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Key Challenges 2: Country Focus
• Country Focus: Country Focus: – Actors:Actors: Academic, Politics, Providers,
People, Public, Private– Issues:Issues: Creation of awareness;
prevention; screening and early treatment; prevent progression of CKD; Rehabilitation
– Setting:Setting: Resource constraint
• Regional & Foreign Support: Regional & Foreign Support:
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Strategies to Enhance Country Focus: Research for Equity
• Promotion of Needs for evidence based action
• Prime Movers interactions with actors
• Knowledge for System management towards EB actions
• Capacity strengthening• Networking
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Strategy: Promotion
• ESRD is preventable and predictable– Awareness & dealings with local belief– Multi-faceted & Multidisciplinary actors
• Risk groups:– NCDs: DM, Hypertension, family history
of ESRD; renal and bladder stones– Infection: strep; HIVAN; hepatitis– Lifestyle: Heroine, smoking, salt,
obesity
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Knowledge for Use by Knowledge for Use by ChampionsChampions
Knowledge: Problem, New advances, ActionEconomic & Social Impact
PoliticalProcess
SocialProcess
Champions
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System Management
• Actors: Public, private, academic, industry, NGOs, and the people
• Multi-level Causation & Intervention:– Policy– Infrastructure & Social Norms– Awareness, Behavior and lifestyles– Screening, Early TRT, TRT of CKD,
ESRD
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Capacity: Supply Side 1Capacity: Supply Side 1
• Knowledge: Individual & Institution– Generation: Minority under-
represented; biomedical sciences; clinical sciences; socio-economic impact; health system performance
– Translation (VDO) >> Access: Geography; Affordable; Acceptable
– Application: New nephrologists; Task based training
– Monitoring and Evaluation
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Capacity: Supply Side 2Capacity: Supply Side 2
• System leadership & management: – Stewardship; Management; Leadership– Partnership: Negotiations; teamwork; IEC– Resource mobilization– Understanding & upholding ethics
• Models: access to services and Drugs• Research: Clinical Trials, Clinical &
biomedical Research: PURE, H5N1, malaria
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Capacity: Demand SideCapacity: Demand Side
• Research Users: – Policy makers; Practitioners; Public &
Communities
• Potential Research funder– Development Agencies– Investors: Pharmaceuticals & Private
Hospitals.– Corporates, Media, Other Programs.
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Capacity Development & Retention
• Development– Strategic Objective for sustainability – Significant Research cum Capacity Dev– Individual & Institutional: Matched – Strategic research network Linkage – Network grant competition:– Small grant mentorship program
• Retention:– Environment; Network; Volunteerism
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Networking & Partnership(Components of Partners)
• Public Sector:Public Sector: Inter-government or Government; Research network; Mentorship network
• Civil Society:Civil Society: Academics, NGOs, Philanthropies, ‘Not-for-profits'
• For-Profit Sectors:For-Profit Sectors: Drugs & 'Biotech' companies, private hospitals, etc
• Intended Beneficiaries:Intended Beneficiaries: people
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Principles of PartnershipPrinciples of Partnership
• Decide on the objective together• Build up mutual trust• Share information: develop networks• Create transparency• Monitor and evaluate the collaboration• Apply the results• Share benefits• Increase capacity and personal
development• Build on the achievements
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Monitoring PartnershipMonitoring Partnership
– AgreementAgreement needed, 'good intention' not enough
– Who has the best claim of 'moral Who has the best claim of 'moral high ground'?high ground'? Who assesses whom? To assess partners or partnerships?
– Practicality:Practicality: Are guidelines practical? Do we know what works best for every situation? Will they stifle new ventures?
– Self-AssessmentSelf-Assessment might be more useful
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Key Research Areas
1. Research to enhance responsiveness of health systems
2. Models for efficient & effective care for ALL
3. Risk management in unique groups
4. Model to improve prevention5. Clinical trials
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Key Research 1: Enhancing Health System
Responsiveness• Knowledge to Enhance System
Capacity – Financing & Inter-related Market – Organization for Optimal Care;
referrals; public; private – Rules for incentives for providers
and users of health systems• Effective Engagement in Political
& Social Processes
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Problems with Unprepared Response: e.g., Social
InsuranceHealth professional etiquette:
– Setting artificial price– Corruption:– Referral of rich patients to private
clinics and use government facilities to give services to the rich but collection of fees at private clinic
Two tier health system
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Knowledge to Enhance Knowledge to Enhance ResponsivenessResponsiveness
What & How to Finance? Inter-related Market: finance, hu
man resource plan, facilities, drugs, education
Tools & their Linkages Communication and Consensus:
- Goals: Needs versus Rights
- Goals: Social harmony vs Prosperity- Allocation: Budget versus Price- Voice from the People- Choice of more enlightened public
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How do we organize Optimal How do we organize Optimal CareCare
Organize Service Delivery : Money does not produce service . It goes through an o
rganization: Role of different ministries
- Protect the weak; Quality; Information;
Targeting, Monitoring and Supervision. Public, private and Pharmaceuticals
:- Reform of civil servants- Competition versus partnership- Mentality, Language, Trust
Political commitment
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Management , Regulation and Incentives:
(setting the rules of the game)
Human resource and Facilities- Payment of providers
- Paying the facilities, fair pricing Information system:
- The Indicators: Equity, Efficiency, Accountability (Private &
Public) Monitoring , Auditing and feedb
ack
- Internal quality Improvement- External friendly evaluation
Incentives and CorrectiveActions
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Key Research 2: Effective System for Delivery of Optimal
Care Screening, Early TRT, TRT of CKD DM
Glycemic Control Eye Exam Proteinuria ACEI, ARB
Blood Pressure Control Dyslipidemia ? Rehabilitation: CAPD; HD; Transplant
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Key Research 3: Unique Risk management
• Exposure to and Management of Sore throat
• Unique risk of IDDM, NIDDM, MODY • Unique Risk for Hypertension • Renal stones• Use of NSAIDS• HIVAN • Heroine
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Key Research 4: Models to Improve Prevention
Creation of Awareness Lifestyle
Salt Intake Exercise Body Weight Stop Smoking NSAIDS Prevent HIV & Heroine
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Key Research 5: Clinical Trials & Basic Biomedical
Sciences Involve underprivileged in Clinical
Trials of TRT Specific group with modifiable risk High Prevalence Areas e.g., stone Variations in Use & Side Effects of
Drugs Bio-medical research
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The Range of Intervention
TargetSocietyBehavior& Values
TargetHighRiskBehavior
PredictivePreventiveMedicineGene RxStem Cell Rx
Biological markerIndividualScreening & Rx
HealthPromotionPrograms
CommunityInfrastructure
National PoliciesTax IncentivesSocial Norms
UPSTREAMUPSTREAMHealthy Public PolicyHealthy Public Policy
DOWNSTREAMDOWNSTREAMPrevention and Curative FocusPrevention and Curative Focus
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Success !!!
High Profiles in National & Local Agenda Good Leaders & Young Researchers Exchange with Mentoring Networks:
"Volunteerism & Virtual Campus" Information to tract progress. Periodic Internal Review of Progresses External Review Effective Interaction with Political &
Social Processes