1. Peer educator networks for diabetes and hypertension in Cambodia Health literacy, ICT & empowerment

2. If there are access-to-chronic-care problems such as… costly distancecostly distance unreliable drug supplyunreliable drug supply unresponsive servicesunresponsive services long waiting timeslong waiting times over-loaded medical staffover-loaded medical staff exclusionexclusion lack of certain services lack of referral to other specialisations over-pricing (cf. reference) unnecessary services inappropriate information 2

3. ….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 3

4. 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-management 4.Be intermediary: Make appointments on behalf of patient with Dr 5.Follow-up by outreach to patient’s home if necessary; 6.Set up Village HBP Groups in each village, maintain monthly visits 7.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) 4

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6. 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 Hospitals o 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 Insulin o 7,170 HBP patients (non-diabetic) 6

7. Health Literacy in Outputs & Outcome Re-assessments + Rewards (yearly..?) Health Literacy in Outputs & Outcome Re-assessments + Rewards (yearly..?) 7 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

8. ICT for empowerment of: 1. Groups & 2. Individual Patients Database “ internet ” Registration data (1st assessment by PE) creates E.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 8

9. Use Database as a tool… : Calculate supply needs Revolving Drug FundCalculate supply needs Revolving Drug Fund Measure % adherence to prescribed medicationMeasure % adherence to prescribed medication Measure performance by main actors by areaMeasure 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 actorsDetermine financial rewards for the main actors Long term cohort recordsLong term cohort records Measure use of special subsidies/discountsMeasure use of special subsidies/discounts 9

10. 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% 10

11. 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 System 11

12. final slide ! Sustainability & Acceptability Activity 4 new market(s) 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 applications Internet 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 Database Potential 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 12