Strengthening Health Research Capacity in Developing

Countries for Equity in ESRD Prevention

Chitr Sitthi-amorn, MD PhDInstitute of Health Research

February 2004

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

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)

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.

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

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

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:

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

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

Knowledge for Use by Knowledge for Use by ChampionsChampions

Knowledge: Problem, New advances, ActionEconomic & Social Impact

PoliticalProcess

SocialProcess

Champions

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

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

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

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.

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

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

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

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

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

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

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

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

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

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

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

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

Key Research 4: Models to Improve Prevention

Creation of Awareness Lifestyle

Salt Intake Exercise Body Weight Stop Smoking NSAIDS Prevent HIV & Heroine

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

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

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