Case study: Diabetes, Cambodia's silent killer

28 May 2011

CAP42_photo_PAG15-thumbAccessible care for diabetes in Cambodia

In Cambodia, diabetes is a devastating disease. Expensive clinical care is accessible only to the urban rich, while the poor remain untreated and die. The Cambodian organisation, MoPoTsyo, has an innovative solution that has already saved many lives.

In the early nineties, Cambodia’s public health system started to be rebuilt after decades of war. Health experts and international donor agencies designed a system in which most resources went to combat communicable diseases. Non- communicable diseases, many of which are chronic conditions, were largely ignored.

A prevalence survey carried out in 2010 showed that as many as 2.3% of rural Cambodians aged between 25 and 60 had diabetes and that 10% had hypertension. While the prevalence of these conditions is not particularly high in comparison with other countries, what is worrying is that a comparatively high number of lean Cambodians suffer from diabetes and hypertension. The reasons are unknown, but experts attribute it to a genetic predisposition combined with environmental factors. Cambodia’s post-war public health system is not fit for purpose in that it does not know how to deal with patients suffering from chronic diseases such as diabetes. Health reform is needed urgently as the society rapidly modernises and lifestyles change.

Diabetes is one of Cambodia’s silent killers – the great majority of patients go undiagnosed. The average reported history of diabetes in a group of more than 500 patients who registered at Kossamak National Hospital was just four years. Only one in ten patients reported a history of more than ten years. This suggests that most people with the disease live for only a short time after contracting the condition.

As well as killing otherwise healthy adults in the prime of their productive lives, the fallout of diabetes drains households of their assets. Parents are forced to take their children out of school to work and supplement the family’s income. Livestock and even land are sold to pay for treatment, leaving debts that can never be repaid.

There is little protection against such costs. High-risk debtors – which poor people typically are in the eyes of their creditors – pay the highest interest rates: 2% per day is not unusual. And when interest rates are high, poorer patients lose any assets they might have. Losing land is a growing problem for the rural poor. Landlessness rose from 13% in 1997 to 20% in 2004, and experts speculate that this has already risen to 30%. According to a much-quoted survey, half the rural poor who have lost their land blame it on health care costs. Treatment for diabetes is based on medication and monitoring by clinic-based professionals. But in Cambodia, only well-off city dwellers can afford regular medication – insulin in the private sector costs US$16 for 10 ml, without the syringes.

The MoPoTsyo solution
Cambodian non-governmental organisation, MoPoTsyo, came up with an alternative to expensive clinic-based support. They started involving ‘experienced’ diabetes patients in the early diagnosis, treatment and education of new patients. This experimental programme started in 2005 in two slum areas in the capital, Phnom Penh. It gradually expanded into five slum areas and by June 2007, the first rural project had begun in Takeo province, about 100 kilometres south of Phnom Penh.

The core of the programme consists of community-based peer educators who have diabetes themselves, but who are managing their own symptoms well. They receive a six- week training course, after which they take an examination. These trained patients form Peer Educator Networks (PENs), and their homes become weekly meeting points for diabetes patients living in the community.

The peer educators visit people at home and help to increase awareness of the disease. For early diagnosis, they hand out urine glucose test strips, and do blood glucose tests. This screening helps to identify who is diabetic. Anyone whose blood glucose levels show diabetes can register with the patient information centre. Membership is free and there are currently 63 peer educators running patient information centres from their homes, with a total membership of 2906 diabetics.

Self-financing
The income needed to run the programme is generated by providing services to registered patients. MoPoTsyo acts as an importer and wholesaler of routine medication, which is sold to the pharmacies in the communities where the peer educators are active. These contracted pharmacies sell the prescription medicines to the registered members and peer educators at the lowest possible price.

The payment scheme for peer educators is innovative too. Peer educators whose patients have the best health outcomes – in terms of knowledge and understanding, blood pressure, blood sugar and weight control – receive higher rewards. Twice a year, peer educators from another province evaluate the work of their colleagues by assessing random samples of patients.

CAP42_photo_PAG15Peer educators also guide patients through Cambodia’s often confusing and highly commercialised health system. They help new patients to find the health service provider that gives best value for money. This can be a provider trained by and paid by the PEN, or a recommended affiliated provider. Once detected with diabetes, patients are coached in the ins and outs of the medical system so that they will know how to get what they need from the public service, and be able to recognise the more trustworthy providers.

Peer educators try to protect vulnerable diabetes patients against buying services from untrustworthy health care providers. Patients outside the system continue to pay too much for very poor quality care. But informed patients who are members do not just save money, they are healthier, more confident and better equipped to voice their concerns and improve their situation. The financial advantages of being registered with a PEN help to keep patient retention at about 90% annually. According to a study carried out by Chean Men, a senior researcher at the Center for Advanced Study in Phnom Penh and a member of MoPoTsyo’s board, the average monthly spend on routine medication for PEN members is US$4 – before registration, they would have been spending about US$12.

Peer educators run courses to help patients learn about their condition, but for many patients, the personal contact between them and their trusted peer educator is just as important, especially in the early stages. Patients build up a practical understanding of how they can control the disease and slow its progress.

Diet and lifestyle

Courses given by the peer educator consists of six sessions:

  1. An explanation of basic human biology
  2. How diabetes affects the body’s mechanisms
  3. How to restore and keep the blood–glucose balance (physical activity, food intake and medicines)
  4. The various types of medicine and their roles
  5. Nutrition and healthy eating for Cambodians with diabetes
  6. How to self-test, set targets, self-measure and record progress

The courses emphasise the importance of lifestyle changes. Most Cambodian diabetics do not realise that white rice, particularly Cambodian rice, is highly glycaemic, meaning that the large quantities of glucose in the rice are very quickly released into the blood stream. Average Cambodians take more than 80% of their daily energy from white rice.

MoPoTsyo’s food pyramid is a great help for the patients too. Every registered patient receives a poster showing where commonly eaten food items are on the glycaemic index: highly glycaemic foods are shown in red at the top of the pyramid, and foods with a low glycaemic index rating are shown in the green layer at the bottom. The pyramid helps hyperglycaemic (type 2 diabetes) patients to bring their glucose levels down by encouraging them to replace white rice with healthier sources of energy.

Further promising results
In rural Takeo province, over 70% of people diagnosed with diabetes had been unaware of their condition until they were detected by the peer educator. Early diagnosis is a key step in the prevention of complications, especially because the screening activity is combined with access to affordable care.

Independent assessments based on random samples of registered patients show a relatively consistent pattern of health improvements. Despite low levels of literacy, PEN members have a better understanding of their condition and of how to improve their health and lifestyle. Taken together in all random assessments, average blood glucose and blood pressure levels improve significantly after registration. The vast majority report that they are more physically active and are eating less white rice than before. Studies show that there are also fewer episodes of hospitalisation after registration with a PEN. Health expenditure is reduced by a factor of three.

Facing the future
The PEN approach challenges the widespread notions that diabetic patient populations can only be reached effectively through professional health services, and that any strategy aiming to deliver secondary prevention requires investment in clinic- based care and the strengthening of the capacity of professional health service providers. The results achieved by the PENs provide a strong case for attempting to scale up this initiative. There are a number of critical risks factors that need to be considered though:

Integration within the wider health system – Local health authorities need to get involved in governance in order to strengthen the system further. If such a system is allowed to develop on its own without adequate links to other parts of the health system, patients may miss out on opportunities for care that they would have received had they remained within the public system.

The status of the peer educator in the system – At primary care level, confusion can arise about the precise definition of a peer educator in terms of:

  • hierarchy, responsibilities and accountability
  • lines of communication
  • how the PENs can complement the
  • existing primary care system
  • how they are financed (level and mode of payment)

Quality of care – Many community-based peer educators have had little formal education. They are trained only in very specific health problems and have no background in general health care before becoming peer educators. This limits their scope when dealing with the complexity of the chronic cases that they follow up. It is important to bear in mind that peer educators have to remain motivated. A particular challenge will be how to deal with serious complications over time. Members are starting to live longer and develop complications in greater numbers than they would have had there been no programme. There will be a growing demand for core professional health services with the capacity to deal with complex chronic cases. This type of responsibility cannot be shifted to lay health workers.

Possibly these challenges can best be addressed through supervision, by organising training and by elaborating good policies and procedures to govern the system. More research is needed to explore the potential of this innovative approach. But it is already clear that PENs are a worthwhile investment as part of a health system response to the needs of one million Cambodian citizens affected by diabetes and high blood pressure.
 

Further reading
Biddulph,R.2000.Where has all the land gone? In: Makingthe Poor More Visible: Landlessness and Development Research Report, volume 4. Oxfam Great Britain, Cambodia land Study Report.

Men, C. 2011. The Peer Educator Network: An Intervention to Reduce Health Care Costs and Improve Health Outcomes of Patients with Diabetes and Hypertension. A Baseline Study of the Thmar Pouk Partnership Project. ICCO and KiA.

Men, C. et al. 2007. I Wish I Had AIDS: Qualitative Study on Access to Health Care services for HIV/AIDS and Diabetic Patients in Cambodia. European Commission.

 

Case study: Diabetes, Cambodia's silent killer Maurits van Pelt Director, MoPoTsyo, Phnom Penh, Cambodia
Case study: Diabetes, Cambodia's silent killer Chean Men Board member, MoPoTsyo and Researcher, Center for Advanced Studies, Phnom Penh, Cambodia
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