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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
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