Strengthening Health Research Capacity in Developing Countries for

Strengthening Health Research Capacity in Developing Countries for Equity in ESRD Prevention Chitr Sitthi-amorn, MD Ph. D Institute of Health Research February 2004

Health Research Needs 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 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

Key Challenges 2: Country Focus • Country Focus: – Actors: Academic, Politics, Providers, People, Public, Private – Issues: Creation of awareness; prevention; screening and early treatment; prevent progression of CKD; Rehabilitation – Setting: Resource constraint • 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 Champions Knowledge: Problem, New advances, Action Economic & Social Impact Champions Political Process Social Process

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 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 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, H 5 N 1, malaria

Capacity: 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: Inter-government or Government; Research network; Mentorship network • Civil Society: Academics, NGOs, Philanthropies, ‘Not-for-profits' • For-Profit Sectors: Drugs & 'Biotech' companies, private hospitals, etc • Intended Beneficiaries: people

Principles 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 Partnership – Agreement needed, 'good intention' not enough – Who has the best claim of 'moral high ground'? Who assesses whom? To assess partners or partnerships? – Practicality: Are guidelines practical? Do we know what works best for every situation? Will they stifle new ventures? – Self-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 prevention 5. 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 Insurance Health 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 Responsiveness What & How to Finance? q Inter-related Market: finance, human resource plan, facilities, drugs, education q Tools & their Linkages q 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 Care Organize Service Delivery : Money does not produce service. It goes through an organization: q Role of different ministries -Protect the weak; Quality; Information; Targeting, Monitoring and Supervision. q Public, private and Pharmaceuticals : -Reform of civil servants -Competition versus partnership -Mentality, Language, Trust q Political commitment

Management , Regulation and Incentives: (setting the rules of the game) q Human resource and Facilities -Payment of providers -Paying the facilities, fair pricing q Information system: -The Indicators: Equity, Efficiency , Accountability (Private & Public( q Monitoring, Auditing and feedback -Internal quality Improvement -External friendly evaluation q Incentives and Corrective Actions

Key Research 2: Effective System for Delivery of Optimal Care q q q 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 q Creation of Awareness q Lifestyle § § § Salt Intake Exercise Body Weight Stop Smoking NSAIDS Prevent HIV & Heroine

Key Research 5: Clinical Trials & Basic Biomedical Sciences q Involve underprivileged in Clinical Trials of TRT q Specific group with modifiable risk q High Prevalence Areas e. g. , stone q Variations in Use & Side Effects of Drugs q Bio-medical research

The Range of Intervention National Policies Tax Incentives Social Norms Health Promotion Programs Community Infrastructure UPSTREAM Healthy Public Policy Target High Risk Behavior Target Society Behavior &Values Predictive Preventive Medicine Gene Rx Stem Cell Rx Biological mark Individual Screening & Rx DOWNSTREAM Prevention 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