Highlights April – July 2011
In July 2011 the first voucher scheme for members
with chronic disease took off in the urban slums. It is for Diabetic
members who face relatively high prescription costs and who are poor. MoPoTsyo’s membership database makes it possible to track their
adherence over time to the prescribed medication. The voucher system is
meant to help create a meaningful cycle of care, so the benefit package
contains much more than just a discount on pharmaceuticals for
people with chronic disease. The 5 urban Peer Educators
distributed 3 vouchers to every one of the 55 poor diabetics
in 5 slum areas.
During 3 consecutive months, these 3 vouchers help these
registered members purchase their prescription drugs monthly at one of
the two private pharmacies contracted by MoPoTsyo in urban Phnom Penh.
These two sell medicines from MoPoTsyo’s Revolving Drug Fund exclusively
to MoPoTsyo’s members at fixed prices. The voucher holders can use 3
vouchers at once to buy a 3 months stock or they can use the voucher month by
month. In great majority of cases the voucher covers 50% of their
monthly prescription drug costs, but in some cases the assistance is as
high as 80%. The Peer Educator must meet with the patient personally in
order to hand over the vouchers because that creates the opportunity to
check blood sugar, blood pressure, weigh, check the records in the
self-management book and talk as trained patient to patient. All Peer
Educators have diabetes themselves and can help other patients improve
their knowledge and self-management skills.
voucher is therefore not an additional health financing scheme but an
additional health service tool to help patients adhere better to
follow-up care !
The first group of beneficiaries of these vouchers was already receiving
financial assistance from MoPoTsyo’s own equity fund but
that system was “cash based” so not suitable scaling-up. With this new
voucher system we contribute to the design of comprehensive “social health protection”
for chronic patients. That is in this case preventing catastrophic
health expenditure related to chronic illness and prevention of
secondary complications. Cambodia has already specific policy for health equity fund and vouchers
but only for acute illness and symptomatic treatment. This voucher
system is the first for a “continuum of care”
as the retail price of prescription drugs has been loaded with the costs
of the continuum of care.
During these first 3 months, Ministry of Health officials and MoPoTsyo
monitor how it works. Then, if the system works
satisfactorily, we will expand it to other provinces during Quarter 4 of 2011 to get experience with the system in rural
areas. The right level of subsidy must be determined. Benefits can be
added and it can be linked with other
programs that make benefits available for vulnerable groups. After all,
more than two thirds of our members are women and among them 40% is in
the fertile age group. But there are also ideas to provide TB screening
to this group or special subsidies to help prevent blindness.
5- year document experience
Encouraged by the
for Health Policy and Systems Research, we began to document the
first 5 years of experience with the Peer Educator Networks for Diabetes and High
Blood Pressure over the period 2005 – 2010 resulting in a 150 page
document, which can be downloaded
The document helps also to create an evidence base for a Policy Brief
that contains MoPoTsyo’s advice on how to proceed with the PEN and how they can
best be framed and as part of Cambodia’s national response to
emerging threat from chronic NCD. The Policy Brief is available in
English and in
versions. This is the start
of a process of integration into the primary care system, more in
particular the Operational District which runs Cambodia’s public primary
care system. With official integration the road opens to create
functional vertical and horizontal linkages that are needed for the
PEN’s proper governance and supervision. The opening of an office inside
the Provincial Health Department in Takeo is also an important step into
the same direction as the PHD will have to carve out a role for itself
in the supervision of the OD’s in how they deal with the PEN;s. For the
moment, the PEN’s are reporting based on 25 standard progress indicators
that together create a picture of the activity and achievements in each
health center coverage area but also a summary per OD and a summary per
province and also a summary for the whole country, that is from OD’s
where the activities are implemented so far.
Alliance news Letter
MoPoTsyo has also begun to make a modest contribution to the
Access To Medicines (ATM) policy research program of the Alliance for
Health Policy and Systems Research see
Alliance news letter 21 with 2 abstracts accepted at the ICIUM
conference (November 2011). Although we are not a real research
organisation our data can help create better insight in what works for
chronic patients suffering from chronic NCD in low income
Bernadette Thomas Nephrologist
A Senior Nephrology Fellow from the University of
Washington Medical Center was introduced to the urban Peer Educator
Network in July 2011 by Prof Jim
Logerfo, from the same University. With the
intervention’s improvements in blood sugar and blood pressure there is opportunity to delay and prevent Chronic Kidney Disease among many
of MoPoTsyo’s members. We have to learn more about the extent of the
problem and our impact on it
through the appropriate indicators. It is
wonderful that they are going to advise us how to get a better handle on this issue
and on hypertension in general.
Jackie Green biochemist/biochemist PLUS anthropologist
A Canadian biochemist-anthropologist worked as
volunteer with MoPoTsyo for six weeks to help us monitor the use of our
laboratory services and in particular the use of the urine glucose
Results will be
available in September this year.
Spotlight on Kompong Speu
Province, Kong Pisey OD
In 2009, the Australian government in Canberra
contracted MoPoTsyo to set up its 8th Peer Educator Network.
Operational District in Kompong Speu province had been chosen because it
borders Ang Roka OD in Takeo with a mature OD, which makes it easy to
replicate. About a year later there are significant results to
15 (79%) out of 19
community based diabetic (=with DM) Peer Educators at work in their
health center coverage area.
574 patients (15%)
have become member. Among 574 members 62% are women. Among these women
30% are between 15 and 49 years old, so 1 in 5 members is in fertile age
Among these (62%)
rural 356 women there are 160 with DM (and among them 64 women who have
both DM and HBP (=high blood pressure) and 196 females with HBP but no
313 persons with HBP
(but no DM) have become member.
261 persons with DM
have become member.
392 members (=68%)
have consulted with the Medical Doctor and received a generic
prescription to use medicines from the Revolving Drug Fund.
9 DM patients are
1 patient benefits
from MoPoTsyo’s own Health Equity Fund.
17,983 persons (15%)
self-screened for DM with a urine glucose test in 67 villages (15%).
35 Village High
Blood Pressure Groups have been created.
2 times biochemistry
laboratory services were made available for the members.
members (no doubles) benefited from these opportunities to get
affordable and reliable lab-results which help facilitate the
prescription by the Medical Doctor during consultation.
selected by the OD authority have been contracted to dispense the
prescribed medicines from the Revolving Drug Fund to our members.
1 Health Facility is
used for Medical Consultation, namely Kong Pisey Referral Hospital 2
times per month since October 2010.
Per 30 April 2011, +/
USD 127,175 (41% of the grant budget) has
By using the laboratory services and by buying the
prescribed medicines from the Revolving Drug Fund, the members have
started to generate revenue so they will be able to sustain financially
their own PEN (Peer Educator Network) as well as their routine
prescription medication and the laboratory services at the end of the
project period, so December 31st
of the year 2012.
Since October 2010,
two of the Government’s Medical Doctors who are regular staff at Kong
Pisey Referral Hospital receive on-the-job training from the Cambodian
Medical Specialist hired by MoPoTsyo as consultant twice a month so that
in the future they will be able to provide the members with medical
consultations during the special Medical Consultation sessions organized
and staffed by the PEN itself for its membership.
The Province has
asked MoPoTsyo to help it replicate this intervention to other OD’s in
the province. The needs are enormous.
WHO-Worldbank NCD Delegation report
In April this year, the PEN
in Kong Pisey OD was visited by a heavy international WHO-World Bank Delegation whose
members were on their way to Moscow to join in the first Interministerial Conference on
Chronic NCD, to prepare for the UN Summit on Chronic NCD
later this year. The visit made a positive impact on the Delegates as
can be read in the mission’s report, which can be
The World Bank also recommends
the Cambodian government to use peer education and self management in
primary care with community involvement. Exactly how peer education and
self-management can best be integrated into primary care depends on the
Letter in the Lancet: "......We need to radically rethink our concept of
health care to address the rise of non-communicable disease. This shift
implies very simple diagnostic and treatment protocols, fewer barriers
to essential medicines, greater access to simple monitoring devices, and
a move towards true empowerment of patients." writes Raoul Bermejo III
in The Lancet and mentions MoPoTsyo as an example (download).
Wow…..already 3 theses that are available!
Khmer & 2 in English
Cambodian students from different universities and
enrolled in various faculties have studied parts of MoPoTsyo. This has
produced some interesting robust findings resulting in sound academic
achievements and commensurately awarded with great praise and high
scores from the referees.
Center of Hope helped us with
temporary supply of HCZ
to avoid a stock out
Our Hydrochlorothiazide 25 mg arrived too late
friends from Center of Hope lent us enough to meet the gap for a couple of weeks.
In 2010 July it also happened but then with Metformin. It is not easy
to expand and estimate the right quantities...
destruction of expired drugs
The other side of the same coin is that this year for
the first time we organized a destruction of medicines that had expired.
It was almost all Propanolol and very little of anything else.
We have adopt a transparent administrative and practical process for
this activity which can be
downloaded here. MoPoTsyo has always
had a standard
policy of not using expired drugs. Yes it is well known that for certain medication it is
no problem to use these beyond the expiry date and also that
insulin is among those, but we decided not to do that. We must keep
the quantities of drugs that have to be destroyed as small as possible and yet avoid
having to borrow from our friends.
Peers For Progress
Among a wealth of information on peer education
initiatives all over the world, PFP announced the appearance of the
report of the Kuala Lumpur meeting which can be
The financial audit of financial 2010 has been
completed by our regular Auditing firm Vanda. It will be submitted to
MoPoTsyo’s Board at the next board meeting in August 2011. The World
Diabetes Foundation (http://www.worlddiabetesfoundation.org)
has introduced new audit procedures for which WDF has contracted an
international audit firm. So for our WDF09-463 grant the audit 2010 will
have to be repeated later on by the international firm.