How to Approach CKD Prevention in Large Country SK Agarwal
Outline • Introduction • Preventive program in other countries • Proposed prevention program in India • Healthcare set-up in India • Government approach to Non-communicable diseases • Where we need help at present • Summary
Summary Incidence of ESRD 260 / pmp RT 3 / pmp HD 2 / pmp CAPD 1 / pmp Govt. spend 8$/capita/yr RRT /person /yr 750-3000 $ What to rest 254 pmp ? Death Prevention is only solution
Preventive Program for Chronic Illness Issues involved: • Is the disease prevalent in the country • Are the effects serious to warrant prevention? • Is the disease/causes of disease easy to detect? • Can disease be easily prevented? • Is the cost of prevention less than the treatment? • Can the preventable program sustainable? Yes Yes Yes Yes Yes ???
Major Causes of Chronic Kidney Disease (CGN+TID)
Etiology of CKD in India Hospital based studies Field study
Risk of CKD in Relatives of High Risk Group Familial aggregation of CKD is high • Hypertension • Diabetes mellitus • IgA Nephropathy • FSGS • Systemic lupus Brown WW et al Am J Kid Dis 2003;42:22-35
Approaches for Prevention Programs for CKD Selected Community High Risk Group Whole Population Australian Program • KEEP • South Africa NKF Singapore
Possible Prevention Program in India Selected Community High Risk Group • Diabetics • Ht • 10 Relatives of • CKD • Diabetics • Ht Whole Country
Multiple Level Approach Awareness of CKD in Community Both Medical, Paramedics, Non-medical Start making a base For community Level screening as part of existing Infrastructure Start early detection program Of CKD in “High Risk Group”
Possible Prevention Program in India Start program with a network in Urban area initially • Diabetes and HT more common • It will be easy to educate • It will be easy to organise & implement • Some networking is existing • Positive results are likely in short period • Impact of program will be faster Make a base in rural area utilizing existing infrastructure
Zonal Coordinator (15) Zonal Member Possible Prevention Program in India Central Coordinating Team • Nephrologist • Community Medicine person • Biostatistician • Administrator / Ministry • Nephrologist • Community Medicine • Administrator • Nephrologist / Internist • Nurse / Other paramedics Medical Colleges / Private Hospital / Pvt. Clinics
Z-13 India with Zones for CKD Prevention Program Chandi Z-1 HP Zone-3 Punj Uttar Hary Sikkim A P Z-2 Z-5 UP Assam Rajas Bihar Naga Z-15 Z-14 Z-6 Jhar Mani MP Gujrat WB Z-7 Chatt Megha Z-4 Orrisa Z-8 Trip Maha Mizo Z-9 Karna AP Z-10 Z-11 Goa Pond TN Kerala Z-12
Possible Prevention Program in India In addition to screening high-risk group • Multicentric study for prevalence of CKD and its etiology in community • Education program for CKD in community • Audio-visual aid • Information booklets • Posters • Interactive session with healthcare team • PEP (Patient-educates-patient)
Health Care Set-up in India, its changes with time Government Priorities and Policies
Demographic High mortality High fertility Low mortality Low fertility • Epidemiological Malnutrition Communicable Dis. Chronic Non - Communicable Dis. • Social Low knowledge Low expectations Public sector High knowledge High expectations Private sector • Economical • Low cost / event • Diarrhea • High cost / event • MI Transition of Indian Health System
Indian Health Care System RURAL URBAN Community Health Center CHC By State Govt. Dispensaries Hospitals Primary Health Center PHC By State Govt. • CGHS • Railways • ESI • MCD • NDMC • Many others Sub-Center SC By Central Govt.
Indian Health Care in Rural Area: Infrastructure Rural Health Statistics in India 2002, Govt. of India
Current Health Policy & Problems in India Cont…. • Unplanned increase in urban population • 35% population is illiterate, thus education • Public funding, central and state funding less • Research utilization only 1.4% of 80,000 Crores (98-99) • Only “Vertical” implementation of health programs • Programs NOT having vertical implementation ?? • Absence of disease surveillance network • Absence of scientific health statistics database Rural Health Statistics in India 2002, Govt. of India
Demographic Changes in India (1951-2000) National Health Policy 1983, Registrar General of India
Impact of Public Health Expenditure Rural Health Statistics in India 2002, Govt. of India
National Health Policy 2002 in India • OBJECTIVES • To achieve acceptable standard of good health for all • Establishing new infrastructure in deficient area • Upgrading infrastructure in existing area • More equitable health service across the country • Increasing the contribution by central government • Contribution of private sector in health to be enhanced • Prevention & first line curative service at PHC level • Other traditional system of Indian medicine to be utilised Rural Health Statistics in India 2002, Govt. of India
National Health Policy 2002 in India • key Points • 55% / 35% & 10% public health budget in Primary, secondary and tertiary care • Health programs should be under single field administration • Autonomous bodies involvement should be more • Exclusive staff for individual program + common staff • Common staff should be trained appropriately • More in-service training for staff • Establish a baseline estimates for NCD Rural Health Statistics in India 2002, Govt. of India
Goal to be achieved in India by 2015 Rural Health Statistics in India 2002, Govt. of India
WHO statement on Non-communicable diseases 2001 The increasing burden of noncommunicable diseases (NCD), particularly in developing countries, threatens to overwhelm already-stretched health services. The factors underlying the major NCDs (heart disease, stroke, diabetes, cancer and respiratory conditions) are well documented. Primary prevention based on comprehensive population-based programes is the most cost-effective approach to contain this emerging epidemic.
WHO statement on Non-communicable diseases 2001 In 2000, the 53rd World Health Assembly passed a resolution on the prevention and control of non-communicable diseases with the goal of supporting Member States in their efforts to reduce the toll of morbidity, disability and premature mortality related to NCDs.
Where we need help? From WHO • Recognize CKD importance • Include CKD in thrust areas of NCDs • Training in public health issues
Where we need help? From ISN A. Include AIIMS as center of excellence • Govt. recognizes it as center of excellence • It is strategically placed • Our group is interested • We have done work in this field B. Help organising prevention conference in Delhi • Initiate enthusiasm in local peoples • Stress CKD importance in local leaders
Where we need help? From ISN A. Help in funding for attending preventive conferences in world for key peoples • Keep enthusiasm alive • Help in building partnership B. Expertise & funding for • Research in key areas of local importance • Help in establishing registries
Summary • CKD is a public health problem in India • Diabetes and Hypertension are common causes • Risk factors for CKD & CKD itself is easy to detect • Prevention program is the only way to handle CKD • Education for CKD is urgently needed • Initially the program can be started in urban areas • Ultimately it has to go to primary health center level • A networking approach is correct approach • International funding is required for this program