Patrones de Diseño

Attempting to integrate a kidney disease focus within a chronic disease management program is challenging. People’s health status and quality of life will not be improved solely by medication and technical advances; and thus healthcare systems have to move away from the current dominant model of ‘‘find it and fix it’’ to a more integrated approach (Katz, 2005b, Epping-Jordan, 2005). Such solutions often require cooperation between government, private funders and non-governmental organizations. This is in keeping with the WHO definition of a

‘health system’ which comprises all organizations, institutions and resources devoted to producing health actions (World Health Organization, 2000a). Programs often rely on outside organizations and appropriate technologies to stimulate their development (Bachmann, 2007), but although non-governmental and private-for profit organizations are important players in stimulating innovation, they cannot carry out the central activities of the public health sector (World Health Organization, 2005a) . This responsibility has to fall on policy makers, government departments and the people and institutions that are responsible for public health care.

Programs like CDOP require the acquisition of skills but also resources and funding. We have to balance our enthusiasm to initiate programs with the practical reality and recognition that most countries like South Africa, which need prevention and detection programs, are also those in which they are most difficult and time consuming to set up. Establishing these intervention

programs often require many years from the time of conception to implementation and even more time to scale up.

The strengthening of health systems in developing countries remains a key challenge, especially in the wake of the existing epidemics of HIV and chronic diseases. Fragmentation of health systems, by developing parallel programs, can lead to chaos (McCoy et al., 2005, Sanders and Chopra, 2001, Sanders et al., 2005). The energy and activism around HIV/AIDS should be joined with other chronic illness programs, providing an opportunity to strengthen and integrate health systems. Integrated programs are more likely to develop health systems horizontally across sectors and this will have a positive affect for all chronic illnesses. Chronic disease programs facilitate the long-term social processes of capacity building of both

communities and health workers. CKD and HIV share similarities, their risk factors and complications can be effectively detected and treated.

In South Africa, nephrologists have had significant experience in CKD. As dialysis and transplantation are a scarce resource to which access is limited, great efforts have been made to ensure equitable access to this resource and better patient adherence (Dirks and Levin, 2006, Moosa and Kidd, 2006). The problems in strengthening health systems and scaling up therapies in the face of HIV and CKD include the scarcity of human resources, caused by an inadequate supply, maldistribution, the low remuneration health workers receive and the increased migration to more favourable environments (Schneider et al., 2006, Victora et al., 2004). Poor productivity and culture of service delivery is also a problem (Hongoro and McPake, 2003).

Another key challenge is insufficient financial investment into already weakened health systems. Although global funding has increased, adequate funding has been a challenge with scaling up of HIV programs. Even if there were adequate funding, the human resources

required to provide treatment falls far short of what is required (Rosen et al., 2005, McCoy et al., 2005). Health system infrastructure is also inadequate. Such challenges cannot be reversed in the short term.

In chronic disease programs, it is critical to link treatment with prevention. Integrating the therapeutic and prevention roles has improved care provided by obstetricians and paediatricians (Rose, 1981). Integrating treatment and prevention is shown to have a greater impact on

outcomes than treatment alone (Salomon et al., 2005) (see figure 2). Success has been achieved in Australia and the United States from the late 1970s where this focus resulted in the reduction of mortality from coronary artery disease (Rose, 1981, Lenfant, 2003). For coronary artery disease, although both primary and secondary prevention and treatment components are necessary to maximise health care, the greatest benefit is seen with primary prevention (Unal et al., 2005). This may prove true also for other chronic diseases. Strategies should focus on primary prevention, particularly tobacco control, healthier diets and exercise.

People with chronic illnesses often present late in the natural history of their disease, when the disease is well advanced. An integrated health care system, involving all ‘structures’

including prevention and treatment components, is particularly appropriate for the ongoing care of any chronic illnesses, such as tuberculosis, DM, HIV (Epping-Jordan, 2005). Prevention strategies would include focusing on those at highest risk for disease and utilising a mass strategy of prevention and treatment to shift the whole population distribution of that risk variable (Rose, 1981). However, many questions have yet to be answered with regard to health systems and chronic illnesses: how to ensure the availability of low-cost generic drugs for people at high risk of CVD or CKD and their uptake and long-term use without financial burden. Other

questions include how to identify people at high risk in primary health-care settings and ensuring appropriate referral. A simple set of indicators and good information systems for monitoring progress in implementing strategies to manage chronic conditions is also needed (Beaglehole et al., 2007).

In South Africa, chronic disease systems for managing HIV and TB have received a greater focus and are better funded and receive more attention for political and emotive reasons.

But the management of all chronic diseases require a functioning health system and so tackling these problems should be integrated under the same banner (Epping-Jordan, 2005, Couper, 2007). The health system in South Africa requires significant strengthening given the epidemics both of non-communicable chronic disease and HIV. Research and evaluation of health systems has taken place in developing countries (Joint Learning Initiative, 2003, Sanders et al., 2005), and especially with regard to HIV (McCoy et al., 2005, Schneider et al., 2006) but also non-communicable chronic illnesses (Abegunde et al., 2007, Epping-Jordan, 2005).

Health Systems Evaluation

The evaluation of a health system is best approached by firstly understanding the

environment in which it functions and then breaking the health system down into its components.

The impact of a health system or program depends on socio-economic and social stratification factors such as race or ethnicity,genderandage, and because of this, quantitative evaluation of the outcomes may not provide all the answers to controlling illness. Despite the existence of many programs, a relatively small number of these are evaluated. Program evaluation determines which programs are needed, effective and utilised (Potter, 1999).

A prerequisite for effective implementation of any secondary prevention strategy,

including early detection and prevention programs, is a functioning and equitable primary health-care system. The provision of affordable and reliable drugs for chronic disease is a major challenge, with many patients missing out on effective and cheap treatments. Proper planning and implementation of prevention and control strategies depend on reliable and comparable information to monitor the burden of chronic diseases and their risk factors. In the poorest countries, the availability and quality of health information systems are often inadequate to inform health policies and resource allocation at global, regional, and country levels (AbouZahr and Boerma, 2005, Murray et al., 2004). The rapid escalation of demand for chronic care services has been poorly documented, and major gaps in the supply of health information for developing countries are apparent. An information system allows for evaluation of challenges, and quick reaction to new methods to tackle problems. Good examples exist of the use of data for evidence-based decision-making leading to better health (Mubyazi and Gonzalez-Block, 2005). Inadequate health information contributes to the non-recognition of the burden of chronic diseases, inadequate resource allocation, improper planning of control strategies, and little means of monitoring the effect of health policies (Boerma and Stansfield, 2007).

The environment includes the policies and politics in which a system must function, the economic dynamics which prevail, and the underlying risk of disease in that community. In the case of a chronic disease like CKD, this includes risk factors associated with CKD like smoking, obesity, DM, HTN and HIV/AIDS. It also includes socio-economic factors. Evaluation has to take

into account the various components needed to ensure service delivery such as urine dipsticks measurements, blood HbA1c and eGFR measurements. It also includes the existing structures required to manage the disease, such as the clinics and PHCN staff. Finally, constant evaluation of the processes and outcomes are required, in keeping with the participatory action research methodology.

Models like the Wagner CICM and WHO ICCC recognise these complexities (Epping-Jordan et al., 2004, World Health Organization, 2002a), highlighting the need for adequate resources, appropriate protocols and systems, and for health workers and patients to work together. Integration can occur at many levels, including at the level of program management (Schneider et al., 2006, Si et al., 2008). This includes integrating the financing, procurement of resources and monitoring of the programs at the national level.