Cooperation with developing countries: the example of Nicaragua
Transcript of Cooperation with developing countries: the example of Nicaragua
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Cooperation with developing countries:
the example of Nicaragua
A. Edefonti1, G. Marra1, F. Sereni1 , M. Sandoval2, Y. Silva Galàn2
1 UOC. Nefrologia e Dialisi Pediatrica, Clinica Pediatrica G e D. De Marchi, Milano, Italy2 Departamento de Nefro-Urologia Pediatrica, Hospital Infantil de Nicaragua MJR, Managua, Nicaragua
42° Annual ESPN Meeting, Lyon, September 11-14, 2008
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Introduction
• No specific pediatric workshop dedicated so far to the initiatives of cooperation, but increased awareness of the matter
• ISN organizing a COMGAN workshop during WCN, Milan 2009
• Pediatric contributions in the literature about the epidemiology of renal diseases in the developing countries, but not about models of cooperation
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• Pediatric Nephrologists always open to educational matters (courses, stages for doctors of developing countries)
• ESPN members regularly receiving traineesfrom abroad and developing differents types of projects
• No systematic documentation so far of the initiatives of pediatric cooperation worldwide
– IPNA Fellowship Committee starting to require feed-back and track doctors receiving educational grants
(Cont.)
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Is cooperation with developing countries only an educational (teaching /training) issue?
A provocative question
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The start of the cooperation with the Pediatric Nephrology Unit of Managua
• 1997-1999 Stage in Milano of Dr. Mabel Sandoval Dìaz
• 1999-2000 Complain about lack of tools to properly diagnose and treat renal diseases in the Nicaraguan Hospitals
• 2000 Visit to Nicaragua of Italian pediatric nephrologists and recognition of the paucity of human, instrumental and economic resources at Hospital Infantil MJR
• 2001 Start of the project of cooperation, financed initially by the Associazione per il Bambino Nefropatico, Milano
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• Methodology of the project
• Results of the project– Clinical activity– Epidemiology
• Points of discussion
Topics
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Nicaraguan demographic indicators
Total Population
5 142 098
Child Population
2 514 144
Child mortality 36/1000
Annual per capita income
$ 730
Life expectancy
Male 67.0 years
Female 71.0 years
www.inec.gob.ni
Censo de Poblaciòn 2005.
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Characteristics of the initial project • Free of charge basic assistance for children with
renal diseases• Lab test, drugs, imaging (in the private system, whenever
necessary)
• Establishing shared nephrological protocols for the main kidney and UT diseases (the 10 clinical syndromes)
• Establishing a Pediatric Nephrology Unit in a public Children University Hospital in Managua
• Scaled training in Milano of the different components of the team, (Pediatric Nephrologists, Urologists, Imaging specialist, Pathologists, Dialysis Nurse)
• Building a new Pediatric Nephrology ward
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Characteristics of the initial project
• Implementation of a database
• to gather data on the epidemiology of renal diseases (with special regard to CKD)
• to record and monitor clinical activity
• to make quality control of the diagnoses
5. Web connection between Milano and Managua for clinical consultation
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Expansion of the initial project
• Start of a RRT program (2 beds for HD, CAPD and 6 living donor Tx per year) for selected children with ESRD
• Establishing a Pediatric Nephrology Network including 5 District Hospitals covering about 55% of the Nicaraguan population
- to increase diagnostic and therapeutic power in each hospital (supply of lab test, medications, imaging tools, shared protocols)
- to avoid patient and family unnecessary transfer to Managua, whenever possible
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Expansion of the initial project
• Proposal of the model of cooperation to other Central America countries
• Sharing database with Guatemala
• Conference on the Prevention and Management of CKD in five Central America countries (29th of February 2008)
• Extension of the project to a 6th District Hospitalwhere CKD prevalence is allegedly high (61% of population covered)
• Project of early diagnosis and treatment of kidney and UT diseases in the peripheral “Unidades de Salud”depending from the 6 District Hospitals
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Managua Milano
Chinandega
Granada
Jinotega León
MasayaMatagalpa
The Pediatric Nephrology Network in Nicaragua at September 1 st 2008
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2001 2002 2003 2004 2005 2006 2007 2008
Basic assistance
Protocols/guidelines
Team training
Database
Web connection MI – MA
Infrastructure
Dialysis and Renal Transplantation
Network of 5 District Hospitals
Database shared with Guatemala
Central America conference on CKD
Extension to a 6th District Hospitals
Extension to territorial “Unidades de Salud
Chronology of the project of cooperation
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Funding of the cooperation project (2001-2008)
Private Foundations Public Grants
Associazione per il Bambino Nefropatico, Milano (2001-2008)
Health Ministry of Regione Lombardia
(2004-2008)
Asociación para Niños Nefropáticos, Managua (2004-2008)
IPNA Educational Grant (2008)
€ 600 000 € 550 000
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Funds from Nicaraguan Health Ministry
• Salaries for 4 Pediatric Nephrologists, 2 Urologists, 1 Pathologist, 11 Nurses, 1 part time Dietician and 1 Psychologist in Managua and 6 Pediatricians of District Hospitals
• Costs of hospitalization, essential medications, lab test and imaging
• Costs of Peritoneal Dialysis, (CAPD and APD) in Managua
• Cost of immunosuppressive medications for renal transplant in Managua since 2008
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• Methodology of the project
• Results of the project– Clinical activity– Epidemiology
• Points of discussion
Topics
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Clinical activity of the Pediatric Nephrology Unit of HINMJR during the year 2007
Number of hospitalizations 818Number of outpatient visits
– Nephrology 3096– Urology 1842
Number of renal biopsies 29Number of urodynamic tests 61
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Clinical activity of the Pediatric Nephrology Unit of HINMJR at 31 th of December 2007
Number of children with CRI/ESRD 166Number of children treated with chronic HD 13Number of children treated with PD 9Number of transplanted children 17
• 2004 – 2007 14 • 2008 3
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Cumulative number of children with kidney and UT diseases entered in the database
0
500
1000
1500
2000
2500
20022003
20042005
20062007
Pediatric Nephrology Unit of HINMJR (2002 – 2007) 2019 patients
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50
100
150
200
250
300
june-05 sept-05 dic-05 mar-05 june-06 sept-06 dic-06 mar-07 june-07 sept-07 dic-07
GranadaJinotegaMasayaLeonMatagalpa
Cumulative number of children with kidney and UT diseases entered in the database
District Hospitals (2005 – 2007) 858 patients
Managua
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0
50
100
150
200
250
300
350
400
450
500
APSGN
SSNS
Neu
rogen
ic b
ladd
er
Obs
t. Uro
pUTI N
D
Lith
iasis
SRNS
VUR
Kidne
y hyp
opla
sia
Micro
hem
atur
ia
Lupus
nep
hriti
s
Oth
ers
Main diagnoses of kidney and UT diseases in Nicaragua
Pediatric Nephrology Unit of HINMJR (2002 – 2007) 2019 patients
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Main diagnoses of kidney and UT diseases in Nicaragua
0
50
100
150
200
250
300
350
400
APSGN UTI
Nephr
otic
synd
ome
Other
neph
ropa
ties
Obst.
Urop
Rena
l Ins
uffic
iency
Lith
iasis
5 District Hospitals (2005 – 2007) 858 patients
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Epidemiology of CRI in Nicaragua
Incidence in the period 2002 - 2007
0,0
2,0
4,0
6,0
8,0
10,0
12,0
14,0
16,0
2002 2003 2004 2005 2006 2007
* Ardissino GL. et al. Epidemiology of chronic renal failure in children data from ITALKID project (2003) Pediatrics 111;4:382-387
Nicaragua Italy *Point Prevalence
(patients/pmpp) 36,4 74,7
Incidence
(patients/pmpp) 9,8 12,1
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Primary renal diseases causing CRIat HINJMR (2002 – 2007) 166 patients
0
50
100
150
200
250
300
350
400
450
500
APSGN
Neurog
enic
bla
dder
Obst. U
rop ND
Lith
iasis
SRNS
VUR
Kidney
hyp
opla
sia
Lupus
Nep
hritis
Others
GFR:≤90ml/min/1,73
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0
30
60
90
120
150
180
210
León
Masaya
Estelí
Manag
uaRAA
Granad
a
Boaco
Rivas
Chinan
dega
Matag
alpa
Caraz
oRSJ
Chonta
les
Nueva S
egovia
Jinote
ga
pre
vale
nci
a p
mp
Prevalence of CRI (patients/pmp) in the Nicaraguan Districts
Districts inside the project
Districts outside the project
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Follow-up of patients with CRI
CRI166
Deceased67
Lost to follow-up41
On follow-up58
HD7
On RRT13
CRI32
* Without RRT54
Tx14
PD5
* Medical decision 27 % Family decision 48 % (socioeconomic reasons) Deceased before the onset of the RRT program 25 %
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• Methodology of the project
• Results of the project– Clinical activity– Epidemiology
• Points of discussion
Topics
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Points of Discussion
• The problem of allocation of financial resources to pediatric subspecialties by Health Ministries of developing countries- Low budget expected
- More for primary care than for tertiary care
• Top-down model (development of a central unit prior to peripheral hospitals) preferable for pediatric subspecialties?
• Financial feasibility of the assistance to CKD/ESRD in a developing country and scaled transfer of the costs to the government
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Points of Discussion
• Need for fund-raising programs from private and public institutions to finance a cooperation project
• Role of data-bases to assess and monitor the efficacy of a project and to allocate financial resources
• Ethical issues, like allocation of financial resources to dialysis/Tx vs prevention programs of CKD or selection criteria for patients in need for RRT
• Extension of the cooperation model to other countries (methodological aid instead of financial aid)
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Is Cooperation with developing countries only an educational (teaching/training) issue?
A provocative question
No. There’s something more to do than just giving the instructions to catch the fish
You should provide also (at least one) fishing rod
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What is the fishing rod?
• Experience in the development and management of a Pediatric Nephrology Unit and Pediatric Nephrology Network
• Financial resources, through fund-raising programs, both in the developing and industrialized countries
• Experience in scientific communication
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What about scientific communication?
• Need for discussing models of cooperation and confronting different experiences
• Need for spreading a culture of cooperation among pediatric nephrologists
Dedicated workshops?Publications in pediatric journals?
Internet?Registry?
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Life is calling. How far will you go?
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Thanks