Engagement activity with stakeholders at the macro level of the health system in Lima- Peru

Summary: Engagement activity with stakeholders at the macro level of the health system in Lima- Peru

On May 3, the COHESION project in Peru held a meeting with stakeholders, where stakeholders related to the health sector and the diseases related to the project (diabetes, hypertension and neurocysticercosis) were invited. The purpose of the meeting was to present the project, create links with different institutions and receive inputs or recommendations for the project.

The meeting was attended by members of the COHESION project in Peru, part of the COHESION team from Switzerland, public officials from both the Ministry of Health and the Superintendence of Health, as well as some civil society organizations such as the Diabetes Association of Peru and the Peruvian Federation of rare diseases.

The meeting began with the words of welcome from Jaime Miranda, Director of “CRONICAS center of excellence in chronic diseases”. During his welcoming he remarked the intention of the meeting to carry out a co-creation process between the COHESION project and the assistants, to think together ways of improving the health system, especially in the attention given in the primary health care.

Following, David Beran principal investigator of the COHESION project made a presentation of the project COHESION (in Spanish). He explained the linkage between the project with the Millennium Development Goals and the Sustainable development objectives. He also pointed out important qualities of the project like being a multidisciplinary and multi-country team. Finally he explained the different stages that the project has carried out and the stages to come in the next years.

Subsequently, the words were given by María Kathia Cárdenas, coordinator and researcher of the COHESION project and at CRONICAS Center of Excellence in Chronic Diseases. During her presentation she explained the COHESION project in the Peruvian scenario. She specified the project is being carried out in the region of Piura, in the health posts of Sicacate and Pingola, located in the districts of Montero and Ayabaca respectively. During this presentation it was also specified two of the studies that the project is carrying on, the evaluation of policies and the health system assessment. She explained details of each study and the different levels of analysis. Furthermore, she also explained the methodology that is being implemented based on the manual “How to investigate access to care for chronic noncommunicable diseases in low and middle income countries” (2012) from the WHO, and she also explained the activities that were already performed at the community level such as interviews with patients, health workers, head of facilities, among others.

Next, María de los Ángeles Lazo, researcher of the COHESION project and at CRONICAS Center of Excellence in Chronic Diseases, detailed the steps that will follow the project in the next months to involve the stakeholders at the macro or national level. She explained to the participants the important need of their support and expressed the intention of the project to involve them actively in the process, as well as with other key stakeholders. It was also specified that in the short term the COHESION project will be contacting them to have personal interviews, to know their opinions on the health systems facilitators and barriers.

Finally the discussion was opened to the attendees so they could express their opinions, comment or question of the project. This final part was moderated by María Amalia Pesantes, coordinator and researcher of the COHESION project and at CRONICAS Center of Excellence in Chronic Diseases. Some of the most important arguments and recommendations are detailed below:

  • To include the perspective of caregivers. It is important the health system recognized their task, not only in a financial support, but also to be trained in the care of the patients and to consider the importance of psychological support for the caregivers, who were also called “acompañantes” (companions).
  • Developing engagement with key stakeholders such as public officials and political representatives is a long-term endeavor.
  • It is necessary to establish relations with the regional health directorate in Piura. This entity is the responsible of providing the health service, while the Ministry of Health is in charge of regulating and monitoring. It was also suggested to interview the head of the department of Planning and Budget and Human Resources, and to include the Regional Government, who has also responsibilities related to health, poverty, access to water and sanitation.
  • It was also highlighted the important role played by community agents in the health system.
  • It was acknowledged the low ability of the Ministry of Health to communicate strong messages. Furthermore, civil society lack of relevant information about diseases, especially the most neglected population.
  • Past experiences on training diabetes educators were shared and it was noticed that one of the main difficulties in the training of health workers was the high rotation to other health establishments, and this should be taken in to account for the project.

Participants:

COHESION Team (Switzerland):

  • David Beran
  • Sarah Lachat
  • Suzanne Suggs
  • Nathaly Aya Pastrana

COHESION Team (Peru):

  • Jaime Miranda
  • Maria Kathia Cardenas
  • Maria Amalia Pesantes
  • Maria de los Angeles Lazo
  • Charlotte Darwis
  • Rosa Salirosa
  • Silvana Perez Leon

Participants:

  • Jorge Calderón (President of the Diabetes Association in Peru)
  • Luciana Bellido Boza (Representative of Intendance of Research and Development – SUSALUD)
  • Jorge Ferrandiz (Executive Director of the Department of Prevention and Control of Noncommunicable, Rare and Orphaned Diseases)
  • Maria Lourdes Rodriguez (President of Hecho con Amor-asociation of multiple sclerosis in Peru and President of the Peruvian Federation of rare diseases)
  • Lilliam Lindley (Representative of Hecho con Amor-asociation of multiple sclerosis in Peru and President of the Peruvian Federation of rare diseases)

 

The selected sites of Ayabaca and Montero in Piura – Peru

The COHESION project assesses the barriers that underserved communities face when accessing Primary Health Care (PHC) to treat chronic conditions in Peru, Mozambique, and Nepal. In Peru, the selected districts are Ayabaca and Montero in the Ayabaca province of Piura, North-Peru.

The northern region of Piura is well known for its tropical climate, white-sand beaches and surf. Far from the beaches on the coast, we find the province of Ayabaca in the highlands of Piura. Ayabaca is about six hours away from Piura city and it can only be accessed by road. Rural Ayabaca has often been neglected and forgotten by policy makers and private investors. Although blessed with rich flora and fauna, the Ayabaca province faces poverty and exclusion.

The Peruvian COHESION project team chose as its intervention sites two districts of the Ayabaca province: Montero and Ayabaca, where 6,683 and 38,339 people live respectively1. According to the National Institute of Statistic and Informatics, the poverty rate in Ayabaca is 69.4% and 55.9% in Montero1. One of the main problems in these districts is the lack of access to sanitation and clean water. Ayabaca province has one of the highest drinking water shortages and lack of basic sanitation, with wide differences between its urban (54%) and rural (99%) areas2. Lack of sanitation is one of the major risk factors3 for some Neglected Tropical Diseases like neurocysticercosis.

Access to health in places like Ayabaca is crucial and yet, scarce. Health facilities in both Ayabaca and Montero only provide very basic health services, focusing on maternal and child health. Out of the 31 health facilities in Ayabaca, 29 are basic primary health care posts. The other two are health centres. Montero, on the other hand, has only three basic primary health care posts and one health centre. The health centres have few health professionals and rudimentary hospitalization facilities. If there is an emergency in either of these districts that requires an urgent referral of the patient, the closest regional hospital is located in Sullana-Piura and it takes about four hours to get there by private vehicle. However, the ambulance in these health centres is not always operating. Addressing diseases like neurocysticercosis, hypertension, and diabetes in resource-limited districts like Ayabaca and Montero needs effective interventions that work at a community-based level and that are focused on the poorest of the poor.

Health Center – Ayabaca

 

Pingola Main Square

 

References:

  1. Instituto Nacional de Estadística e Informática (2016). “Peru en Cifras: Ayabaca, Piura” Retrieved November 04, 2016, from https://www.inei.gob.pe/.
  2. Instituto Nacional de Estadística e Informática  (2010). “Mapa del Déficit de Agua y Saneamiento Básico a Nivel Distrital, 2007”. Lima: Instituto Nacional de Estadística e Informática. Available at: https://www.inei.gob.pe/media/MenuRecursivo/publicaciones_digitales/Est/Lib0867/libro.pdf
  3. Garcia HH et al. (2016). “Elimination of Taenia solium Transmission in Northern Peru”. The New England Journal of Medicine. 2016 Jun 16; 374(24): 2335-44. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27305193

Fieldworkers trained for Community Health Perceptions work in Peru

Fieldworkers received training in data collection tools and methods before heading to the selected sites: Ayabaca and Montero, located in the region of Piura in the north of Peru. They will be conducting interviews and focus group discussions, elements of the Community Health Perceptions research component of the project. Their work will be informed by the findings of a community mapping that took place in October 2016, and will be complemented by the insights of a Ph.D. student in Social Marketing from Lugano, Switzerland, who is joining them in the field.

The fieldwork takes place in February 2017, during the rainy season and some challenges lie ahead of the team. However, the team is excited to engage with the communities.

National Policy Analysis in Peru

One of the main research outputs of COHESION consists of an analysis of global and national policies related to non-communicable (NCDs) and neglected tropical diseases (NTDs). The partners in Switzerland conducted the global policy analysis, whereas national policy analyses are in progress in Mozambique, Nepal, and Peru.

The COHESION team in Peru met on January 23rd to review the preliminary findings of their national policy analysis. Interesting perspectives were raised in relation to the Peruvian policy agenda, methodological considerations were shared and lessons learned were expressed that will be shared with the partner countries. In addition, participants spoke about potential activities that will follow once the analysis is finalized, including publications and dissemination of findings to national stakeholders.

 

 

Selecting the NTD in Peru

“Selecting the NTD in Peru:
Engaging stakeholders in the difficult decision of selecting what underserved disease to prioritize”

The COHESION Project aims to address the double burden of disease that face health systems and communities by improving capacities at the national, local and community levels in three countries (Mozambique, Nepal and Peru). To assess the barriers that underserved communities face when accessing Primary Health Care (PHC) each country team selected a Neglected Tropical Disease (NTD) and two Non-communicable Diseases (NCDs) (diabetes and hypertension). These three diseases would be used as “tracer” conditions to understand the challenges of local health systems to effectively manage these diseases at the PHC level.

Why tracers? Because individuals with one or both, NTD or NCD, have the unique scenario of requiring chronic, engaging, meaningful, respectful and effective care. Both of these tracers, NTDs and NCDs, allow us a second chance to get it right, to redefine the user experience with our healthcare system.

In Mozambique, the selected NTD was Schistosomiasis, while the Nepalese team chose Leprosy. In Peru, we had initially selected Chagas but we felt we needed more information about the various NTDs with chronic sequels affecting people in Peru before making a final decision.

After several discussions with experts and internal conversations about the appropriateness of Chagas and other NTDs including Leprosy, Hydatidosis and Neurocysticercosis, we decided on Neurocysticercosis.

In this post, we share the reasons that lead us to this decision.

We first contacted an expert in Leprosy. We learned that it has not been fully eradicated in some regions in Peru, although the national prevalence rate is lower than 1 case x 10 000 inhabitants (Burstein, 2014). Leprosy still affects some small localities of the Amazon regions, where several geographical barriers and a dispersion settlement pattern predominate (Burstein, 2014). Addressing Leprosy is a challenge given the under diagnosis and other problems related with the epidemiological information systems for reporting of new cases.

Chagas disease affects over 8 million people in the Americas and about 190,000 persons with this disease live in Peru (Bayer et al., 2009). After different national and regional efforts in the nineties for the elimination of the Chagas vector (Triatoma infestans), the incidence of this disease was reduced. The main region affected in Peru is Arequipa, in the Southern Andes. As a result of efforts from different public and private institutions the vectorborne transmission of the disease has been significantly reduced and is now located in peri-urban shantytowns near the city of Arequipa as a response of urbanization processes and migration (Delgado et al., 2011). There is still work to do to eradicate Chagas, starting with the approval of a standardized protocol for the management of the disease and intensification of efforts in diagnosing people plus more thorough surveillance activities with special focus in shantytowns (Bayer et al., 2009). One reason that leads us to reconsider Chagas as the selected NTD is that symptoms may take about 20 years to develop and only few persons who have lesions show a recovery after pharmacological treatment. Additionally, the migration of the disease to peri-urban zone would leave us without the opportunity to explore the response of PHC for patients with NTD in rural area and to develop strategies to enhance the user experience with services provided by the PHC.

When exploring Hydatidosis and Cysticercosis, we learned that “controlling the parasitic infection in animals is crucial to reduce the incidence of human disease” (Otero-Abad & Torgerson, 2013). Both diseases are closely related with human behavior, for example with education about the transmission of the diseases and the prevention with hygiene actions. Currently, there is no vector control program for Hydatidosis in Peru. There was an effort for developing a program that included radio programs with educational messages and the empowerment of school teachers as providers of health and sanitary messages. However, control programs and educative activities were discontinued. Moreover, this disease is not notifiable in Peru, which makes it harder to know its current prevalence.

Finally, we looked into Neurocysticercosis (NCC), which is an “infection of the nervous system by the cystic larvae of Taenia solium” (Garcia, Nash, & Del Brutto, 2014) that frequently causes seizures and epilepsy. Worldwide, over 5 million cases of epilepsy are caused by Neurocysticercosis (Nash, Mahanty, & Garcia, 2013). Neurocysticercosis is especially endemic in areas characterized by poor water and sanitation systems and where pigs are not corralling with access to human feces (García, Gonzalez, Evans, & Gilman, 2003). In Peru, Neurocysticercosis affected approximately 35% of persons with active epilepsy, which is a very high rate comparable with Honduras and India. Only one out of every four patients with active epilepsy receive pharmacological treatment, but in sub-therapeutic doses (Moyano et al., 2014). It has been demonstrated that the transmission of Taenia solium was eliminated in 105 of 107 villages in Tumbes (region located in the north of the country) after an “attack phase” during one year that comprises people and pigs, and this result persisted over 1 year (Garcia et al., 2016; Maurice, 2014). However, there are still cases of NCC in the intervened region after several years of the implementation of the control program and there are other endemic regions affected by this disease in Peru.

The aforementioned efforts for the different NTDs and the pending actions for reaching the control of the diseases were the main topics discussed with different experts in the field. We were impressed with their high motivation, solidarity and expertise gained through the years. For example, there are strong research teams for the study of Chagas and Cysticercosis that have made relevant contributions like the risk mapping of the zones to inform surveillance system for Chagas or the massive intervention in persons and pigs from rural villages of northern Peru for blocking transmission of cysticercosis.

All experts agreed that whatever NTD we chose, we would be making a difference because they affect the most vulnerable.

Our decision about the selection of Neurocysticercosis for the purpose of the COHESION project was made considering to prioritize an NTD that generates a chronic condition that requires long-term treatment like epilepsy and affecting the poor of the poorest population in rural area, where PHC response is more relevant as the first point of entry for care. In so doing, by choosing NCC, together with an understanding of other major prevalent NCD conditions like diabetes and hypertension, will provide us with a second chance to get it right, to redefine the user experience within our healthcare system.

Acknowledgments: We thank César Náquira, Ricardo Castillo, Valerie Paz-Soldán, Aldo Lucchetti, Luz María Moyano, Ricardo Gamboa and H. Hugo García for their valuable time and insights about NTDs for the purpose of the COHESION project.

References:

Bayer, A. M., Hunter, G. C., Gilman, R. H., Carpio, J. G. C. del, Naquira, C., Bern, C., & Levy, M. Z. (2009). Chagas Disease, Migration and Community Settlement Patterns in Arequipa, Peru. PLOS Negl Trop Dis, 3(12), e567. http://doi.org/10.1371/journal.pntd.0000567

Burstein, Z. (2014). Critical appraisal about control programs and elimination of leprosy in Peru, and its consequences for Peru and America. Revista Peruana de Medicina Experimental Y Salud Pública, 31(2), 336–342.

Delgado, S., Neyra, R. C., Machaca, V. R. Q., Juárez, J. A., Chu, L. C., Verastegui, M. R., … Levy, M. Z. (2011). A History of Chagas Disease Transmission, Control, and Re-Emergence in Peri-Rural La Joya, Peru. PLOS Negl Trop Dis, 5(2), e970. http://doi.org/10.1371/journal.pntd.0000970

García, H. H., Gonzalez, A. E., Evans, C. A. W., & Gilman, R. H. (2003). Taenia solium cysticercosis. Lancet, 362(9383), 547–556. http://doi.org/10.1016/S0140-6736(03)14117-7

Garcia, H. H., Gonzalez, A. E., Tsang, V. C. W., O’Neal, S. E., Llanos-Zavalaga, F., Gonzalvez, G., … Gilman, R. H. (2016). Elimination of Taenia solium Transmission in Northern Peru. New England Journal of Medicine, 374(24), 2335–2344. http://doi.org/10.1056/NEJMoa1515520

Garcia, H. H., Nash, T. E., & Del Brutto, O. H. (2014). Clinical symptoms, diagnosis, and treatment of neurocysticercosis. The Lancet Neurology, 13(12), 1202–1215. http://doi.org/10.1016/S1474-4422(14)70094-8

Maurice, J. (2014). Of pigs and people—WHO prepares to battle cysticercosis. The Lancet, 384(9943), 571–572. http://doi.org/10.1016/S0140-6736(14)61353-2

Moyano, L. M., Saito, M., Montano, S. M., Gonzalvez, G., Olaya, S., Ayvar, V., … Peru, for T. C. W. G. in. (2014). Neurocysticercosis as a Cause of Epilepsy and Seizures in Two Community-Based Studies in a Cysticercosis-Endemic Region in Peru. PLOS Negl Trop Dis, 8(2), e2692. http://doi.org/10.1371/journal.pntd.0002692

Nash, T. E., Mahanty, S., & Garcia, H. H. (2013). Neurocysticercosis—More Than a Neglected Disease. PLOS Negl Trop Dis, 7(4), e1964. http://doi.org/10.1371/journal.pntd.0001964

Otero-Abad, B., & Torgerson, P. R. (2013). A Systematic Review of the Epidemiology of Echinococcosis in Domestic and Wild Animals. PLOS Negl Trop Dis, 7(6), e2249. http://doi.org/10.1371/journal.pntd.0002249