SK Agarwal

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How to Approach CKD Prevention in Large Country
SK Agarwal
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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

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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
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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
???
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Major Causes of Chronic Kidney Disease
(CGNTID)
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Etiology of CKD in India
Hospital based studies
Field study
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Prevention Program in Other Countries
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Can Causes and CKD easily detectable?
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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 20034222-35
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Approaches for Prevention Programs for CKD
Selected Community
High Risk Group
Whole Population
Australian Program

• KEEP
• South Africa

NKF Singapore
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Proposed Prevention Program in India
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Possible Prevention Program in India
Selected Community

High Risk Group

• Diabetics
• Ht
• 10 Relatives of
• CKD
• Diabetics
• Ht

Whole Country
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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
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Top 10 Specific Causes of Death in India, 1998
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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
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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
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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
MP
Mani
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
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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)

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How to run the program?
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Health Care Set-up in India, its changes with
time Government Priorities and Policies
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Transition of Indian Health System
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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.
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Indian Health Care in Rural Area Infrastructure
Rural Health Statistics in India 2002, Govt. of
India
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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
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Demographic Changes in India (1951-2000)
National Health Policy 1983, Registrar General of
India
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(No Transcript)
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Impact of Public Health Expenditure
Rural Health Statistics in India 2002, Govt. of
India
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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
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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
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Goal to be achieved in India by 2015
Rural Health Statistics in India 2002, Govt. of
India
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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.
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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.
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WHO Stepwise Approach to NCD Surveillance
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Risk factors Common to Major NCD
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Where we need help?
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Where we need help?

• From WHO
• Recognize CKD importance
• Include CKD in thrust areas of NCDs
• Training in public health issues

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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

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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

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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