Scaling up

This is the final post of a three part series of guest blogs based on writings provided by Maurits van Pelt, Director of MoPoTsyo Patient Information Centre in Cambodia. Collectively these writings provide a roadmap for scaling up peer educator networks and developing sustainability for what is now still an intervention organized and facilitated by a Cambodian NGO. Part 1 focused on developing a Niche and Demonstrating value. Part 2 Focused on Integration. Part 3 focuses on the scaling up process.

Why do many organizations fail to scale up interventions?
There have been many attempts to scale up interventions in the health sector by engaging with the community that have not been successful. The reasons for these failures in low resource contexts are multiple and complex (Bloom & Ainsworth, 2010). Often times there is not a lasting community engagement even when resources are made available because training is either too short or handed down as a set of technical instructions from the service supply side to community representatives without appropriate explanation. A top-down inflexible package that is neither adapted nor responsive to the needs of the local community can be delivered but the results will frequently disappoint.

MoPo Tsyo’s approaches to scaling up
MoPoTsyo’s has experienced successful growth thus far by focusing on replication and selecting candidates from new areas to receive extensive training. These candidates travel and stay several weeks in places where they can learn and interact with others that have been successful. This experience helps prepare candidates for travel to places where there is a need for training and supervision of others.

Once networks are mature, selected members play a key role in helping to create other networks. Some of them grow to become managers and are involved in organization, negotiation and representation. The organization at the central level lets members grow and take on more responsibility but also adds people with special skills that cannot be found among the staff. Continuous learning and standardization is achieved through a centralization of information at the NGO’s relatively small office in Phnom Penh. There are no plans to establish physical infrastructure in the provinces outside the existing public health infrastructure. The organization is aiming to coordinate and finance its growth by intensifying its partnership with the existing public health care system where it can without losing quality, effectiveness, efficiency and responsiveness.


Bibliography

Bloom, G., & Ainsworth, P. (2010). Beyond Scaling Up: pathways to universal access to health services. Sussex UK. Retrieved from http:\\www.steps-centre.org\publications.

INTEGRATION makes sense, but HOW?

This is the second post of a three part series of guest blogs based on writings provided by Maurits van Pelt, Director of MoPoTsyo Patient Information Centre in Cambodia. Collectively these writings will provide a roadmap for scaling up peer educator networks and developing sustainability for what is now still an intervention organized and facilitated by a Cambodian NGO. Part 1 focused on developing a Niche and Demonstrating value. Part 2 Focuses on Integration. Maurits van Pelt.

INTEGRATION makes sense, but HOW?

Recognizing the cost effectiveness of the Peer Educator Networks (P.E.N.), the Cambodian Ministry of Health recently approached MoPoTsyo to have the benign neoplastic P.E.N. become more integrated into Cambodia’s primary health care system. This could increase MoPoTyso sustainability by getting government network costs not yet recovered through revenues generated from service provided to members, as well as lead to better access to medical services for patients outside the scope of the Networks. However, what does such integration mean in practice?

Challenge 1: Can peer educators carry out new tasks?
Access to additional medical services can be critical in an environment where diabetic peer educators are untrained and unqualified to provide services outside their own chronic disease. It should be noted these educators are not community health workers and may easily overlook signs of other health problems that need priority attention. Consequently, much of the added value of Peer Educators will be lost if peer educators delay proper care instead of facilitating it.

Challenge 2: Linking various programs at the lowest is hard to do.
Patients often require horizontal functional linkages at the lowest levels of the health system with the National Mother- and Child Health, Neonatal Health program and Communicable Disease program. Unfortunately, many low income countries are notorious for problems with linking these kinds of different programs. However, these turf wars are mainly waged at the top of the program silos where policies are set for allocating resources. Fortunately, at the point of service delivery, patients and staff have different worries and offer little or no resistance to a more integrated approach provided the right conditions are in place.

Challenge 3: The current system may not have the capacity to satisfy consumer needs.
When preceding this integration, service capacity and availability can be a severe constraint. In other words, it makes no sense to train people in doing something if the conditions are not in place for delivery. For example, there are many barriers that delay seeking of professional care: transportation costs are relatively high and trust in public health services is generally low. If a peer educator recommends a patient to go for medical consultation many patients simply will not follow the advice because of real or perceived barriers.

MoPoTsyo’s approach to the challenges: Let’s pilot test at implementation level
Solutions for these technical challenges must be found that work in the local context. With the decentralization of the health system under way, it is likely that these horizontal and diagonal linkages are best piloted at the implementation level. After all, "how to brew the best soup collaboratively and steadily over time as it must be eaten locally". As an example, MoPoTsyo has an opportunity to strengthen the system’s ability to target subsidies to individuals and households who are most vulnerable in order to help them adhere better to prescribed treatment and cope better with the cost of their chronic illness. A voucher system is being piloted in the urban slums starting in July 2011 and can be rolled out to 4 provinces in the 4th trimester of 2011 if the results prove satisfactory. However, a broad regulatory framework for the operational district level is now required that captures the Peer Educator Network to become incorporated under the primary health care system. This can shift specific management tasks to local health authorities in exchange for proper rewards for their extra work and added responsibilities without clipping the wings of the Peer Educator Networks.

Peer Support: Developing a Niche and Demonstrating Value

This will be the first of a three part series of guest blogs based on writings provided by Maurits van Pelt, Director of MoPo Tsyo Patient Information Centre in Cambodia. Collectively these writings will provide a roadmap for scaling up peer educator networks and developing sustainability for what is now still an intervention organized and facilitated by a Cambodian Non-Government Organization (NGO). Part 1 focuses on developing a Niche and Demonstrating value. Maurits van Pelt.

Program Outline
The NGO MoPo Tsyo Patient Information Centre ‘s office is located in the capital Phnom Penh. It organizes capacity building of diabetes patients to become peer educators. Once these trained patients have passed the peer educator exam, they return to their communities and begin to run MoPoTsyo Patient Information Centres from their own home using basic equipment and materials supplied to them by the NGO based on their activity reports.

The urban slums and rural Cambodia are characterized by high poverty rates and extremely limited resources to sustain a chronic disease care system.

The Peer Educators promote lifestyle changes and teach diabetes and high blood pressure self-management. The diabetic educators have learned to manage diabetes themselves and are familiar with the typical ups and downs of diabetes self-management helping them communicate effectively with the people they are supposed to assist. They are trained to provide screening services, home visits, run education courses and help navigate the complex, confusing and often costly disease management system and services. The Peer Educators (khmer “Mit Abrom Mit”) create personal contact and bring understanding to the disease. They remain motivated through social financial innovations of the patient educator networks. Their efforts provide social and emotional support that combine with the innovations to provide success stories such as 87% patient member annual retention average over the past 5 years in the urban slum areas, improved knowledge, self-care skills & lifestyle, and significantly reduced costs to the participating patients. Regular re-assessments show that levels of Blood glucose and blood pressure remain significantly reduced compared to these values at time of registration into the network among the majority of the patients who are in peer educator follow-up.

History
In 2005 the first MoPoTsyo project started in Phnom Penh’s slum areas as a “knowledge provider” and was not intended to become involved in medical service provision as there were already 2 charities running medical services for people with diabetes in the area. As a result, MoPoTsyo was able to concentrate on a core mission of finding and helping diabetes patients in the slums that wanted to learn diabetes self management. After a few years the charities ran out of money and ended their projects. Consequently, the prices of medical services quickly rose to unaffordable prices for MoPoTsyo members. This development put MoPoTsyo in the dilemma of deciding whether to continue working in advocacy for the lowering of prices from existing professional medical services providers or to expand the scopes of its own action and begin to organize services.

In many development sectors this is a common dilemma. Many initiatives experience ups and downs forcing organizations like MoPoTsyo to develop community action plans to try and support a marginalized community. With the closing of the two charities patients now needed affordable medical services. Consequently, it was decided to organize delivery of services for its members by selecting interested public and private partners to work with the peer educators.

Working toward to a sustainable model with impact
With a well organized group and agenda MoPoTsyo educators were able to take advantage of their resources and make an impact on multiple obstacles in the community that had previously seemed insurmountable. The peer educators were able to make many positive changes by negotiating at the local level and introducing change in a gentle low key fashion. In these negotiations MoPoTsyo utilized a system approach by establishing a proper regulatory framework and governance at multiple levels. By negotiating and drawing up contracts with its partners from the public and private sector, a set of transparent rules of engagement have been formulated that provisionally fill the policy gap. Besides clarifying relevant practical issues, this creates accountability among those who engage to abide by the rules. Local engagement and support are very strong as a result of the chosen approach. It seems inconceivable to achieve similar ownership if a top down service supply driven approach were suddenly adopted to benefit from perceived cost efficiencies. If given the chance, MoPoTsyo will continue to scale-up by supporting the existing Peer Educator Networks to replicate in response to demand from patients willing and able to take an active role.

As a result of this low key practical approach by familiar faces there were no turf wars between peer educators, local health centers and referral hospitals located within the operational districts that serve a population of 100,000 to 200,000 residents. After 5 years, the peer educator networks have shown to be a cost effective and affordable strategy to change and adapt health system relationships among local stakeholders into a more productive and more collaborative health market: One that can meet a great unmet health need for a population that would otherwise have remained excluded from a continuum of care.

Coming up
Next month, I will share more about integration of Patient Educator Networks (peer support) into the primary care system in Cambodia and scaling up our program.

Bridging the Gap: Students and Professionals in Peer Support

By Clayton Velicer,
UNC MPH Candidate 2012,
Health Behavior and Health Education

As Peers for Progress continues to collaborate with peer support programs around the globe there is an increased opportunity for students to become involved and gain valuable work experience in peer support and establish connections with PFP partners. At the University of North Carolina the MPH program affords its’ student this opportunity by having a practicum requirement in the summer between the first and second years of the program. This practicum can be either 200, 300 or 400 hours of work experience in the field that allows a student to set up a series of deliverables for the organization and North Carolina by creating a learning contract in the spring. This past summer Peers for Progress sent 6 students to projects including sites in China, Mexico and Australia for their practicum projects.

I was one of these students and spent 3 months working for the Australasian Peers for Progress Diabetes Project at Monash University in Melbourne Australia. This blog will briefly share some of my experiences with this project and allow other Peers for Progress partners the opportunity to read about the kinds of activities students can become involved in at placements in future years.

After arriving in Melbourne in May I was quickly caught up to speed on the project through a series of meetings with the program director and members of the research team. I was provided copies of all education materials included in the intervention, trained on physical data collection methods such as taking blood pressure and measuring waist circumference and informed of developments with the project to date. I then accompanied a member of our research team to the community intervention and control sites throughout Victoria and assisted in collecting the physical data and 6 month questionnaires. This provided a unique experience unavailable in my previous education training to interact with the peer leaders and participants of an ongoing multilevel intervention directly at a community basis.

At the same time my program’s training in qualitative methods provided me with background experience and knowledge for transcribing and coding interviews and focus groups. This allowed me to take on a personal project for the program with the teleconferences that had occurred between the peer leaders and the research teams as a means of ongoing support for the first six months of the study. My presence on site allowed me the time to transcribe and code 15 transcripts and examine the kinds of support that had been delivered during these calls. The summary of this analysis is a paper on ongoing support for peer supporters currently being drafted fostering ongoing collaboration between the University of North Carolina and the University of Monash in Melbourne. An abstract for this paper has also been submitted for poster presentation at the Society of Behavioral Medicine in the Spring of 2012.
Overall I have found the experience to be involved in a peer support project as a researcher while still a student to be an extremely rewarding experience that has allowed me to develop my professional network and become a larger part of Peers for Progress. I would encourage Peer Support Programs to think of ways they can build similar relationships with students to establish future mutually rewarding experiences.

Think with us- What makes Peers for Progress endure

Over the summer the Economist had an interesting article called the Test of Time about organizational endurance. The point it develops is that organizational endurance comes from identifying and serving a need, not from occupying and controlling a specific product niche. It draws an interesting contrast between IBM and Apple that the author thinks have done the former versus Dell (computers) and Microsoft (Windows today, Windows tomorrow...) that seem to be taking the latter path.

Perhaps the key line in the piece is at the start of the second paragraph: "IBM's secret is that it is built around an idea that transcends any particular product or technology." When we were getting started, Craig Doane (Chair of the Peers for Progress Executive Committee; Executive Director, American Academy of Family Physicicians Foundation) told me our goal was to be "the go-to source on peer support around the world." That seems still to ring wise to me.

As we succeed, groups will develop that want to do various things within the general space of "peer support and health." I think our opportunity and challenge will be to stay focused on how, as the "global go-to source," we can add value to the many more local and focused efforts we may predict will come as a result of our success. We will need to find ways to embrace and cultivate our successes but also to watch them prosper, sometimes on their own terms.

I think our key will be to continue to add value as the global "go-to source." From all our experience, it seems that we are very much viewed that way. I think our brief history and accomplishements combined with the simple fact that peer support has been around for millennia and is not in danger of going away provides us an attractive opportunity. That is to grow as the global "go-to" source and continue to culivate the "value added" we can provide to the many peer support programs around the world.

Edwin B. Fisher, Ph.D.

Global Director, Peers for Progress

Professor of Public Health and Psychology, University of North Carolina at Chapel Hill

Peers for Progress Annual Letter

Dear Friends,

We hope that your holidays were joyous and relaxing, and that 2011 is looking promising to you. The past year was very successful for Peers for Progress, the program of the American Academy of Family Physicians Foundation dedicated to promoting peer support for prevention, health, and health care around the world. In the following paragraphs, we would like to share some highlights in Peers for Progress’ own support and in the network we are developing around the world.

In many ways, 2010 saw impressive advances in our networking and promotion of exchange of knowledge about peer support around the world. A major activity was the October meeting in Kuala Lumpur, Malaysia that included not only our fourteen Peers for Progress grantees from nine countries, but additional representatives of other leading peer support programs and leaders of key organizations interested in peer support, including the International Diabetes Federation and the World Organization of Family Physicians. Over 60 individuals convened in Kuala Lumpur, representing Australia, Cambodia, Cameroon, Chile, China, South Africa, India, Iraq, Malaysia, the Netherlands, Pakistan, Sri Lanka, Thailand, Uganda, the United Kingdom, and the United States. Over the three-day meeting, they formed a learning community of collaborating experts spanning key areas of health (e.g., diabetes, cancer, HIV, maternal and child health, mental health) and settings of peer support programs (e.g., rural populations, programs for women and children, ethnic minorities). They identified and discussed critical aspects of peer support interventions, their effects, dissemination, and sustainability. Most gratifying, there was tremendous enthusiasm in this impressive and diverse group for the value of the kind of exchange they had begun. Already, several international collaborative projects have emerged from the connections cultivated in Kuala Lumpur. So, this meeting gave clear endorsement to the value of Peers for Progress’ dedication to growing a network of peer support leaders from around the world.

Other global networking during 2010 included a series of trips to Australia, Chile, China, France, Germany, and Mexico along with contacts in the United Kingdom and the Netherlands. In each of these, we met with national organizations interested in peer support and in working with us to enhance both the quality of their peer support programs as well as their recognition and sustained funding. A prime example of this was our visit to Beijing in August to participate in the International Symposium on Diabetes Education and Management of the Chinese Diabetes Society that attracted over one thousand participants. In addition to presenting several lectures on diabetes patient education and peer support, we met with diabetes leaders from China, pictured here, who were interested in developing peer support programs, such as among older adults in Anhui Provence or as extensions of diabetes education classes in Nanjing. This represents something of a new direction for healthcare and prevention in China. In addition to those interested in diabetes, we are also developing links with leaders in mental health and in prevention, especially smoking cessation, both areas to which peer support may provide great benefit. We are pursuing collaboration with a number of those who attended the meeting and planning a follow-up meeting through the 2011 Symposium to be held in August in Nanjing.

Peers for Progress also extended our networking in 2010 through collaboration with the Johnson & Johnson Diabetes Institute, established in a number of countries around the world to provide training in diabetes patient education for nurses and other professionals. The Institute’s focus on training professionals is a natural complement to that of Peers for Progress on the role of peer support. Through the Institute, we presented a webinar on the role of peer support in diabetes care to over 100 participants this past December, and have begun planning with its leaders for a follow-up presentation in 2011 that will highlight applied examples of peer support programs and their adaptability to various populations, settings, cultures, and other contexts.

2010 also saw expansion of the Peers for Progress Global Advisory Board with its responsibility for help in strategic development. In addition to continuing representatives from the YMCAs of America (Lynne Vaughn, Senior Vice President, Chief Innovation Officer) and the American Association of Diabetes Educators (Lana Vukovljak, CEO, Amparo Gonzalez, former President), the Board has been joined by Bert van den Bergh from the Executive Board of Iroko Holdings and a retired Eli Lilly executive with extensive global experience, and Ronald Aubert, Ph.D., Vice President of Clinical Analytics and Outcomes Research at Medco Health Solutions Inc. and author of one of the first major research papers documenting the value of ongoing patient support in diabetes management. Additional new additions to the Peers for Progress family in 2010 included Mu Chieh “Maggy” Coufal who joined the Program Development Center at UNC-Chapel Hill as Program Manager. A native of Taiwan, Ms. Coufal has masters degrees in both public health and organizational management, and has been enormously helpful in expanding our ability to reach out to colleagues in China.

Turning to organizational growth and funding, in November Peers for Progress was pleased to be one of four projects initially funded by the Bristol-Myers Squibb Foundation as part of its new, $100 million initiative, Together on Diabetes. We received $5 million to support a project that will show the value of peer support as a strategy for reaching individuals and communities in need from the “patient-centered medical home.”

Especially exciting, this new project will entail collaboration with the National Council of La Raza, the nation’s largest Hispanic civil rights and advocacy organization. Focusing on delivering services to Latino communities, we will work with NCLR to show the value of “promotoras” as peer supporters in diabetes care. The award also includes funding to establish a national collaborative network of programs interested in peer support approaches. This will add to our networking and promotion working with NCLR and its 300 affiliates and constituents around the country. Also joining in this project is TransforMed, the subsidiary of the American Academy of Family Physicians that is dedicated to helping primary medical care groups develop their patient centered medical home programs and services.

The funding from Bristol-Myers Squibb Foundation and collaboration with the National Council of La Raza are great milestones for Peers for Progress as they signify that the program is gaining respect and recognition as a major force in peer support both in the United States and around the world. This grant also expands our funding base beyond the Eli Lilly and Company Foundation, further solidifying our ability grow and sustain Peers for Progress for many years to come.

With a growing set of leaders in peer support and health interested in working with us around the world, new partners in the National Council of La Raza, and expanded funding Peers for Progress is excited that 2011 will see great accomplishments in our mission, accelerating best practices in peer support around the world. We hope the year is a great one for you as well and the many fine causes we all serve, and look forward to being in contact with you as the year unfolds.

Sincerely,

Edwin B. Fisher, Ph.D.
Global Director, Peers for Progress,
Professor of Public Health and Psychology,University of North Carolina at Chapel Hill