An analysis of the gap between available healthcare services and deficiencies in care and treatment among patients with Chronic Kidney Disease in Chinandega and León, Nicaragua
This document provides an analysis of gaps in healthcare services and deficiencies in care for patients with Chronic Kidney Disease (CKD) in Chinandega and León, Nicaragua. It finds that while the Nicaraguan Ministry of Health (MINSA) has developed guidelines for CKD diagnosis and treatment, and built specialized clinics, resource shortages and poor implementation have undermined quality of care and patient access. The document suggests creating a CKD Task Force to improve dissemination of guidelines, address training needs, and identify solutions to gaps in services and unmet patient needs.
The document summarizes key findings from the BT CIO report 2016 regarding the changing role of the CIO. Some of the main points from the summary are:
- The three most disruptive technology trends driving change are cloud computing, mobility/collaboration, and data. A fifth of organizations describe themselves as completely cloud-centric.
- CIOs are playing a more central strategic role in the boardroom and are expected to drive innovation. Their skills must embrace faster-paced digital change.
- While security concerns still present challenges, the cloud is seen as an opportunity to improve security for many organizations. CIOs are measuring success against new digital-focused KPIs.
- S
Diapositivas de la conferencia del Dr. Gustavo de Armas para el curso "El Centro Educativo como espacio de posibilidad y cambio" El Abrojo / Telefónica
This document is the Google Scholar profile for Dr. David J. Hand, a British statistician and academic. It lists over 300 publications authored or co-authored by Dr. Hand spanning his career, with recent works focusing on machine learning, big data analysis, and applications of statistics in domains like healthcare and finance. The citation metrics indicate Dr. Hand is a highly influential researcher in his field with an h-index of over 100 based on the works included in his Google Scholar profile.
O documento apresenta as informações pessoais do autor, que é professor, casado e pai de dois filhos. Ele também é representante de uma associação de bairro. O autor discute desafios de participação social, como sentir a importância da coletividade para resolver problemas e participar de eventos comunitários. Ele também fala sobre os desafios da globalização, da necessidade de usar a tecnologia para a comunidade e reflexão sobre sustentabilidade.
A Escola Estadual Antônio João Ribeiro realizou um projeto para arrecadar alimentos para a comemoração de seus 60 anos, onde alunos e professores pediram doações de moradores. Foram arrecadadas mais de 40 cestas básicas que foram distribuídas para várias entidades, incluindo igrejas e lares de idosos, para ajudar famílias necessitadas.
This presentation is a learning material supporting a workshop on presentation skills during a training course called You - the young entrepreneur.
The training course took place in Brno, Czech Republic between 21.8.2015 - 27.8.2015 and was fully supported by European fund Erasmus+. The project was organized by PROACTIVE MIND. For more information about outputs of the project please visit www.proactivemind.eu
La ley establece la obligación para personas naturales y jurídicas de elaborar y presentar planes de contingencia ante las autoridades competentes. Los planes deben actualizarse cada 5 años o cuando cambien las condiciones de la actividad y serán aprobados por las autoridades correspondientes. La ley también establece sanciones por incumplimiento y responsabilidades de capacitación y difusión de los planes.
A Floresta Amazônica é caracterizada por (1) ser uma floresta densa e perenifólia que cresce em terras baixas abaixo de 400m de altitude, (2) conter grande diversidade de espécies sobre bacias sedimentares, e (3) ter solos profundos e úmidos, com temperaturas entre 24-26°C e altos índices pluviométricos que variam de 1,700-3,500mm anuais.
The document summarizes key findings from the BT CIO report 2016 regarding the changing role of the CIO. Some of the main points from the summary are:
- The three most disruptive technology trends driving change are cloud computing, mobility/collaboration, and data. A fifth of organizations describe themselves as completely cloud-centric.
- CIOs are playing a more central strategic role in the boardroom and are expected to drive innovation. Their skills must embrace faster-paced digital change.
- While security concerns still present challenges, the cloud is seen as an opportunity to improve security for many organizations. CIOs are measuring success against new digital-focused KPIs.
- S
Diapositivas de la conferencia del Dr. Gustavo de Armas para el curso "El Centro Educativo como espacio de posibilidad y cambio" El Abrojo / Telefónica
This document is the Google Scholar profile for Dr. David J. Hand, a British statistician and academic. It lists over 300 publications authored or co-authored by Dr. Hand spanning his career, with recent works focusing on machine learning, big data analysis, and applications of statistics in domains like healthcare and finance. The citation metrics indicate Dr. Hand is a highly influential researcher in his field with an h-index of over 100 based on the works included in his Google Scholar profile.
O documento apresenta as informações pessoais do autor, que é professor, casado e pai de dois filhos. Ele também é representante de uma associação de bairro. O autor discute desafios de participação social, como sentir a importância da coletividade para resolver problemas e participar de eventos comunitários. Ele também fala sobre os desafios da globalização, da necessidade de usar a tecnologia para a comunidade e reflexão sobre sustentabilidade.
A Escola Estadual Antônio João Ribeiro realizou um projeto para arrecadar alimentos para a comemoração de seus 60 anos, onde alunos e professores pediram doações de moradores. Foram arrecadadas mais de 40 cestas básicas que foram distribuídas para várias entidades, incluindo igrejas e lares de idosos, para ajudar famílias necessitadas.
This presentation is a learning material supporting a workshop on presentation skills during a training course called You - the young entrepreneur.
The training course took place in Brno, Czech Republic between 21.8.2015 - 27.8.2015 and was fully supported by European fund Erasmus+. The project was organized by PROACTIVE MIND. For more information about outputs of the project please visit www.proactivemind.eu
La ley establece la obligación para personas naturales y jurídicas de elaborar y presentar planes de contingencia ante las autoridades competentes. Los planes deben actualizarse cada 5 años o cuando cambien las condiciones de la actividad y serán aprobados por las autoridades correspondientes. La ley también establece sanciones por incumplimiento y responsabilidades de capacitación y difusión de los planes.
A Floresta Amazônica é caracterizada por (1) ser uma floresta densa e perenifólia que cresce em terras baixas abaixo de 400m de altitude, (2) conter grande diversidade de espécies sobre bacias sedimentares, e (3) ter solos profundos e úmidos, com temperaturas entre 24-26°C e altos índices pluviométricos que variam de 1,700-3,500mm anuais.
Přednáška na PPC Offline 18.8.2016 o třech změnách v měření a atribuci AdWords:
1) Zrušení Konvertovaných kliknutí
2) Zahrnutí Konverzí mezi zařízeními do Konverzí
3) Reportování atribuce mezi zařízeními
How Behavior Based Marketing Can Cut Customer Onboarding Time in HalfAutopilot
Watch the webinar replay: http://flightschool.autopilothq.com/video/narrative-onboarding-journey-webinar/
Try Autopilot free for 30 days: https://autopilothq.com/free-trial.html
Delivering a "wow" onboarding experience helps people fall in love with your product and become customers for life.
Join Autopilot's CMO Guy Marion along with Segment's VP, Success Jake Peterson and Narrative's Community Manager Sarah Massengale as they share how Narrative improved their customer onboarding using behavior based marketing automation.
In this webinar, you’ll learn:
-How a highly personalized onboarding experience can accelerate your customer conversion rate
-Key steps to optimizing your onboarding and activation funnel
-How Narrative, the startup behind the world's most wearable camera, built their onboarding journey and cut conversion time in half
Marketing & Media Club VŠE - Případová studie PROFIZOOSun Marketing
U našeho klienta PROFIZOO s.r.o, který prodává chovatelské potřeby, jsme na správu Facebooku šli s citem. Zkoumali jsme, co jejich fanoušky baví, o čem si rádi povídají, co je dokáže rozesmát a která zvířata mají nejraději. Občas jsme do příspěvku přihodili otrackovaný odkaz do e-shopu a pak už jsme jen sledovali, co se bude dít. Účastníkům přednášky na VŠE jsme ukázali, jak se nám kombinací zábavných postů a přesně zacílené reklamní kampaně podařilo zvednout tržby díky Facebooku o 289 %.
Since the dawn of the computer age, storage of data has always been a major concern. As technology progressed and computers got more powerful, the amount of data has increased too. This created an everlasting demand for more storage space. The evolution of data storage has been phenomenal. Storage devices have drastically evolved from huge trunks with the capacity of a few kilobytes of data to thumb sized drives that can store gigabytes of data. Here is a look back at this massive evolution of data storage technology.
Marília está se preparando para o Halloween. Crianças vão de casa em casa pedindo doces neste dia 31 de outubro. Muitos vão se fantasiar de monstros, bruxas e outros personagens assustadores para a noite de festa e diversão.
The document provides an introduction and overview of focused antenatal care (FANC) in Tanzania, including the goals of early detection, treatment, and prevention of diseases during pregnancy. It describes the characteristics of effective ANC, such as skilled providers, preparation for birth, and health promotion. The document also discusses quality in ANC services and the ANC quality improvement process used to measure performance against established standards.
The document summarizes the results of a survey conducted by PAHO on the status of TB-HIV collaborative activities in countries of the Americas in 2010. Key findings include:
1) Most countries have coordination mechanisms for TB-HIV activities, though representation from key groups is still limited. Joint planning is lacking in 29% of countries.
2) HIV surveillance in TB patients is implemented in all countries but only 46% of TB cases know their HIV status.
3) Fewer than half of countries monitor key TB-HIV indicators due to limitations in information systems and data sharing between programs.
4) Coverage of interventions like TB screening for people with HIV, isoniazid preventive therapy and antire
The document provides guidance for the management of bacterial meningitis and meningococcal septicaemia in children and young people under 16 in primary and secondary care settings in the UK. It includes recommendations on initial symptoms and assessment, pre-hospital management, diagnosis, treatment and long-term management. The guidance aims to optimize care for this patient population while respecting patient preferences and the need for informed consent.
This document provides a public expenditure review of the Kenyan Ministry of Health for 2007. It outlines the overall and specific objectives of the review, which include presenting government health policies and programs, examining public health expenditure distributions, and assessing budget effectiveness and constraints. Key findings are that communicable diseases remain prevalent, but fertility and population growth rates are declining. The multi-tiered health system has issues with capacity, financing, accessibility, and centralized allocation of funds. The National Health Sector Strategic Plan is aligned with the country's Economic Recovery Strategy to improve financing, target the poor, increase cross-sector cooperation and efficiency, and boost government health funding.
Nevada integrated hiv prevention and care plan 2017 2021 interim monitoring p...#GOMOJO, INC.
This interim report summarizes progress on Nevada's 2017-2021 Integrated HIV Prevention and Care Plan through June 2017. For Goal 1 of reducing new HIV infections, key accomplishments include increasing mobile HIV testing vans, improving client notification of testing results, and conducting over 22,000 HIV tests in 2016. Workgroups have been formed to review HIV testing data and develop targeted testing strategies. To increase awareness of testing, a new website on testing locations is launching in July 2017 and community events have been held. Rapid HIV testing has also been expanded through training programs. Overall, activities show progress on improving HIV testing rates and linking results to care, while work remains to be done on strategies to engage priority populations.
Nevada integrated hiv prevention and care plan 2017 2021 interim monitoring p...#GOMOJO, INC.
This interim report summarizes progress on Nevada's 2017-2021 Integrated HIV Prevention and Care Plan through June 2017. For Goal 1 of reducing new HIV infections, key accomplishments include increasing mobile HIV testing vans, improving client notification of testing results, and conducting over 22,000 HIV tests in 2016. Workgroups are discussing strategies to increase targeted testing and community awareness of testing importance and locations. A new website launching in July 2017 aims to improve information on testing sites. Overall, activities show progress with some completed and others ongoing, helping to advance the goals of increasing HIV testing and reducing new infections in Nevada.
2006 Expert Patients For Art Lit Review Kk&Wvdwvdamme
The document reviews expert patient programs for chronic disease management in high-income countries and explores their relevance for HIV/AIDS care in low-income countries with severe shortages of health care workers. It finds that current models of antiretroviral treatment delivery are too intensive in their use of skilled staff to scale up in most sub-Saharan African countries. However, chronic disease self-management programs that train lay people living with the conditions to support others have improved health outcomes and reduced healthcare use. Similarly, people living with HIV/AIDS currently play roles in HIV prevention, home-based care, treatment adherence and literacy that could be expanded under an expert patient model to help address the human resource constraints facing HIV treatment scale-up
The Queensland Strategy for Chronic Disease 2005-2015 aims to prevent and better manage chronic diseases through a partnership approach. It involves stakeholders across the healthcare system, from hospitals to general practitioners to community groups. The strategy seeks to promote healthy lifestyles to prevent chronic diseases, identify diseases earlier, and improve management of existing conditions. It focuses on high-risk groups like those in rural areas, Indigenous peoples, culturally diverse communities, and socioeconomically disadvantaged populations.
Horticulture Project for People with Mental Disorders or Epilepsy
`
For more information, Please see websites below:
`
Organic Edible Schoolyards & Gardening with Children =
http://scribd.com/doc/239851214 ~
`
Double Food Production from your School Garden with Organic Tech =
http://scribd.com/doc/239851079 ~
`
Free School Gardening Art Posters =
http://scribd.com/doc/239851159 ~
`
Increase Food Production with Companion Planting in your School Garden =
http://scribd.com/doc/239851159 ~
`
Healthy Foods Dramatically Improves Student Academic Success =
http://scribd.com/doc/239851348 ~
`
City Chickens for your Organic School Garden =
http://scribd.com/doc/239850440 ~
`
Simple Square Foot Gardening for Schools - Teacher Guide =
http://scribd.com/doc/239851110 ~
National Survey of Patient Activity Data for Specialist Palliative Care Services MDS Full Report for the year 2009-2010
The 2010/11 Minimum Data Set for Specialist Palliative Care Services (MDS) report is the 16th since the original collection in 1995/6 and it is the second to report on activities since the rollout of additional investment associated with the End of Life Care Strategy in England. Launched in 2008, the Strategy announced additional investment into end of life care of £88m in 2009/10 and a further £198m in 2010/11.
This document provides guidance on providing noncommunicable disease (NCD) and mental health services in Tanzania during the COVID-19 pandemic. It discusses (1) general health systems issues and recommendations for coordinating NCD and infection control, (2) specific issues and recommendations for pulmonary disease, cardiovascular disease, dialysis, oncology, diabetes, and other conditions, and (3) mental health and psychosocial support during COVID-19. The guidance aims to help reduce NCD risks, prevent SARS-CoV-2 infection, and lower morbidity and mortality for NCD and mental health patients during the pandemic.
cog-curriculum-final-jan-08.phf hdix did jdjDocHams
academic Knowledge of the normal structure and function of the human body (as an
intact organism) and of each of its major organ systems.
2. Knowledge of the molecular, biochemical, and cellular mechanisms that is
important in nutrition and maintaining the body’s homeostasis.
3. Knowledge of the various causes (genetic, developmental, metabolic, toxic,
microbiologic, autoimmune, neoplastics, degenerative, and traumatic) of
maladies and the ways in which they operate on the body (pathogenesis).
4. Knowledge of the major pathological processes and their biological alterations
based on knowledge of altered structure and function (Pathology and
Pathophysiology) of the body and
Planning for the Future of Cambridge Public Health HKSG MPP masters thesis PAEBo Warburton
This document analyzes the Cambridge Public Health system and provides recommendations for its future. It finds that while Cambridge has a supportive environment for public health, the current Health Department structure results in overlap and underfunding of important functions. It recommends short-term improvements like completing assessment projects. In the intermediate term, it recommends establishing reporting processes, moving direct treatment to the Hospital, and hiring staff. In the long term, it proposes a new Health Department model with units focused on health intelligence, community health coordination, grants, and emergency response to address trends in public health and better meet community needs.
Abstracts of NCD & Prevalence of risk factors in Sri Lanka 1990 to 2012Anura Jayasinghe
This document presents an abstract of a study that compiled published literature on the prevalence of non-communicable diseases (NCDs) and associated risk factors in Sri Lanka from 1990 to 2012. The study aimed to uncover data on NCD prevalence and burden to inform national prevention strategies. It involved searching libraries, databases, and organizations for relevant publications. Abstracts were extracted and categorized based on study design and population. The results provide an overview of NCD and risk factor prevalence in Sri Lanka over 20 years to support evidence-based policymaking.
Abstracts of NCD & Prevalence of risk factors in Sri Lanka 1990 to 2012Anura Jayasinghe
This document presents an abstract of a study that compiled published literature on the prevalence of non-communicable diseases (NCDs) and associated risk factors in Sri Lanka from 1990 to 2012. The study aimed to uncover data on NCD prevalence and burden to inform national prevention strategies. It involved searching libraries, databases, and organizations for relevant publications. Abstracts were extracted and categorized based on study design and population. The results provide an overview of NCD and risk factor prevalence in Sri Lanka over 20 years to support evidence-based policymaking.
Přednáška na PPC Offline 18.8.2016 o třech změnách v měření a atribuci AdWords:
1) Zrušení Konvertovaných kliknutí
2) Zahrnutí Konverzí mezi zařízeními do Konverzí
3) Reportování atribuce mezi zařízeními
How Behavior Based Marketing Can Cut Customer Onboarding Time in HalfAutopilot
Watch the webinar replay: http://flightschool.autopilothq.com/video/narrative-onboarding-journey-webinar/
Try Autopilot free for 30 days: https://autopilothq.com/free-trial.html
Delivering a "wow" onboarding experience helps people fall in love with your product and become customers for life.
Join Autopilot's CMO Guy Marion along with Segment's VP, Success Jake Peterson and Narrative's Community Manager Sarah Massengale as they share how Narrative improved their customer onboarding using behavior based marketing automation.
In this webinar, you’ll learn:
-How a highly personalized onboarding experience can accelerate your customer conversion rate
-Key steps to optimizing your onboarding and activation funnel
-How Narrative, the startup behind the world's most wearable camera, built their onboarding journey and cut conversion time in half
Marketing & Media Club VŠE - Případová studie PROFIZOOSun Marketing
U našeho klienta PROFIZOO s.r.o, který prodává chovatelské potřeby, jsme na správu Facebooku šli s citem. Zkoumali jsme, co jejich fanoušky baví, o čem si rádi povídají, co je dokáže rozesmát a která zvířata mají nejraději. Občas jsme do příspěvku přihodili otrackovaný odkaz do e-shopu a pak už jsme jen sledovali, co se bude dít. Účastníkům přednášky na VŠE jsme ukázali, jak se nám kombinací zábavných postů a přesně zacílené reklamní kampaně podařilo zvednout tržby díky Facebooku o 289 %.
Since the dawn of the computer age, storage of data has always been a major concern. As technology progressed and computers got more powerful, the amount of data has increased too. This created an everlasting demand for more storage space. The evolution of data storage has been phenomenal. Storage devices have drastically evolved from huge trunks with the capacity of a few kilobytes of data to thumb sized drives that can store gigabytes of data. Here is a look back at this massive evolution of data storage technology.
Marília está se preparando para o Halloween. Crianças vão de casa em casa pedindo doces neste dia 31 de outubro. Muitos vão se fantasiar de monstros, bruxas e outros personagens assustadores para a noite de festa e diversão.
Similar to An analysis of the gap between available healthcare services and deficiencies in care and treatment among patients with Chronic Kidney Disease in Chinandega and León, Nicaragua
The document provides an introduction and overview of focused antenatal care (FANC) in Tanzania, including the goals of early detection, treatment, and prevention of diseases during pregnancy. It describes the characteristics of effective ANC, such as skilled providers, preparation for birth, and health promotion. The document also discusses quality in ANC services and the ANC quality improvement process used to measure performance against established standards.
The document summarizes the results of a survey conducted by PAHO on the status of TB-HIV collaborative activities in countries of the Americas in 2010. Key findings include:
1) Most countries have coordination mechanisms for TB-HIV activities, though representation from key groups is still limited. Joint planning is lacking in 29% of countries.
2) HIV surveillance in TB patients is implemented in all countries but only 46% of TB cases know their HIV status.
3) Fewer than half of countries monitor key TB-HIV indicators due to limitations in information systems and data sharing between programs.
4) Coverage of interventions like TB screening for people with HIV, isoniazid preventive therapy and antire
The document provides guidance for the management of bacterial meningitis and meningococcal septicaemia in children and young people under 16 in primary and secondary care settings in the UK. It includes recommendations on initial symptoms and assessment, pre-hospital management, diagnosis, treatment and long-term management. The guidance aims to optimize care for this patient population while respecting patient preferences and the need for informed consent.
This document provides a public expenditure review of the Kenyan Ministry of Health for 2007. It outlines the overall and specific objectives of the review, which include presenting government health policies and programs, examining public health expenditure distributions, and assessing budget effectiveness and constraints. Key findings are that communicable diseases remain prevalent, but fertility and population growth rates are declining. The multi-tiered health system has issues with capacity, financing, accessibility, and centralized allocation of funds. The National Health Sector Strategic Plan is aligned with the country's Economic Recovery Strategy to improve financing, target the poor, increase cross-sector cooperation and efficiency, and boost government health funding.
Nevada integrated hiv prevention and care plan 2017 2021 interim monitoring p...#GOMOJO, INC.
This interim report summarizes progress on Nevada's 2017-2021 Integrated HIV Prevention and Care Plan through June 2017. For Goal 1 of reducing new HIV infections, key accomplishments include increasing mobile HIV testing vans, improving client notification of testing results, and conducting over 22,000 HIV tests in 2016. Workgroups have been formed to review HIV testing data and develop targeted testing strategies. To increase awareness of testing, a new website on testing locations is launching in July 2017 and community events have been held. Rapid HIV testing has also been expanded through training programs. Overall, activities show progress on improving HIV testing rates and linking results to care, while work remains to be done on strategies to engage priority populations.
Nevada integrated hiv prevention and care plan 2017 2021 interim monitoring p...#GOMOJO, INC.
This interim report summarizes progress on Nevada's 2017-2021 Integrated HIV Prevention and Care Plan through June 2017. For Goal 1 of reducing new HIV infections, key accomplishments include increasing mobile HIV testing vans, improving client notification of testing results, and conducting over 22,000 HIV tests in 2016. Workgroups are discussing strategies to increase targeted testing and community awareness of testing importance and locations. A new website launching in July 2017 aims to improve information on testing sites. Overall, activities show progress with some completed and others ongoing, helping to advance the goals of increasing HIV testing and reducing new infections in Nevada.
2006 Expert Patients For Art Lit Review Kk&Wvdwvdamme
The document reviews expert patient programs for chronic disease management in high-income countries and explores their relevance for HIV/AIDS care in low-income countries with severe shortages of health care workers. It finds that current models of antiretroviral treatment delivery are too intensive in their use of skilled staff to scale up in most sub-Saharan African countries. However, chronic disease self-management programs that train lay people living with the conditions to support others have improved health outcomes and reduced healthcare use. Similarly, people living with HIV/AIDS currently play roles in HIV prevention, home-based care, treatment adherence and literacy that could be expanded under an expert patient model to help address the human resource constraints facing HIV treatment scale-up
The Queensland Strategy for Chronic Disease 2005-2015 aims to prevent and better manage chronic diseases through a partnership approach. It involves stakeholders across the healthcare system, from hospitals to general practitioners to community groups. The strategy seeks to promote healthy lifestyles to prevent chronic diseases, identify diseases earlier, and improve management of existing conditions. It focuses on high-risk groups like those in rural areas, Indigenous peoples, culturally diverse communities, and socioeconomically disadvantaged populations.
Horticulture Project for People with Mental Disorders or Epilepsy
`
For more information, Please see websites below:
`
Organic Edible Schoolyards & Gardening with Children =
http://scribd.com/doc/239851214 ~
`
Double Food Production from your School Garden with Organic Tech =
http://scribd.com/doc/239851079 ~
`
Free School Gardening Art Posters =
http://scribd.com/doc/239851159 ~
`
Increase Food Production with Companion Planting in your School Garden =
http://scribd.com/doc/239851159 ~
`
Healthy Foods Dramatically Improves Student Academic Success =
http://scribd.com/doc/239851348 ~
`
City Chickens for your Organic School Garden =
http://scribd.com/doc/239850440 ~
`
Simple Square Foot Gardening for Schools - Teacher Guide =
http://scribd.com/doc/239851110 ~
National Survey of Patient Activity Data for Specialist Palliative Care Services MDS Full Report for the year 2009-2010
The 2010/11 Minimum Data Set for Specialist Palliative Care Services (MDS) report is the 16th since the original collection in 1995/6 and it is the second to report on activities since the rollout of additional investment associated with the End of Life Care Strategy in England. Launched in 2008, the Strategy announced additional investment into end of life care of £88m in 2009/10 and a further £198m in 2010/11.
This document provides guidance on providing noncommunicable disease (NCD) and mental health services in Tanzania during the COVID-19 pandemic. It discusses (1) general health systems issues and recommendations for coordinating NCD and infection control, (2) specific issues and recommendations for pulmonary disease, cardiovascular disease, dialysis, oncology, diabetes, and other conditions, and (3) mental health and psychosocial support during COVID-19. The guidance aims to help reduce NCD risks, prevent SARS-CoV-2 infection, and lower morbidity and mortality for NCD and mental health patients during the pandemic.
cog-curriculum-final-jan-08.phf hdix did jdjDocHams
academic Knowledge of the normal structure and function of the human body (as an
intact organism) and of each of its major organ systems.
2. Knowledge of the molecular, biochemical, and cellular mechanisms that is
important in nutrition and maintaining the body’s homeostasis.
3. Knowledge of the various causes (genetic, developmental, metabolic, toxic,
microbiologic, autoimmune, neoplastics, degenerative, and traumatic) of
maladies and the ways in which they operate on the body (pathogenesis).
4. Knowledge of the major pathological processes and their biological alterations
based on knowledge of altered structure and function (Pathology and
Pathophysiology) of the body and
Planning for the Future of Cambridge Public Health HKSG MPP masters thesis PAEBo Warburton
This document analyzes the Cambridge Public Health system and provides recommendations for its future. It finds that while Cambridge has a supportive environment for public health, the current Health Department structure results in overlap and underfunding of important functions. It recommends short-term improvements like completing assessment projects. In the intermediate term, it recommends establishing reporting processes, moving direct treatment to the Hospital, and hiring staff. In the long term, it proposes a new Health Department model with units focused on health intelligence, community health coordination, grants, and emergency response to address trends in public health and better meet community needs.
Abstracts of NCD & Prevalence of risk factors in Sri Lanka 1990 to 2012Anura Jayasinghe
This document presents an abstract of a study that compiled published literature on the prevalence of non-communicable diseases (NCDs) and associated risk factors in Sri Lanka from 1990 to 2012. The study aimed to uncover data on NCD prevalence and burden to inform national prevention strategies. It involved searching libraries, databases, and organizations for relevant publications. Abstracts were extracted and categorized based on study design and population. The results provide an overview of NCD and risk factor prevalence in Sri Lanka over 20 years to support evidence-based policymaking.
Abstracts of NCD & Prevalence of risk factors in Sri Lanka 1990 to 2012Anura Jayasinghe
This document presents an abstract of a study that compiled published literature on the prevalence of non-communicable diseases (NCDs) and associated risk factors in Sri Lanka from 1990 to 2012. The study aimed to uncover data on NCD prevalence and burden to inform national prevention strategies. It involved searching libraries, databases, and organizations for relevant publications. Abstracts were extracted and categorized based on study design and population. The results provide an overview of NCD and risk factor prevalence in Sri Lanka over 20 years to support evidence-based policymaking.
CAH has worked with front-line organizations in Estonia, Mozambique and South Africa to prepare analytic case studies of three outstanding initiatives that have scaled up the provision of health services to adolescents. The South African case study is of the Evolution of the National Adolescent Friendly Clinic Initiative which was an integral part of the high profile loveLife programme. The Mozambican case study was of the progress made by the multisectoral Geraçao Biz programme, a key component of which was youth-friendly health services, in moving from inception to large scale. The Estonian case study was that of the nationwide spread of the Amor youth clinic network, led by the Sexual Health Association in that country.
New 2016 ANC Model Applicability in Ethiopia (ppt): Natnael Dechasa Gemeda, S...Dire Dawa University
Power point for the 2023s' second round college-wide seminar for health science instructors (lecturers) by Natnael Dechasa Gemeda, who is a lecturer and researcher at the Dire Dawa University College of Medicine and Health Science.
The document discusses Pakistan's health care system and health districts. It defines a district health system as a vehicle for providing primary health care to a defined geographical area through participation of communities and health care providers. A health district is a well-defined part of an area in which primary health care is delivered by one authority. The document also outlines responsibilities in health care delivery, and describes issues like inequitable rural/urban services, ineffective services, lack of sanitation and funding. It identifies facilities from basic health units to teaching hospitals and discusses problems in rural and urban health areas as well as the role of district management teams.
The document provides clinical audit tools and data items for monitoring acute kidney injury (AKI). It describes six clinical pathways where AKI care can be audited: acute hospital admission, elective vascular surgery, laboratory, adverse event review, primary care, and renal replacement therapy (RRT). For acute hospital admission, the pathway shows the process from presentation through risk assessment, enacting prevention/care plans, monitoring for AKI resolution or need for RRT, and outcomes of discharge, death, or ongoing RRT dependence. Standards, indicators and specific data items are defined for collecting information across the different pathways to allow comparison of AKI care and outcomes.
Similar to An analysis of the gap between available healthcare services and deficiencies in care and treatment among patients with Chronic Kidney Disease in Chinandega and León, Nicaragua (20)
An analysis of the gap between available healthcare services and deficiencies in care and treatment among patients with Chronic Kidney Disease in Chinandega and León, Nicaragua
1. Mireille Levy-Culminating Experience
Page 1
Boston University School of Public Health
Department of Global Health and Development
Culminating Experience Cover Page
Name: Mireille Levy
CE Advisor: James Wolff
Culminating Experience Paper Title: An analysis of the gap between available healthcare services and
deficiencies in care and treatment among patients with Chronic Kidney Disease in Chinandega and León,
Nicaragua
Abstract
Currently, there is an epidemic of Chronic Disease of unknown causes (CKDu) in the farming
communities of Chinandega and León, Nicaragua. An increase in the incidence rate of CKDu over the past decade
have resulted in increases in patient demand for specific services and treatment beyond what the government is
able to sufficiently provide. El Ministerio de Salud (MINSA) in Nicaragua has responded by developing the
Norma y Protocolo Para El Abordaje De La Enfermedad Renal Crónica, a medical provider protocol guideline
for early detection, treatment and management of patients with CKD/u1
and by building sub-clinics that
specializes in CKD/u in high impact areas. However, quality and access to care and treatment for CKD/u is
compromised by a set of systemic issues arising from resource shortages, lack of programming and poor
implementation of key initiatives by MINSA and sub agencies. This paper discusses systemic issues that
undermine the quality of patient care, the economic impact of CKDu on Nicaragua’s healthcare system, medical
resource shortages and patient barriers to care in areas most affected.
To address these issues, I suggest that MINSA create a CKDu Task Force that collaboratively provides
recommendations to improve dissemination, training and provider education on the CKD protocol guideline and
to address areas of unmet needs and service gaps that improve the quality of care and health outcomes among
patients with CKD/u.
1
CKD/u is used in instances where the context applies to both CKD and CKDu patients.
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TABLE OF CONTENTS
Section PAGE
Glossary ........................................................................................................................................................ 3
Introduction................................................................................................................................................... 4
Chronic Kidney Disease (CKD ................................................................................................................. 4
Standard Methods of Diagnosis.................................................................................................................... 5
Blood Tests....................................................................................................................................... 5
Urine Tests....................................................................................................................................... 5
Epidemiology................................................................................................................................................ 6
Identified Risk Factors for CKDu................................................................................................................. 6
Occupational Risk Factors .............................................................................................................. 6
Environmental Risk Factors ............................................................................................................ 7
Pharmaceutical Risk Factors........................................................................................................... 7
Behavioral Risk Factors .................................................................................................................. 8
Healthcare System Structure in Chichigalpa, Chinandega ........................................................................... 8
Systemic Issues That Compromise Quality of Patient Care ......................................................................... 9
Physician Protocols for CKD/u Diagnosis and Treatment.............................................................. 9
Absence of Provider Education: A departure from standard methods of diagnosis and patient education10
Barriers to Patient Care............................................................................................................................... 11
Transportation Barriers................................................................................................................. 11
Renal Replacement Therapy Barriers............................................................................................ 11
Medical Services Capacity at the JD Health Center ................................................................................... 13
Infrastructure................................................................................................................................. 13
Organization of Health Service ..................................................................................................... 13
Equipment and Supplies................................................................................................................. 15
The CKD Task Force.................................................................................................................................. 15
CKD Task Force Staff Support ...................................................................................................... 16
Task Force Members...................................................................................................................... 16
The Division of General Health Services....................................................................................... 17
The Division of Financial Administration ..................................................................................... 17
The Division of General Medical Supplies .................................................................................... 17
The Division of Procurement for Medicines.................................................................................. 18
The National Diagnostic and Reference Center ............................................................................ 18
The Division of Teaching and Research ........................................................................................ 18
Hospital Directors ......................................................................................................................... 18
Clinic Managers ............................................................................................................................ 19
SME’s............................................................................................................................................. 19
Preliminary Planning..................................................................................................................... 19
Initial Meeting and planning ......................................................................................................... 19
Moving Forward............................................................................................................................ 20
Conclusion .................................................................................................................................................. 20
Bibliography ............................................................................................................................................... 21
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GLOSSARY
1. ADP - Automatic Peritoneal Dialysis
2. ANF - The American-Nicaraguan Foundation
3. CAPD - Continuous Ambulatory Peritoneal Dialysis
4. CAO - The Office of the Compliance Advisor/Ombudsman
5. CKD – Chronic Kidney Disease
6. CKDu – Chronic Kidney Disease of Unknown Causes
7. CKD/u – Chronic Kidney Disease and Chronic Kidney Disease of Unknown Causes2
8. DGFA - The Division of General Financial Administration
9. DGHS - The Division of General Health Services
10. DGMS - The Division of General Medical Supplies
11. DPM - The Division of Procurement for Medicines
12. DTR - The Division of Teaching and Research
13. GFR - Glomerular Filtration Rate
14. HD - Hemodialysis
15. HEODRA - Hospital Escuela Oscar Danilo Rosales Argüello
16. IFC - the International Financial Corporation
17. JD - The Julio Duran Health Center
18. MIGA - Multilateral Investment Guarantee Agency
19. MINSA – El Ministerio de Salud
20. MOH – Ministry of Health
21. NDRC - The National Diagnostic and Reference Center
22. NSAIDs - non-steroidal anti-inflammatory drugs
23. PD – Peritoneal Dialysis
24. SMEs – Subject Matter Experts
2
CKD/u is used in instances where the context applies to both CKD and CKDu patients.
4. Mireille Levy-Culminating Experience
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Date : November 28th, 2016
To :El Ministerio de Salud (MINSA), Nicaragua
From : Mireille Levy
Boston University School of Public Health MPH Candidate
RE : An analysis of the gap between available healthcare services and deficiencies in care and treatment
among patients with Chronic Kidney Disease in Chinandega and León, Nicaragua
Introduction
A rise in the incidence rate of Chronic Kidney Disease of unknown causes (CKDu) in Chinandega,
Nicaragua over the past decade have resulted in increases in patient demand for specific services and treatment
beyond what the government is able to sufficiently provide thus undermining the quality and accessibility to care
and treatment for patients with CKDu. Key initiatives by Nicaragua’s ministry of health (MOH), MINSA, to
address this issue, such as the development of the Norma y Protocolo Para El Abordaje De La Enfermedad Renal
Crónica, a medical provider protocol document for early detection, treatment and management for patients with
CKD/u and by building sub-clinics that specializes in CKD/u in high impact areas have fallen short of meeting
patient demand for care and treatment and ensuring that patients are receiving quality care in Chinandega and
León. Reasons for this is primarily due to resource shortages, lack of programming and poor implementation
strategies by MINSA and sub agencies.
The purpose of this paper is to discuss systemic issues that compromise the quality of patient care, the
economic impact of CKDu on Nicaragua’s healthcare system, medical resource shortages and patient barriers to
care in the most affected areas. Additionally, a policy recommendation is provided to offer an approach to address
these areas of concerns as a Public Health community in the departments of Chinandega and Léon, Nicaragua.
Information used to write this paper is from a literature review, an in-depth interview with a medical doctor
employed at the Hospital Escuela Oscar Danilo Rosales Argüello (HEODRA), multiple needs assessment reports,
and government documents published by the Nicaraguan Ministry of Health (MOH), MINSA.
Chronic Kidney Disease (CKD)
CKD is progressive loss of kidney function over time. The primary function of the kidneys are to remove
waste product from the blood. Urine created during this process is collected in the kidney, transported to the
bladder and excreted from the body [13]. Each kidney has several renal pyramids which contain a renal medulla
composed of about a million nephrons. Each nephron includes a glomerulus which is a microscopic blood filter.
5. Mireille Levy-Culminating Experience
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Damage to the glomerulus results in a lower filtration rate [15]. The National Kidney Disease Foundation defines
chronic kidney disease as either Glomerular Filtration Rate (GFR) <60 mL/min/1.73 m2
for ≥ 3 months [15].
Standard Methods of CKD Diagnosis
Bio-markers of kidney damage can be identified through blood tests, urine tests, diagnostic imaging or
kidney biopsy [13]. Calculating a patient’s GFR is the standard method for diagnosing a patient with CKD
however other tests should be conducted and compared to detect CKD.
Blood tests
A rapid creatinine test is normally conducted to determine kidney function because it is used to calculate
GFR. When damaged the kidneys cannot remove the body’s load of creatinine from the blood and the level in the
blood rises. Normal creatinine levels range from .5-1.21, this includes ranges for both males and females. A
creatinine test result higher than 1.21 may indicate kidney disease, acute kidney failure or other conditions such
as dehydration, low blood volume, or a meat heavy diet. Elevated creatinine levels should be confirmed either by
a repeated rapid test or a lab test. If results continue to show an elevated level of creatinine, then other tests should
be conducted to confirm the diagnosis of kidney disease.[16].
A BUN test is another way to check how well the kidneys are functioning by measuring the amount of
urea nitrogen in the blood. Healthy adults have a BUN result between 7-20 mg/dL, higher levels of urea nitrogen
in blood may suggest that the kidneys are not working properly [18].
Urine tests
Another efficient method for diagnosing individuals with kidney disease in a low resource setting, like
Nicaragua, is by a multi-reagent dipstick urine test to examine uric acid and albumin. Uric acid is produced from
broken-down cells and other purines and passes from the body during urination. Normal values range from 250
to 750 mg per 24 hours and low levels may indicate that the kidneys are unable to filter uric acid from the body
causing the substance to be retained in the blood stream.
Additionally, albumin can detect kidney disease. An excess amount of albumin in urine is called
albuminuria and indicates that the kidneys are leaking large molecules into urine, however albuminuria also
occurs in individuals with long-standing diabetes, usually type I, hypertension or a recent episode of high level
activity, such as labor intensive work common among young men in rural Nicaragua [22].
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Based on recommendations by the Clinic Reference Laboratory and the National Kidney Foundation, creatinine,
BUN, albumin and uric acid results should be compared and if each result is abnormal, then there is a high
probability that kidney function is impaired [14]. Additionally, it is recommended that an ultrasound be conducted
for differential diagnosis and to assess disease progression, if present, as a supplement to a patient’s GFR.
Epidemiology
Several case reports and published research studies over the past two decades indicate that an epidemic of
CKDu is occurring among agriculture communities in Nicaragua [1,3-11,23-24]. Information generated from
these studies suggest that patients share common demographic characteristics; this condition primarily affects
young males working in agriculture and who live along the pacific coast [1-5,7-9, 23-24] A community prevalence
study conducted among males working in pacific coastal areas in Nicaragua found an estimated CKDu prevalence
of 13.8% [5].
CKDu community prevalence studies have largely been focused in the department of Léon and Chinandega; the
areas with the highest CKDu prevalence in Nicaragua [3, 5-6]. The mortality rate among males age 35-55 years
in Chichigalpa, Chinandega is about five times as high as the national mortality rate [23]. La Isla Foundation, a
non-profit policy and research group reported that between 2002-2012, 75% of deaths among males age 35-55
years in Chichigalpa, Chinandega was due to CKDu [23]. In 2007, the mortality rate of CKD was 5.3 and 5.2 per
10,000 residents in Léon and Chinandega respectively [3]. Between 2004 and 2010 the total number of newly
registered CKD/u cases in the same community rose from 799 to 2,073 cases indicating an average increase of
212 new cases per year [3]. Among the 2,073 registered patients, 9% (183) are stage 0, 16% (332) are stage 1,
21% (428) are stage 2, 35% (726) are stage 3, 14% (291) are stage 4, and 4% (85) are in stage 5 [3].
Identified Risk Factors for CKDu
Several assessment studies conducted in Chinandega and Léon suggest an association between the
development of CKDu with behavioral, environmental, pharmaceutical and occupational exposures [1-4,6-13];
though the true cause of CKDu remains unknown there are several hypothesized risk factors by exposure category.
Occupational risk factors
Mortality data and community prevalence studies found that CKDu occurs primarily among young men
who work in farming. Prolonged exposure to heat and a heavy workload in combination with excess volume
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depletion and dehydration among agriculture workers are considered to be risk factors for CKDu [9]. Sugar cane
workers comprise the majority of patients with CKDu, although cases have been reported among miners,
construction workers and bricklayers [4, 9, 23-24].The departments of Chinandega and Léon, those with the
highest prevalence and mortality rate of CKDu, also host the country’s largest sugar cane plantation and are the
area’s largest employer [1,3,5-6, 23]. Individuals employed to either plant seeds or apply agrichemicals are also
at an increased risk for developing CKDu compared to workers who drive trucks or sort harvested crops on the
same farm [24]. One report found that nearly 70% of sugarcane workers in Chinandega developed CKDu [24]. A
study conducted by Raines et al. assessed potential risk factors associated with agricultural work. Age and sex
adjusted binomial logistic regression analysis of reduced GFR, measured as <60 mL/min/1.73 m2 found that the
odds of developing CKDu among men who indicated >365 lifetime days of harvesting crops were 431% more
than among men who reported less than 365 lifetime days of harvesting crops. (OR 4.31, 95% Cl 1.76-10.52).
Moreover, the odds of developing CKDu among men who reported any lifetime history cutting sugarcane during
the dry season were 586% higher than men who have never cut sugarcane during the dry season (OR 5.86, 95%
Cl 2.45-14.01).
Environmental risk factors
Exposure to heavy metals through contaminated surface dirt and drinking water, pesticides and
agrichemicals have been investigated in several studies. Exposure to pesticides when harvesting personal crops
for consumption and resale is also common among residents in rural communities [1, 8, 24]. A study conducted
by Raines et al assessed exposures to CKDu as potential causal mechanisms found that men who reported inhaling
pesticides from either work or personal use have a 331% higher odds of developing CKDu compared to men who
are not exposed to pesticides in the form of aerosols (OR 3.31, 95% Cl 1.32-8.31).
Pharmaceutical
Chronic and over prescribed use of non-steroidal anti-inflammatory drugs (NSAIDs) are included in the
list of hypothesized risk factors for CKDu [9, 11]. 19 Semi-structured interviews conducted with physicians and
retail pharmacies found that farm workers often suffer from chronic back and muscle pain. These workers
regularly visit their local pharmacy to purchase medications for pain relief. Prescriptions for NSAIDs are not
required in Nicaragua and these medicines are considered to be affordable by residents. A review of median
prices for two frequently consumed NSAIDs in Nicaragua from a WHO/HAI survey conducted in 2008 (adjusted
8. Mireille Levy-Culminating Experience
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for 2016 inflation) reported private sector consumer prices for both Ibuprofen 400mg cap/tab and Diclofenac
50mg cap/tab to be 0.11 USD. Even with a salary of 3-5 USD per day, NSAIDS to treat pain as a result of
strenuous working conditions is considered to be affordable to local residents and may be subject to abuse. In the
public sector, patients at health facilities receive NSAIDS at no charge.
Behavioral risk factors
Alcohol consumption and fructose intake are additional risk factors that have been investigated in multiple
research studies that relate to behavioral exposures [10, 11].A study conducted by Raines et al. assessed potential
risk factors associated with sugar consumption and traditional risk factors for renal failure among individuals with
an occupational history in agriculture. Age and sex adjusted binomial logistic regression analysis of reduced GFR,
measured as <60 mL/min/1.73 m2, found that participants who identified as being a male (OR 6.1, 95% Cl 2.34-
18.74), indicated current or past alcohol consumption (OR 3.25, 95% CI 1.36-7.85) and/or cane chewing (OR
3.24, 95% Cl 1.39-7.58 ), had a significantly higher odds of being diagnosed with CKDu compared to participants
who did not share these characteristics. CKDu is considered to be an unknown type of renal failure primarily
because it does not share the same etiological factors as patients with reduced GFR in developed countries such
as the United States.
In traditional CKD, males and females have similar odds of developing this disease and individuals are
more likely to be diagnosed as they grow older. Further, renal diseases tend to occur in patients who present with
hypertension and diabetes mellitus type II. However, Raines et al. measured hypertension and diabetes among
their participants as an independent variable and found both these characteristics to be an insignificant contributor
to CKDu among the participants in their study [8].
Healthcare System Structure in Chichigalpa, Chinandega
Primary and secondary services for care and treatment of CKD/u are provided free of charge to patients
by MINSA [3]. Chichigalpa is the largest town in Chinandega with a total population of about 46,455, of which
26% live in rural areas. A total of 10 health centers serve about 8,166 people while the rest are served at health
posts.
The Julio Duran (JD) Health Center in Chichigalpa provides primary care services for CKD patients while
secondary medical services are available at Hospital España in Chinandega and at HEODRA in Léon. Local
residents account for 90% of registered cases while the remaining resides in other departments.
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Systemic Issues that Compromise Quality of Patient Care
Physician Protocols for CKD/u Diagnosis and Treatment
A major issue that clinicians continue to face is a lack of protocols for evaluating, diagnosing, and
monitoring patients with CKD/u. Several reports and discussions with medical providers prior to 2009 mentioned
that until a set of treatment guidelines are published by MINSA, patients will continue to be managed based on
different criteria determined by individual general physicians [3]. In 2009, MINSA published their first rules and
protocol guidelines for clinicians on the prevention, collection, and management of patients with CKD. This
guideline essentially acknowledges CKD as a serious public health issue, outlines the epidemiology of this disease
in Nicaragua, and standardizes medical definitions, formulas for calculating GFR, and test result ranges related
to CKD/u. Also included are protocol compliance indicators for data collection, prevention and management of
CKD, standardized forms to record patient information and tests results, and formal protocols for diagnosing
patients with CKD/u. The guideline also provides guidance on determining disease stage, standardized follow-up
periods, including a detailed plan of action for each follow up appointment by disease stage, and CKD risk factors
depending on the patient’s health status [6].
Despite their criticism of a lack of coordinated effort to integrate a CKD protocol into their healthcare
system, providers are not using MINSA’s protocol guideline to diagnose, treat and monitor patients with CKD/u.
The main reasons for poor compliance among medical providers are due to a lack of awareness that a protocol is
available, deficiencies in education for medical providers about diagnostics methods, patient monitoring and care
coordination for patients with CKD, geographical displacement, poor compliance monitoring by MINSA, and a
primarily older physician population3
.
Specifically, providers are not aware that a protocol has been published because the protocol guideline is
only available online and must be downloaded and printed in order to disseminate it around a health clinic and
MINSA has not distributed the protocols to medical providers at clinics that serve patients with CKD4
. This is a
barrier to providing quality care because most healthcare centers do not have a computer and printer on site and
the number of people who have laptops or desktop computers at home remains low in Nicaragua; consequently,
access to electronic information continues to be an issue.
3
Results from an IDI conducted with a medical doctor employed at HEODRA in León, Nicaragua
4
Results from an IDI conducted with a medical doctor employed at HEODRA in León, Nicaragua
10. Mireille Levy-Culminating Experience
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In terms of geographical displacement, providers who care for CKD/u patients in rural areas don’t have
access to reliable or new information related to CKD5
. One major reason is because medical doctors in rural areas
tend to be older and do not have the technical capacity to visit the protocol online and are unwilling to change the
processes that they have been using to diagnose and monitor patients with CKD/u in their respective health clinic6
.
Absence of provider education: A departure from standard methods of diagnosis and patient education
Medical providers in the areas most affected, prevalence >10% in the Department of Chinandega, are not
receiving training specifically for CKD/u or on the protocol guideline resulting in a departure from standard
methods of diagnosing patients with CKD and deficiencies in patient education for personal care and treatment7
.
In Nicaragua, blood and urine tests are primarily used to diagnose patients with CKD because it is less
costly than diagnostic imaging or a biopsy. Providers in primary care clinics containing a sub-clinic specifically
serving CKD patients are relying on two rapid creatinine tests taken at two points in time to determine if a patient
presents with CKD. Additionally, some providers are not measuring and comparing other indicators of CKD such
as BUN or Albumin nor calculating GFR8
. Some medical providers are also unaware that they have to monitor
patients who either have an elevated creatinine level or a GFR between 60-90mL/min/1.73 m29
. The major
problem with this type of diagnosing method is that creatinine levels may change for a variety of reasons other
than kidney failure, such as strenuous labor which is common among male farmers in Nicaragua. The standard
definition for CKD, including staging of the disease is based on a patient’s GFR. Therefore, patients who present
with elevated levels of creatinine may be misdiagnosed with CKD if their GFR is not calculated or/and if the
physician does not conduct other tests that indicate CKD. Additionally, without calculating a patient’s GFR or
using diagnostic imaging, it’s unlikely that a physician will know the stage of disease progression.
Additionally, the lack of CKD training to medical providers undermines the quality of care and treatment
education to their patients. Education provided to diagnosed patients generally consist of a few general tips such
as to reduce salt intake and to drink cool liquids.10
The absence of education specificity during consultation and
supplemental materials to take home contributes to a patient’s lack of awareness about their condition and
5
Rural clinics rarely have internet connection and therefore rely on MOH outreach and provider-to-provider updates on published
information
6
Results from an IDI conducted with a medical doctor employed at HEODRA in León, Nicaragua
7
Results from an IDI conducted with a medical doctor employed at HEODRA in León, Nicaragua
8
Results from an IDI conducted with a medical doctor employed at HEODRA in León, Nicaragua
9
Results from an IDI conducted with a medical doctor employed at HEODRA in León, Nicaragua
10
Results from an IDI conducted with a medical doctor employed at HEODRA in León, Nicaragua
11. Mireille Levy-Culminating Experience
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compromises their ability to appropriately care for themselves to reduce disease staging. For instance, some
patients diagnosed with stage 5 renal failure do not enroll into dialysis because they are unaware of the severity
of their condition and do not perceive that their need for renal dialysis to be urgent11
.
Barriers to patient care
Patients are only referred to a hospital when they are diagnosed with stage 5 kidney failure and require
dialysis therapy in order to survive. The cost of dialysis is covered entirely by MINSA 12
[4], however patients
often do not receive dialysis treatment because of transportation barriers, medical supply shortages at the hospital,
and lack of information provided to them about their condition.
Transportation barriers
As of 2011, Hospital España has already reached their capacity to provide dialysis, so the remaining
patients must visit HEODRA in León [3]. Taxi services from Chichigalpa to HEODRA in León cost about $800
Córdoba or $26 USD round trip. By bus the trip requires four buses for a total of $70 Córdoba or $2.50 round
trip. Bearing in mind that an average daily income for a farmer in this area is between $2-$5 USD, cost of
transportation is a barrier to treatment, especially if they are required to receive dialysis 3 times a week13
.
Renal replacement Therapy barriers
A medical needs assessment report of the Chichigalpa health center was conducted in 2010 that identified
poor and limited infrastructure, lack of trained personnel, shortage of dialysis supplies, lack of functioning
equipment, and insufficient funding sources from the government to pay for patient’s treatment costs to be the
primary barriers to patient access to dialysis. Peritoneal dialysis (PD) is the most common type of dialysis
treatment in Nicaragua because it is the least expensive option, though not necessarily affordable for the
government to cover.
For patients diagnosed with stage 5 renal failure, either a kidney transplant procedure or renal replacement
therapy, such as peritoneal or hemodialysis is required for the patient to survive.
11
Results from an IDI conducted with a medical doctor employed at HEODRA in León, Nicaragua
12
Results from an IDI conducted with a medical doctor employed at HEODRA in León, Nicaragua
13
This information was obtained from 2 farmers in Chinandega and the MD employed at HEODRA
12. Mireille Levy-Culminating Experience
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The cost of PD treatment is very costly for the government to cover [4]. In 2010, the initial cost of PD
catheters were US$600 plus US$900 a month per patient for treatment supplies and equipment totaling at about
$11,400 USD annually in a country that budgets to spend $445 on healthcare services and medication per capita
a year. Lastly, unpredictable shortages of essential supplies such as functioning equipment, dialysis fluid, and
other materials commonly occur within the Chichigalpa healthcare network, which contribute to patient barriers
to life saving treatment [3].
In contrast, HEODRA is able to provide nearly unlimited PD services to patients because they have a
contract with Baxter, a private international dialysis supply company. Moreover, Baxter trains nurses and doctors
at HEODRA on how to appropriately care for CKD patients and operate PD machines; this agreement is strictly
between Baxter and HEODRA, not with the Ministry of Health. Additionally, HEODRA also receives dialysis
supplies from The American-Nicaraguan Foundation (ANF). The problem is that these agreements do not service
the overall Public Health issue of CKDu, which are occurring among low-income and rural male farmers. For
instance, in 2010, HEODRA was providing PD treatment to 50 patients but only 10 were farmers while the
remaining were urban dwelling diabetic women [3]. Further, HEODRA is located in the city of Léon, about 1.5
hours from Chichigalpa by car and nearly twice as long by public transportation, further alienating those who
reside in Chinandega and need treatment the most.
Hemodialysis (HD) is another treatment option for individuals with stage 5 renal failure. It removes waste
products and free water from the blood and requires advance medical equipment, costly reagents, an outpatient
facility, specialized nursing and technical staff in order to provide quality treatment to patients and to ensure that
machines are calibrated. Patients with CKD stage 5 require 3-4 hour sessions 3 times a week. The cost of HD is
about $9,000 per patient annually in HEODRA and thus prohibitively costly for the government to cover based
on the national budget for health expenditure. Moreover in 2008 Hospital España, in Chichigalpa, received a
donation of 8 new HD machines but this health facility is not equipped with a cold storage room for supplies nor
an outpatient facility, therefore they are unable to provide any HD treatment to their patients [3].
Based on the results from a needs assessment report, it would make more sense from a financial
perspective for hospitals to cease PD dialysis and switch to HD dialysis therapy. The primary advantage, is that
Nicaragua’s healthcare system may save an average of $2,400 USD per patient annually when services with HD
dialysis compared to PD dialysis.
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Medical Services Capacity at the JD Health Center:
The Office of the Compliance Advisor/Ombudsman (CAO) is a group committed to responding and
resolving complaints by individuals, groups of people or organizations affected by projects conducted by the
International Financial Corporation (IFC) and Multilateral Investment Guarantee Agency (MIGA); essentially the
CAO promotes social and environmental accountability of IFC and MIGA. A medical needs assessment report
conducted by CAO evaluated the infrastructure, organization of health services, equipment and supplies related
to the ability to treat and monitor CKD/u patients in the department of Chinandega. The majority of CKD/u
patients in Chichigalpa receives their primary medical services form the Julio Duran Health Center; publically
funded by MINSA. As of 2010, the health center in Chichigalpa did not have sufficient amount of space, supplies,
equipment or personnel to meet the medical demands of their community residents including CKD/u patients.
Medical providers from this health center mentioned that a hygienic, comfortable, staffed and spacious
environment is necessary to deliver safe and quality medical care [1, 3].
Infrastructure
The JD health center consists of a small waiting room and two modest consultation rooms staffed by two
physicians. The waiting room was built to accommodate 15 patients, however there are usually about 40 patients
waiting to receive services at any point in time. The waiting room is not air conditioned, which may cause
discomfort for patients and pose additional risks for CKD/u patients. Patients, including those with CKD/u, are
examined and treated openly in front of other patients, compromising privacy and patient confidentiality. In
regards to unstable CKD/u patients, the JD health center has a small observation room but consists of only two
beds. Additionally, the clinic lacks a room to conduct care coordination services, health education discussions
for patients with chronic illnesses, and provider training and education sessions [4].
Organization of health service
CKD is a progressively fatal disease that requires early detection, monitoring, health education, and
medical treatment to prolong and improve the quality of life for a patient. In order to achieve this goal, the health
clinic needs to have a sufficient number of trained personnel, a feedback system for monitoring and evaluating
the quality of services, ancillary services, a stocked pharmacy, patient counseling services and other informational
resources [3].
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As of 2010, the JD consisted of a small CKD clinic staffed by a single nephrologist and an internal
medicine physician whom are responsible for providing treatment and monitoring services for about 2,073 known
registered CKD patients. The CKD clinic provides services from 8:00 am - 3:00 pm Monday-Friday which
includes 1 hour dedicated only to administrative responsibilities. Together these physicians consult about 700
CKD/u patients per month or 40-50 CKD/u patients per day [3]. Consequently, each patient only spends a few
minutes with a physician, an insufficient amount of time for a complex chronic disease that requires consultation
on medication and nutrition, blood and urine tests for monitoring disease progression, discussion of associated
signs and/or symptoms and a primary physical. Moreover, dietary and other type of counseling services such as
health education are necessary for CKD patients, especially for those who are in the later stages of the disease.
The JD Health Center does not have a nutritionist or a social workers on site; therefore CKD patients must seek
ancillary services at Hospital España in Chinandega. Patient appointments are scheduled based on creatinine
levels and care is limited after normal operating hours which is especially dangerous for CKD/u patients who are
either unstable or at the later stages of the disease. Some medical doctors disagree with this mechanism for
organizing medical appointments because several other factors can influence the result of a rapid creatinine test,
such as recent use of medication, high level activity or dehydration, which is common among residents of rural
communities [3].
Additionally, the availability of palliative services for CKD patients, especially those who are in stage 5,
is also concerning as the JD Health Center and most health facilities in Nicaragua completely lack a palliative
care program. Palliative programs are essential for the continuum of care as it providers physical and emotional
support to alleviate pain and suffering for both the patients and their families through the dying process. Currently,
the demand for palliative programs is low among patients and medical providers primarily because other priorities
have been set, lack of patient awareness about the disease and the meaning of palliative care remains low in
Nicaragua [3].
Another essential feature for evaluating the organization and quality of healthcare services are feedback
systems. Feedback systems monitor and evaluate the capacity of the healthcare facility, health staff availability
and quality of care provided to the patient by the provider. It can also identify problems in the delivery of care in
order to take effective corrective action. Feedback systems guided by a set of protocols, such as those produced
by MINSA in 2009, are useful to reduce medical complications, improve health outcomes, and increase the quality
of healthcare services while minimizing costs. In regards to CKD, a clinical feedback system can address
problems that patients have specifically mentioned such as scheduling availability, short appointment times,
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medication and reagent shortages, and low patient satisfaction based on the quality of care they receive. To the
knowledge of both the medical doctor that was interviewed and the assessment reports that were reviewed,
MINSA has not implemented a feedback system between rural clinics, community health centers and hospitals to
monitor and refer CKD/u patients to other health facilities.
Equipment and supplies
The JD Health Center medical needs assessment conducted by CAO also analyzed equipment and
materials required to properly treat CKD/u patients. Although the JD Health Center is sufficiently supplied with
staffing and administrative materials, the report indicated a serious shortage of medical supplies and equipment
required to monitor patients or test those that present with symptoms and characteristics of CKD/u. For instance,
diagnostic reagents and a small refrigerator to store urine and blood samples were missing. Reagents are a
component to diagnosing patients with CKD while blood and urine samples must be stored in a refrigerator unless
they are processed within an hour14
, else the samples will be compromised and will likely yield incorrect test
results.
Another issue the health center faces is the inability to provide emergency treatment for CKD/u patients
if necessary. According to the needs assessment report, the health center needs an EKG machine, an oxygen
delivery system, respirator, manometer, and a separate stock of emergency medications to provide emergency
services to unstable patients. These supplies are not available at this clinic and the pharmacy closes at 4:00 pm
during the week and is closed on weekends [3]. Therefore, unstable CKD patients who require emergency
attention must travel to either Hospital España or HEODRA and may be charged for ambulance fuel expenses,
which is an additional barrier to care and illegal15
.
The CKD Task Force
To improve provider compliance of the CKD protocol guideline and to recognize and work to address areas
of unmet healthcare need among patients with CKD/u, I recommend that MINSA create a stakeholder task force
to plan, organize and monitor the following initiatives in Chinandega and León:
14
Urine should be processed within an hour if not stored at 39o
F. Time to process blood if not sored in a refrigerator depends on
blood type.
15
Fuel expenses charged to the patient was mentioned in the needs assessment report and confirmed by MD that was interviewed
for this paper.
16. Mireille Levy-Culminating Experience
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1. Disseminate, train and improve compliance of the protocol guideline Norma y Protocolo Para El
Abordaje De La Enfermedad Renal Crónica or the Rules and Protocols for Approaching Chronic Renal
Disease in Chinandega, the area with the highest prevalence, incidence and death rate of CKDu.
2. Identify areas of unmet need, such as those mentioned above, and provide recommendations that
addresses those needs to improve the quality of care among patients with CKD/u.
The CKD task force’s intended primary outcomes include an increase in early detection rates, a reduction
in death rates of CKD through improved patient monitoring methods, provider compliance on the CKD protocol
guideline to achieve standard diagnostic methods across providers in high prevalence areas, and recognition of
major and minor medical and non-medical areas of unmet needs among patients with CKD and CKDu. These
objectives should be executed through the provision of informed recommendations to MINSA by the Task Force
members, or stake holders, and subject matter experts (SMEs).
CKD Task Force Staff Support
Implementing the task force requires administrative staff support to organize meeting locations, manage
updates, audio record the meetings, draft meeting minute notes, and supply administrative materials to task force
members and SMEs (agendas, writing utensils, and reports). Reports from respective members should be given
to the Task Force Staff Support team to manage and send out to other members. Ultimately, the task force staff
support is responsible for coordinating and managing the task force meetings, administrative materials and
correspondences among members. This team is critical to ensuring that the Task Force is well organized and able
to properly operate under changing circumstances among several stakeholders. Failure to properly organize a task
force and manage its cohesiveness through logistical and administrative planning can cause the initiative to
collapse early on and waste valuable resources in an already low-resource setting like Nicaragua.
Task force members
I recommend that MINSA officials draft a preliminary list of task force members to represent stakeholders
of this epidemic and SMEs to provide expert knowledge or technical assistance that facilitates informed
recommendations by members in Chinandega and León.
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MINSA can draft a stakeholder and a SME member list to contact and invite them to be a member of the
task force. I recommend that the following agencies should have representation on the task force, but to not limit
the number of agencies on the taskforce. 16
The Division of General Health Services (DGHS)
The DGHS is responsible for conducting needs assessment reports, collecting and presenting data to
stake holders, and developing strategy reports and protocol guidelines for health clinics [25]. A member from
this division can serve to help strategize how the protocol guideline is implemented to both urban and rural
health clinics.
The Division of Financial Administration (DGFA)
The DGFA is responsible for developing Nicaragua’s annual healthcare budget, allocating funds to health
facilities and monitoring health expenditures, among other duties [25]. Representation from the DGFA will help
direct the type of recommendations made based on available funds and willingness to change budget allocations
where needed by the DGFA.
1. Lic. Sergio Guerrero – Director
The Division of General Medical Supplies (DGMS)
The DGMS is responsible for managing the supply chain system for medical supplies in Nicaragua.
Their primary responsibilities are managing logistics and overseeing rational use of medical supplies. They
gather supply consumption information from health units to analyze the prescription, dispensing and use of
medical supplies. Further, they work to identify opportunities for improvement to implement recommendations
that optimize the use of medical supplies [25]. This paper mentions dialysis and other medical supply shortages
at specific clinics in Chinandega as a gap in medical care for CKD patients. Representation from this division
raises awareness to this issue and members can provide directed input for recommendations made to address
this issue.
16
Task force member names were obtained from the official Nicaragua Ministry of Health website at
http://www.minsa.gob.ni/index.php/directorio
18. Mireille Levy-Culminating Experience
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The Division of Procurement for Medicines (DPM)
MINSA works with the Division of General Procurements for Medicines who works with the Division
of Planning and Tracking Contracts and the Contracting Division to negotiate prices and purchase medicines
[25]. Medicine supply shortages data provided from medical needs assessment reports, health clinics and the
DGHS can be delivered to members of the DPM to encourage additional procurement of medicines for patients
with CKD as needed.
The National Diagnostic and Reference Center17 (NDRC)
The NDRC is responsible for handling confirmatory lab requests by smaller health clinics, to educate
health authorities, and guide laboratory directors and technicians to identify responsibilities and functions of
laboratory services. Further, they take into account priorities, needs and the local capacity of a health clinic to
conduct laboratory testing [25]. Representation by the NDRC will help to facilitate logistical planning and
implementing the portion of the CKD Protocol Guide that covers standardized diagnostic methods.
The Division of Teaching and Research (DTR)
The DTR is responsible for providing continuing education for providers, hospital management
education and social services for patients [25]. The division has published a series of continuing education
modules for providers but CKD is not among them. Representation from this division will assist in strategizing
how to implement continuing education on CKD for general physicians working at clinics in Chinandega and
León.
Hospital Directors
Patients who require dialysis services and treatment for disease complications are referred to a hospital for
care [3]. Needs assessment and other reports have indicated a dialysis supply shortage, a treatment necessary for
survival among patients with stage 5 CKD [3]. Hospital directors or their representatives are an important
stakeholder in regards to addressing treatment shortages as a care gap for patients with CKD. Their presence
will help the task force committee plan recommendations to address these issues that incorporate the needs and
perspectives of hospital directors or managers who have the authority to implement recommendations. Further,
19. Mireille Levy-Culminating Experience
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buy-in from hospital directors will be crucial for implementing a continuous training program on the CKD
protocol guidelines for providers in large hospitals. Below is the list of hospital directors.
1. Gaviota Sandoval Rodríguez - Hospital España
2. Dr. Ricardo Cuadra Solórzano – Oscar Danilo Rosales
3. Dra. Vera Mercedes Orozco Iglesias – Rosario Lacayo
Clinic Managers
Clinic administrators or managers from clinics that serve a large number of CKD patients in Chinandega
and León should be members of the task force as they are the front line care givers for patients with CKD. Input
from this group will facilitate the development of realistic recommendations and improve the likelihood that a
recommendation is successfully implemented in their respective clinics.
SME’s
SMEs serve the role of providing technical assistance and help inform recommendations to the task
force. An Epidemiologist specializing in kidney or Chronic diseases, a Nephrologist, and a health educator
should be included in the task force, but additional SMEs can be included depending on the need of the task
force. These members can be appointed by MINSA and asked to present at the first meeting.
Preliminary Planning
MINSA members should meet to discuss task force objectives and to develop a flexible timeline for the
taskforce (i.e. beginning to approx. end date). Task force member selection from each stakeholder group to be
the representative to the task force should also take place during this planning phase. Ideally, several members
from each stakeholder group are given the task force’s purpose, objectives and a formal invitation to participate
with the understanding that a number of invitees will decline the request.
Initial Meeting and Planning
Ideally, The CKD Task Force’s initial meeting should be attended by influential members of MINSA to
encourage awareness about the task force and demonstrate a sense of urgency towards the CKD epidemic in
Chinandega and León. Additionally, it would be ideal to have all meetings open to the public including a brief Q
& A session to allow members of the affected community or other individuals to softly participate. The initial
20. Mireille Levy-Culminating Experience
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meeting can be an introduction to the purpose and objectives of the task force and include presentations from
SMEs and MINSA about the epidemic to further familiarize stakeholders about the issue at hand and where they
fit in terms of addressing those objectives. Additionally, documents outlining specific objectives by MINSA to
address the two major objectives should be given to members of the task force.
Moving Forward
The remaining taskforce meetings should primarily be recommendation and implementation meetings.
Stakeholders should discuss their role and level of contribution to either or both objectives of the Task Force.
Planning meetings between staff support and MINSA should be conducted between The CKD Task Force
member meetings to review meetings minutes, delegate data and other type of requests between members, and
handle other logistical aspects of the CKD Task Force to improve the efficiency of each member meeting.
Conclusion
Over the past 6 years, the MOH, INSS and other health organizations such as non-profits and academic
institutions have responded to the increasing epidemic of CKD, both known and unknown causes, along the
pacific coastal regions of Nicaragua. Nicaragua has nearly doubled their per capita health expenditure from $232
USD in 2010 to $455 USD in 2016 and they have developed and released protocol guidelines for the detection,
treatment and monitoring of chronic kidney disease. However, there continues to be areas of weakness regarding
protocol implementation and provider compliance, equipment and supply shortages, medical provider education,
and patient awareness about chronic kidney disease. Several non-profit organizations have donated medical
equipment and supplies to healthcare facilities, such as the 8 HD machines to Hospital España, but this facility
lacks additional materials needed to expand their capacity to deliver renal replacement treatment. Additionally,
health clinics in general often experience shortages in reagents, other supplies and fuel for transportation.
Academic institutions, such as Boston University, have worked with several other groups to conduct
epidemiological studies, both cross sectional and longitudinal, to better understand the development of this
particular type of kidney disease and to offer technical assistance to MINSA, CAO and other organizations in
Nicaragua.
Medical provider non-compliance to a CKD protocol guideline, gaps in medical need and health
disparities among CKD patients is largely a systemic problem coupled with resource shortages in Nicaragua’s
21. Mireille Levy-Culminating Experience
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healthcare system. Addressing these issues require a collaborative and organized effort among MINSA agencies,
SME’s and members of the affected community. A CKD Task Force comprised of MINSA sub agency members,
SMEs, and members of the affected community is likely to raise awareness to the issues at hand. Moreover,
concerted efforts by staff support, MINSA, members and SME’s may generate realistic recommendations on how
to disseminate, train and improve compliance of the CKD protocol guideline to providers and address identified
areas of unmet need among patients with CKD/u.
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