Dr. Prakash Raj Regmi MD President Nepal Heart Foundation

1. Dr. Prakash Raj Regmi MD
President
Nepal Heart Foundation

2. Disclosure
I do not have any conflict
of interest that might
cause a bias in this
presentation

3. Objectives
1.To elaborate the different approaches
to the heath care systems
2.To describe the benefits of diagonal
approach for launching RHD control
programs

4. NCDs & CDs
• They are two giants of
developing countries causing
double burden to the health
system in developing
countries
• Almost Fifty/ fifty
• Nepal- NCDs 49% CDs 51%
1980- NCDs 30% CDs 70%
NCDsCDs

5. Non- communicable diseases
Introduction
1. Rapidly increasing in developing countries
2. Worldwide 35 millions deaths annually
3. Cause of 60% of all deaths and 47% of the
global burden of disease
4. 80% of total deaths occur in low and middle
income countries
5. Mostly adults & elderly people are affected
6. Shift from elderly to younger, urban to rural
and rich to poor people

6. Rheumatic heart disease
Introduction
1. Major Public Health Problem in developing
countries
2. 15.6 million people affected worldwide,
among them 2.4 million are children of 5-
14 yrs
3. 0.5 million new cases detected every year
4. 350000 deaths annually
5. Children & young adults are mostly
affected

7. • Beginning is communicable-
GAS infection
• Development is Non
communicable-
Immunological response to
the GAS infection

8. Need for prevention program
• High need especially in the
developing countries
• Should focus on the launch and
implementation of RHD & NCDs
prevention and control programs
• These programs can be launched
with different approaches to the
health care system

9. Approach to the health
care system
• Horizontal approach
• Vertical approach
• Diagonal approach

10. Horizontal approach
to health care system
• Focuses on a general
strengthening of the overall
health care system
• No specific priorities to any
programs
• Budget is more or less equally
distributed Continued…….

11. Horizontal approach
• All components are equally
focused
• No disease specific programs
• Good- Strengthening of the
overall heath care system
• Bad- Specific disease
programs are diluted. No
disease specific priorities
Continued….

12. • Focuses on disease specific programs
• Focuses on one specific disease
like HIV/AIDS, TB, Malaria, Leprosy, etc
• Considerable amount of funding is made
to one specific disease
• Does not take care of the primary health
care system Continued…..

13. • Duplication of infrastructures, laboratories,
human resources
• Drain of qualified specialist from primary
health system to the vertical program
• Drain of big portion of budget from primary
health care to the vertical programs
Continued…..

14. Vertical approach
»Good for the
focused specific
disease but bad
for the overall
health care
system because it
ultimately
weakens the
primary health
care system
Continued…..

15. • HIV/AIDS , TB, Malaria , Leprosy control
programs in most of the developing
countries
• In Nepal – HIV/AIDS, Leprosy control
programs
• RHD control program in Bangladesh –
JICA support 5 yrs. 20 yrs back

16. Diagonal approach to
health care system
• New concept
• Hybrid of horizontal and vertical
approaches
Continued….

17. Diagonal approach
• Focuses on specific diseases within the
frame work of primary health care system
• Uses the same infrastructures (diagnostic,
curative, preventive), human resources,
equipments, laboratories. But upgrades
them
• Strengthens the primary health care
system
Continued….

18. Diagonal approach
Example
2005 – SolidarMed started HIV/AIDS control
program named SMART in 10 districts sites in
Tanzania, Mozambique, Lesotho and
Zimbabwe
They integrated SMART into existing primary
health care system and the hospitals
Result was better than with Vertical approach
Continued….

19. RHD control programs
• Most countries do not have such program at
national level
• Developed countries do not need it as the
prevalence rate is already very low
• Developing countries do not have it because
RHD is not in the priority and funding is not
available
• Register based national program exists in
very few countries :
– Australia, New Zealand, Nepal & others

20. Elements of RHD prevention
program (WHO)
1. Strong commitment from local government
(ministry of health and education)
2. Skilled and committed RHD advisory committee
established within the ministry of health , with
membership from medical and nursing
professionals, educators and community groups
3. RHD registry system
Continued…

21. Elements of RHD prevention
program (WHO)
4. Secondary prevention activities
integrated into existing health care
system and aimed at preventing the
reoccurrence of ARF and Severe RHD
5. National notification of ARF and RHD to
the MOH
6. Priority system to help deliver services to
those at greater risk
Continued….

22. Elements of RHD prevention
program (WHO)
7. Reliable medication supply & microbiology
lab support
8. Gradual program establishment starting
from center and extending to the periphery
9. Primary prevention activities to be
launched once the secondary prevention
program is established integrating it into
the primary health care system
Continued….

23. • There is now consensus between
government, civil society and global health
initiatives that health system should be
people- centered rather than disease –
centered, should be diagonal rather than
vertical
• A number of international organizations have
adopted their funding criteria to
accommodate disease- specific intervention
that also strengthen the horizontal system of
primary health care - diagonal programs
Diagonal – preferred approach

24. Funding and health care approach
• HIV/AIDS program (lots of funding) – if
designed in a diagonal way rather than in
a vertical, both HIV/AIDS program &
primary health care will benefit
• RHD program (very less funding) if
designed in a diagonal way rather than in
a vertical way RHD program can become
effective & sustainable

25. How to integrate RHD in diagonal
program?
1. Commitment from the government
2. Include RHD in National Health program
3. Insure for regular funding for the program
4. National program committee is to be
formed including authorities from the
ministry of health, planning commission,
National Heart Foundation, education
sector, civil society etc
5. National heart Foundation should take an
active role
Continued…

26. How to integrate RHD in diagonal
program?
6. Initiate secondary prevention with participation of
district, regional and central hospitals. Later on
expand it to the periphery
7. Keep registers in the participating hospitals.
Have a central registry system within the existing
health care system
8. Upgrade the infrastructures of the hospitals,
laboratories, penicillin injection rooms, staffs
9. Training to doctors and health professionals
Continued….

27. 1. Integrate RHD & NCDs into existing primary
health care programs and longstanding hospital
partnerships
2. Harmonize RHD & NCD with existing similar
programs and bring it in line with the national
health policy
3. Use the budget for RHD & NCDs control to
strengthen the capacity of primary health care
service-such as infrastructure, staff training,
salary top ups that are not specifically related to
RHD & NCDs service

28. Which approach? For RHD Programs
• RHD program in most developing countries
have no funding from the government as well
as from the donor agencies. So vertical
program is not possible.
• Horizontal program does not focus on
RHD so is less effective

29. Diagonal Approach
• RHD program if integrated in diagonal way:
– Primary health care is mobilized
– Staffs are trained
– Facilities are improved
– Medicines are available
– Patient care is improved
– Continuous funding from
government is ensured
• This is the only way to initiate & sustain
RF/RHD prevention program in
developing countries

30. • Because in developed countries- there is no
need of it due to low prevalence
• In under developed countries- communicable
diseases are in the priority list
• Importance of RHD prevention is nowhere
despite of its large impact in the community
• Government does not want to listen about it .
No budget for it
• Strong advocacy is needed

31. Summary
• While launching RHD control programs
1. Horizontal approach may not be effective
2. Vertical approach may not be feasible and
sustainable
3. Diagonal approach is effective , feasible
and also sustainable