Renal Health Models in Latin America: Development of National Programs of Renal Health

Figures & data

Figure 1 Renal Health Model.

Figure 2 The Epidemiological Transition.

Figure 3 Plan to Assist Renal Failure (PAIR).

Table 1 Programming in the Context of the Logical Framework: General Guidelines for a Renal Health Model—Examples by Program and Component

Objective. Give renal patients sustainable integral care. Purpose. Improve efficiency and promotion of equality in renal health through implementation of new renal health care primary attention. Modify established structures of intervention. Background Program. Objective. Have available resources to be used in the development of the model. Purpose. Have economic resources available for funding coverage of renal patients at every stage of treatment, either pre-dialysis aiming at regression or remission, dialysis, and/or transplant. Results. Allocation of resources fund or budgetary item. Activities. Reallocate budgetary items Renal Health Program: Training and Education Component Objective. Improve quality of care to renal health patients as well as cost-efficiency. Purpose. Have qualified medical professional available for integral care of the renal patient. Results. Qualified care givers at the First Level of Renal Health Care. Activities. Courses, seminars, and/or training workshops. Permanent education programs. Renal Health Program: Primary Renal Health Care Component Objective. Improve equality and provide population access for renal health care. Purpose. Generate easy-to-interpret algorithms to be used at the First Level of Care. Have primary health care centers available nationwide. Generate reliable information on renal patient populations. Results. Accessible primary care centers for renal patients. Databases. Control and follow-up algorithms. Activities. Systematic follow-up or renal patients. Completion of follow-up form. Strengthening data base for actuarial curves.

Table 2 Renal Health Program: General Conceptual Framework and Breakdown in Specific Projects (Examples)

Summary of Objectives Objective Improve efficiency and upgrade equality of renal health care by implementing new modalities of renal health care that modify traditional intervention strategies. Purpose Orientation of APS renal health care services to the needy sectors via focusing mechanisms. Increase of accessibility and user satisfaction through implementation of quality control mechanisms. Components Regional: Education, training, and retraining Correspondence of MS structure and new model of renal APS Preparation of regional projects National: Compensation and incentives system Adjustment of infrastructure Information systems Social communication Institutional upgrading Activities Human resources education, training and retraining in renal APS. Definition of professional profiles and certification and recertification mechanisms. Training in the short term. Continuous education programs. Support to local and institutional training strategies. Promotion of APS-oriented medical residencies. Support review of grade syllabus for health care professionals. Support adjustment of health ministry structures associated or to be associated to the model: renal APS information system, social communication programs, institutional upgrade. Support to the preparation of national projects. Support the creation of the Annual Operative Program at each location or institution as required. Verifiable Indicator Upgrade of renal health indicators, especially for diabetic and hypertensive patients. Lengthening of pre-dialysis stage with regression and/or remission of 20% of patients in the program in three years. Increase in resource participation of renal APS. 50% increase of renal health care coverage in three years, especially for needy sectors. Increase in the number of renal APS units, 50 new and 100 reconverted. 20% increase in three years of the number of physicians trained in renal APS. Quantitative goals defined in follow-up indicators matrix. Three or four local or institutional projects completed. Indicators to be defined in detail in the context of the Logical Framework for each location or institution. Budget for the program and its implementation will be included in the Annual Operative Program (POA). Means of Verification Recording of national health information systems. External audits for the program. Follow-up forms and classification matrix. Recording of local information systems. Administrative records in National Health Ministers and external audits. Certificates granted by training institutions and training contracts signed with local governments. Physical and financial monitoring of program goals by Central Execution Unit. Physical and financial monitoring of program goals by local units and by Central Execution Unit. Physical and financial monitoring of program objectives by local or institutional Execution Units and Central Execution Unit, as the case may be. Evaluation of program progress with POA forms.

Assumptions The new Renal Health Model is understood and accepted by players and the general population. Local governments adhere to the program. A management control program for Renal Health Care is added, and associated to area programs for APS in public hospitals. Connection with other health care programs. Incentives are efficient in attracting institutions and especially nephrologists to the APS renal model. Inflow of health care professionals to the new model is suited to needs. Legal framework is built into the program. Area budget, law, or regulation is added Contractual specifications in the Executive Abstract accepted and met by local governments and institutions. Resources earmarked for the program are duly allocated each year in the local or institutional budget. Adjustments are made according to follow-up.

Table 3 Matrix of Allocation of Activities and Physical Resources. Example: Legal Framework in Argentina

		Promotion
Program/ Area/Service	Recipient	Activities: According to Ministry of Health Programs and\or Regulations: PNGCAM- Decree 1424/97, RM 431/00, RM 208/96, RM 899/01, RM 233/01, RM 542/97, RM 252/99, RM 207/96, RM 401/96, RM 141/97, RM 996/98, RM 126/98, RM 208/96, RM 349/94, RM 126/98	Human Resources Laws 17132, 23873, 24004, 24301, D 15/95, RM 98/2000,RM 997/2001	Physical Resources: According to Ministry of Health Programs and\or Regulations: PNGCAM- Decree 1424/97,: RM 252/99, RM 431/2000, RM 47/01, RM 201/98, RM 996/98, RM 208/96, RM 349/94; RM 171/97, RM 233/01, RM 126/98
				Space	Equipment
Program CARMEN (Set of actions for the multifactor reduction of non-transmissible diseases)	Community	Generate conditions to trigger changes in the local management of health care systems, tending to develop a culture of health care through participative, integrated and cross sector local management. Achieve better quality of living. Promote application of program according to feasibility, availability of resources and social and health status. Give technical cooperation to local governments and participate in the organization of projects. Promote inter sector cooperation for development of activities. Use data on prevalence of risk factors that are common to non transmitted diseases.	Health agent / health professional team. Social communication team / community leaders.	Meeting space	Meeting room. Audiovisual aids. Board. Flip chart. Chairs, desks. Teaching material, etc.

Figure 4 Prevalence of dialyzed Patients per Million Population. Latin American Countries.

Figure 5 Patients without access to dialysis. Potential economic impact and scenario modelling. Pacients per Millon Population.

Table 4 Workshops and Declarations

Chile

Declaration of Valdivia

“TOWARD A SUSTAINABLE AND TENABLE RENAL HEALTH MODEL.”

Latin America and the Caribbean are in the process of developing new strategies to face public health issues. In this context, permanent kidney disease is one of the biggest challenges, for the huge socio-economic and ethic impact of the deep inequalities observed in the region and their implication in renal health care coverage, meaning huge or great difficulties to access economic resources sufficient to meet the needs of our peoples.Therefore, to solve the above problems we need a Renal Health Model that sets up the basis for its own planning, programming, execution and evaluation.

All this considered, we determine to embrace the following ACTION PLAN: Set up a patient identification system by stage, and recommend the use of NKF and Puerto Rico classification. Set up a referral and counter-referral system, for orderly progress of renal patients in the context of Primary Health Care. Set up therapeutic objectives and plans, and recommend the use of Diagnostic and Therapeutic Flowcharts and Algorithms. Integrate de Renal Health Model to public national health policies in each country, using the tools of the Logic Framework and the Matrix of Allocation of Activities and Resources.

Signed in the city of Valdivia, Chile, on December 4, 2002. (There follow signatures.)

Argentina

Declaration of Buenos Aires 2003

“TOWARD A SUSTAINABLE AND TENABLE RENAL HEALTH MODEL. APRIL 11, 2003.”

Latin America and the Caribbean, and Argentina in particular, are in the process of developing new strategies to face public health issues. In this context, permanent kidney disease is one of the biggest challenges, for the huge socio-economic and ethic impact of the deep inequalities observed in the region and their implications in renal health care coverage, meaning huge difficulties to access economic resources sufficient to meet the needs of our peoples. Therefore, to solve the above problems we need a Renal Health Model that sets up the basis for its own planning, programming, execution and evaluation.

All this considered, we determine to embrace the following ACTION PLAN: Declare the interest in Argentina for the Renal Health Model proposed by the Latin American Society of Nephrology and Hypertension and the Argentine Society of Nephrology with the endorsement of PAHO. Promote analysis, debate and consensus needed to develop the model in the context of the Federal Health Council and the Health Advisory Committee in the Ministry of Health. Promote the development of a regulatory framework for the Renal Health Model in the context of the National Program of Medical Care Quality Assurance, and promote the formulation of a National Renal Health Program to be applied by local governments and sub sectors in the National Health Care System. Promote the integration of all sub sectors, service providers, funding agencies, scientific societies and associated programs to the development of the Renal Health Model in Argentina. Entrust continuity of actions needed to achieve the goals that have been here stated to the Administration of Special Programs (APE), the consultants in PROS, the Argentine Society of Nephrology and the representative in Argentina of the Renal Health Committee of the Latin American Society of Nephrology and Hypertension.

(There follow signatures.)

Mexico

Workshop: “Renal health Prevention and Early Detection of Chronic Renal Insufficiency in Mexico. A Strategy for the Next Decade.” Queretaro, Jurica, 2006.

Uruguay

Statement of Montevideo

The Workshop “Toward a Sustainable and Tenable Renal Health Model” was held in Montevideo on April 26 and 27, at the Assembly Hall of the Ministry of Public Health of the Republic of Uruguay. Different issues linked to renal health problems and their impact on quality of living as well as the necessary and sufficient connections with area programs in the Ministry of Public Health and Collective Medical Care Institutions were discussed.

The following Statements are the result of the debates held and the consensus reached between participants at the workshop that represented different regulatory and executive levels in the Ministry, the National Resource Fund, the SLANH represented by the Committee for Development of Nephrology and National Problems, the Uruguayan Society of Nephrology, the Committee of Pediatric Nephrology of the Uruguayan Society of Pediatrics, the Program for Prevention and Treatment of Glomerulopathies, the National Medical Convention, the Medical Federation of the Provinces, the Uruguayan Medical Trade Union and the Nephrology Center of the School of Medicine:

Adhere to the Action Plan generated by the Declaration of Valdivia including the following points: Set up a Patient Identification System according to their stage, and recommend the use of NKF and Puerto Rico classification. Set up a Referral and Counter-referral System to ensure orderly progress of patients in the context of the Primary Health Care System. Set up Therapeutic Objectives and Plans and promote the use of Diagnostic and Therapeutic Flowcharts and Algorithms. Integrate the Renal Health Model to National Public Health Policies in each country, using the tools of the Logical Framework and the Matrix of Allocation of Activities and Resources. Recommend that National Societies of Nephrology that are members of SLANH should send to the Committee for the Development of Nephrology and National Problems, all guidelines and therapeutic plans they have devised, so that they can be distributed for debate and consensus. Considering the results of the Program for Prevention and Treatment of Glomerulopathies launched by the Ministry of Public Health in 2000, express the need to officialize the Program for Prevention of Kidney Disease, create a Register of Chronic Renal Failure and make it mandatory to report all Renal Failure patients with persistent increase of plasmatic creatinine over 2 mg/dL and their clinical progress. Create, in the context of the Ministry of Public Health, a permanent honorary committee for Renal Health, whose main aim should be to discuss basic guidelines and the implementation of a Renal Health Model nationwide. Articulate the development of the Renal Health proposal in the Directorate of Non Transmissible Diseases in the Ministry of Public Health.

(There follow signatures).

Paraguay

Declaration of Asunción

Two Workshops were held in Asunción on April 9, 2004: “Toward a National Resource Fund for Special Pathologies” and “Toward a New Sustainable and Tenable Model of Renal Health”, at the Ministry of Public Health of the Republic of Paraguay and Las Margaritas Hotel, respectively.

In the course of the workshops different issues were discussed connected to the problems of funding assistance to highly complex pathologies, which are mostly of low incidence and high cost, including Chronic Renal Failure both for prevention and treatment (dialysis and transplant). Also mentioned was its huge impact on quality of life of population and economy of the society as a whole, with special attention to the necessary and sufficient articulations with area programs in the Ministry of Public Health.

As a result of the debates and consensus generated among attendees, that represented different regulatory and executive levels in the Ministry of Health, and with the attendance of the National Deputy Minister of Health, the National Institute of Nephrology (INN), the Institute of Cardiovascular Prevention (INPCARD), the General Directorate of Non Transmitted Diseases, the Institute of Social Security of Paraguay (IPS), the SLANH, the Paraguayan Society of Nephrology (SPN), the Paraguayan Society of Transplants (SPT), the Renal Foundation of Paraguay (FREPA), declare: To adhere to the Action Plan generated by the DECLARATION OF VALDIVIA, including the following items: Set up a patient identification system by stage, and recommend the use of the NKD and the Puerto Rico classification. Set up a referral and counter-referral System for orderly progress of patients in the Primary Health Care circuit. Set up therapeutic objectives and plans and recommend the use of Diagnostic and Therapeutic Flowcharts and Algorithms. Integrate the Renal Health Model to National Public Health Policies in each country, using the tools of the Logical Framework and the Matrix of Allocation of Activities and Resources. Adapt the Draft Law of National Solidarity Resources Fund (FONARESSA) to ensure its approval by the Legislative and the Executive. Urge the National Institute of Nephrology, the General Directorate of Non Transmissible Diseases and the Paraguayan Society of Nephrology to find the mechanisms to implement the Renal Health Model/Program within 90 days of this date.

(There follow signatures).

Venezuela

Declaration of Caracas

In the city of Caracas, on this date July 30, 2004, a Workshop was completed, “Toward a Sustainable and Tenable Renal Health Model in the context of the CAREM initiative” (Initiative for Cardiovascular, Renal and Endocrine-Metabolic Health, a healthy life Project). The Workshop was held on July 29 and 30 organized by the Ministry of Health and Social Development of the Republic of Venezuela, with the technical assistance of the PAHO.

As a result of discussions held the following document is produced, of which these are the basic conclusions:

Section I:

We subscribe the Action Plan in the DECLARATION OF VALDIVIA: Set up a patient identification system by stage, and recommend the NKF and Puerto Rico classification. Set up a referral and counter-referral System for an orderly progress of patients in the circuit of Primary Health Care. Set up therapeutic objectives and plans and recommend the use of Diagnostic and Therapeutic Flowcharts and Algorithms. Integrate the Renal Health Model to national public health policies in each country, using the Logical Framework and the Matrix of Allocation of Activities and Resources.

Section II:

We state that the assent given to the DECLARATION OF VALDIVIA is aimed at joining it to CAREM, Initiative for Cardiovascular, Renal and Endocrine-Metabolic Health, a healthy life project.

Section III:

Participants unanimously agree to form a specific Working Committees in the context of the MSDS, to elaborate standards of integral renal health care including promotion, prevention, care, rehabilitation, surveillance, monitoring and evaluation of epidemics, as well as research and education, which will be integrated in the CAREM initiative.

Section IV:

There are recommendations to establish the necessary strategies to make this document know among health institutions.

Section V:

We recommend promoting integration among all health care institutions to join the CAREM initiative. (There follow signatures.)

Colombia

Declaration of Bogotá

The Workshop “RENAL HEALTH MODEL: New symbiosis between public health, clinical nephrology and primary care” was held in the city of Bogotá on December 2 and 3, 2004.

This document, “Declaration of Bogotá”, is the product of discussions held, and its basic conclusions are as follows:

Section I:

Adhere to the Action Plan in the Declaration of Valdivia. Set up a National Patient Identification System by stage, and recommend the use of the NKF and the Puerto Rico classification. Set up a Referral and Counter-referral System, for orderly progress of renal patients in the circuit of Primary Health Care. Set up therapeutic objectives and plans, and recommend the use of diagnostic and therapeutic flowcharts and algorithms. Integrate the Renal Health Model to public health national policies in each country, using the Logical Framework and the Matrix of Allocation of Activities and Resources.

Section II:

Create mechanisms to shift from the model of renal disease treatment to the model of prevention and promotion of health most suited to the needs of the population of Colombia.

Section III:

Draw agreements to ensure that information should be provided from the sources (IPS) and national registers should be generated on the part of the Colombian Association of Nephrology.

Section IV:

Continue to create and update guidelines for disease management and for renal health, to be adopted and implemented by all the players in the system.

Section V:

Recommend that the necessary strategies should be put in place for the State to commit to allocate and redistribute resources to make the health model viable, Sustainable and Tenable.

Section VI:

Achieve the integration and commitment of all the players in the system to project the Renal Health Model, and promote the creation of multidisciplinary committees with representatives of different public and private organizations, as necessary.

Section VII:

Create committees within the Colombian Association of Nephrology to implement and develop all the actions involved in the Renal Health Model.

Section VIII:

The Colombian Association of Nephrology should coordinate with the Universities the review of nephrology grade and post grade syllabi to make them agree to the guidelines above. (There follow signatures.)

Ecuador

Declaration of Guayaquil

In Guayaquil, on this date April 8, 2005, the Workshop “Toward a Sustainable and Tenable Model of Renal Health” was completed. It was held during April 7 and 8 at the Costa Insular Regional Undersecretariat of Health, jointly organized by the Costa Insular Regional Undersecretariat of Health and the Ecuadorian Society of Nephrology, with the participation of cardiologists, endocrinologists, internists, sanitarists and representatives of the Junta de Beneficencia de Guayaquil, PAHO, the Army, the Police Forces, the Ecuadorian Institute of Social Security, the School of Medical Sciences and SLANH.

In the course of the workshop, participants analyzed the epidemiological and attention problems of kidney disease and its huge socio-economical impact on patients, their environment and health care services, as well as the need to articulate actions by the institutions involved and those which will join in the future.

This document is the product of the debate carried out, and its fundamental conclusions are as follows:

Section I:

We subscribe the following Action Plan:

We adhere to the Declaration of Valdivia, with some modifications for the case of Ecuador:

Set up a Patient Identification System by stage, and recommend the use of the NKF and the Puerto Rico classification. Include this information in the Mandatory Notification Subsystem of the National Kidney Foundation (NKF)

Set up a Referral and Counter-referral System for orderly progress of renal patients in the three levels of attention.

Set up Therapeutic Objectives and Plans, and recommend the use of Diagnostic and Therapeutic Flowcharts and Algorithms that are updated and evidence-based.

Integrate the Renal Health Model to National Public Policies in Ecuador, in the context of Control of Non-transmitted diseases, and strengthen control of connected diseases. To build the program, use the tools of Logical Framework and Matrix of Allocation of Activities and Resources.

Section II:

We conclude that we must reorient the model of kidney disease care toward a model of renal health that highlights prevention of disease and promotion of health.

Section III:

Participants unanimously commit to have the Ecuadorian Society of Nephrology join the National Committee of Non Transmitted Diseases.

Section IV:

We recommend that the Society of Nephrology should take part in the preparation and implementation of renal health control guides and their widespread dissemination throughout the country.

Section V:

We state the need to implement a system of risk surveillance for cardiovascular and other non transmissible diseases, including terminal kidney disease, following the recommendations of the 42^nd Board of Directors of PAHO. (There follow signatures.)

Puerto Rico

Renal Health Model for Puerto Rico. An Approach to a Sustainable and Tenable Proposal. August 2005. (Rafael Burgos Calderón (Local Counterpart) and Santos Depine, (External Consultant). Document prepared for the Coordination Office of PAHO/WHO in Puerto Rico.

Perú

Workshop “Toward a Sustainable and Tenable Renal Health Model”, held at the Ministry of Health in September 2005. Document “Renal Health Model” Draft - EsSalud (Edmundo Alva Bravo - Manager)

Brasil

Letter of Intention: With Participation of the High and Average Complexity of the Health Department, Coordination of Hypertension and Diabetes, Latin American Society of Nephrology and Hypertension and Brazilian Society of Nephrology.

Defined the necessity and the convenience of the establishment of a Program of Renal Health for Brazil, the signatories of this Letter of Intentions wake up that following activities will have immediately to be taken: Implementation of a work group with the Secretariats of the Health Department, Scientific Societies and PAHO, for elaboration of a Strategical Planning, with the purpose to develop a Model for the Promotion, Prevention, Control and Treatment of the prevalent chronic disease.

Figure 6 Renal Health Model. Symbiosis between public health and clinical medicine.