Contributed by Paul Southworth:
There are a number of good reasons for us to look at health from a global perspective, especially looking at resource-poor countries. The first, and most obvious to most of us, is simply compassion. It is an oft-repeated statistic, but it is important to remember that Sub-Saharan Africa has 10% of the world’s population, 24% of the disease burden, 3% of the healthcare workers and 1% of the healthcare spending. For many of us, this is reason enough to do our best to look at the world as a whole and try to deal with health issues which may be less prevalent in our own countries. However, there are a number of advantages we can gain for our own countries by looking at the developing world.
The most immediate of these benefits is prevention of pandemics and spread of infectious disease. In the 14th century, Black Death took three years to cross Europe. In the 21st century, SARS took three days to cross the globe. Political borders are no barrier to the spread of disease. The extensive travel which helps spread diseases should also give us pause for thought about our own travel. What healthcare do you expect to receive should you be visiting a resource-poor area? As Ernest Madu put it so pithily in a TED talk he gave in Tanzania, “What will happen if you go back to your room at night and you start getting chest pains, shortness of breath, sweating; you’re having a heart attack. What are you going to do? Will you fly back to the US, Germany, Europe? No, you will die.” If you plan on travelling to a resource-poor area of the world at any point in your lifetime, you should be interested in the quality of their healthcare.
“Science knows no country, because knowledge belongs to humanity, and is the torch which illuminates the world.” – Louis Pasteur
However, this is not the sort of the benefit I am talking about. I would like to advocate for looking to resource-poor areas of the world for ideas to improve health in countries with greater resources. It is an agenda growing in popularity and expounded by the likes of Nigel Crisp in his excellent book “Turning the World Upside Down” (I can’t recommend it enough). There is a tendency for wealthier countries to export their healthcare ideas to poorer countries in the belief that the former’s healthcare system is the ideal to which the latter should be aspiring. However, I believe there are good reasons to think that resource-poor countries can be excellent sources for new ideas:
- Many of these countries are starting from scratch. They are not fighting to gradually change an already existing health system and as such can effect ideas which might be seen as ‘too radical’ in an established system with vested interests.
- The very fact that these countries have low resources means that any solutions found will be cost-effective. In a time of more and more constrained budgets, this is a very major consideration.
An example that springs to mind is that of the aforementioned Ernest Madu and his Heart Institute of the Caribbean. Dr Madu wanted to provide quality healthcare to all in the West Indies, an area with great inequality. He took some pretty basic steps such as only buying durable machinery, preferably multifunctional machinery and partnering with a local university to train people to fix the machinery in-house, greatly reducing costs. The Heart Institute also bought their own radiopharmaceutical generators from companies rather than buying doses individually, apparently costing US$2 per dose as opposed to the US$250 hospitals have to pay in the US. Using schemes like this, Dr Madu claims that world-class treatment at the Heart Institute costs 10% of what it would in the US and they never turn anybody away because of ability to pay. One full-paying patient provides enough money to treat four patients for free.
Dr Madu’s system looks like a great model for healthcare in all countries, both wealthier and poorer. However, I’m not just talking about how to make our existing healthcare ideas more cost-effective. I believe we can get completely new ideas from resource-poor countries which can transition to wealthier countries. One idea which has been shown to be successful in several poorer countries is training healthcare professionals for the job required, rather than the profession. In other words why require someone to have full medical training to do a procedure which doesn’t need that level of training?
For the last 20 years in Mozambique, a large proportion of obstetric surgeries have been done not by doctors, but by ‘tecnicos de cirurgia’. These tecnicos have taken a two year course and one year residency in obstetric surgery and now do most of that surgery in rural areas. Studies show that health outcomes are not significantly different between doctors and tecnicos and that retention of tecnicos in rural areas is much greater than retention of doctors. 7 years after graduation, 88% of tecnicos stayed in rural areas compared with 0% of doctors. That’s not a typo – no doctors stayed in rural areas long-term. Uganda has attempted a similar scheme in cooperation with the charity Sightsavers International, but this time for opthalmic surgery. Sightsavers provide the training of specialist opthalmic surgeons and in return, the government guarantee all students jobs upon graduation. Again, studies show a low complication rate for these surgeries (comparable to rates of doctors) and a high retention rate of professionals. In this case, only one of the graduates has left the government program to work for private practise.
In both these cases, similar health outcomes were achieved for surgeries with much lower resources. Training is much cheaper – in the case of opthalmic surgeons in Uganda, the training requires only a room and a projector – and the pay of these non-physicians is lower than that of doctors, saving more money. For common and simple surgeries or healthcare procedures in wealthier countries, could similar schemes not be established? This could have huge health benefits in more remote areas with low doctor-population ratios.
The low-resource nature of the countries I have been writing about means that they have to drive down costs in everything they do. This can take a very direct form as in driving down costs of diagnosis equipment. For example, ultrasound machines normally cost somewhere around US$100,000; this was far too expensive for rural clinics in China and India. GE recognised that there is an enormous market in that part of the world, a market in which they would like to be a major player. Hence they developed a plugin ultrasound for laptops which cost only US$15,000 and further interest diagnosing gallstones and inflamed livers drove the cost down further to US$8,000. Obviously this is less directly applicable to wealthier countries, but it certainly serves to illustrate the level of power countries have as purchasers. In countries like the UK, where there is a single large purchaser, companies can be persuaded to bring down prices for fear of being excluded from a profitable market.
This driving down of costs usually takes a different form in resource-poor areas. If they cannot afford to implement expensive treatments, they must either look to local traditions or develop new treatments. One example of this is the Aravind Eye Centre in Southern India. The wealth of most people in the region was simply not enough to pay for the cataracts which could restore sight to large numbers. The Aravind Centre’s solution was simple – to make their own cataracts. They managed to develop a cataract which costs only US$2 and a simple procedure which means that doctors can perform 15 operations an hour. That’s one doctor (one salary) treating 15 patients in one hour. These cataracts are now being used in over 120 countries worldwide and provide a great exemplar of what we can learn from poorer areas.
It is not only new procedures which can help us. There is much that can be learnt from traditional treatments in these areas. Dr Steve Mannion, an orthopaedic surgeon from the UK, has spent much of his medical career in resource-poor countries. While working in Malawi, he saw many children with clubfoot, a disorder which would normally be treated with multiple surgeries in the West. The people of Malawi could not come near to affording this kind of expensive treatment, but they had their own methods. By repeatedly manipulating the children’s legs and feet and binding them in the correct position, the Malawians could effectively treat clubfoot at a much reduced cost and with much less pain and risk to the child being treated. So effective is this method that it is now standard practise in the UK.
I think it is important to note at this point that it is not just health-improving ideas we can get from resource-poor countries are not restricted to those from healthcare. Prevention is obviously better than cure and there are great public health lessons we can learn too. In Mexico, the ministry of health set up a monetary incentive scheme called Oportunidades which aims to improve the health of children. In the scheme, parents are paid if they meet certain requirements, including (but not restricted to) attending prenatal and postnatal care; ensuring their child gets all their immunisations; attending health and nutrition classes; and ensuring a high level of school attendance for their child. The scheme has shown huge successes in health and education. The health benefits include: improved child behaviour, less anaemia, higher prenatal care attendance, higher birthweight, lower obesity and hypertension and less growth retardation. I’m finishing with this example because it is indeed being transferred into the US as a pilot program called Opportunity NYC. If we can see benefits with programs like these, why stop there.
I think Nigel Crisp put it wonderfully when he said we need to think less about developing and developed countries, with the implication that the latter should aim to become the former, and more about codevelopment.
Great post, Paul – thanks! These are some excellent ideas. I especially like the monetary incentives for preventative medicine in Mexico.
One thing you touched upon, but didn’t discuss any further, was how these changes, which might seem “too radical,” could be put into place in an already “established system with vested interests”. This is a very important issue. So many of these ideas are great, but how can we effectively put them in place? One challenge I would expect would come from the public. Already in this nation, there is a preference for MDs over nurses, even though in some situations, the nurse can do the same procedure and may even have more experience doing it than the doctor! Therefore, with this existing prejudice, I’m skeptical that Americans would be very receptive to surgery done by a non-MD. Even if the data exists showing that outcomes do not differ on procedures administered by tecnicos or doctors, I still think it would be difficult to unbias an American patient from preferring the doctor. Though maybe a difference in cost of procedure might be a deciding factor.
In any case, these are great ideas that I hope find their way into discussions by individuals responsible for making decisions that can change healthcare systems.
I think that the data showing the efficacy of this work in resource-poor countries should be used to greater effect to persuade wealthier countries. I actually don’t think the biggest problem will be persuading the public – if you can persuade them that they can get the same care for cheaper, I think they’ll go for it. The problem is more likely to be with the doctors. In the current US system they get very well remunerated for each procedure they perform. It is very much in their interest to be the only professionals doing these procedures rather than get undercut by less costly professionals. It would be a struggle, but I think that if governments lead the way these changes can be made.
Talking specifically about the doctors, in Brazil we have the same problem, that we call “Medical Act”. And there’s a wide and long debate about “Medical Act: Yes” versus “Medical Act: No” and I think I don’t need to explain who’s in each side. I have my undergrad in Biomedical Sciences and a Master in Pathology, but I was not allowed to apply to the last 3 public bids for a faculty position in General Pathology in Federal Universities in Brazil (Rio de Janeiro, Ouro Preto and my own UNESP, where I studied!). Because the rules say that the positions are open only for Medical Doctors with Residency in Anatomical Pathology. Although I had myself some teachers that were not Medical Doctors, just biologists. Although I had applied and approved in 2003 for the same position in other university, but I was in 3rd place and there was only 2 vacancies. So I don’t know what is happening around the world that Brazil seems to be copying but this is another problem that we might have to face from now on or look for a solution that should be good to everyone involved.
Again, I’d like to leave my comments, but I can only do it by my experience in Brazil, so I apologize if I sound too nationalist. I have nothing against other countries and cultures. On the contrary, I’m exactly trying to contribute with what we have as our best. Although still regarded as a developing country in some aspects, in other circumstances Brazil has become a leader, specially in / to the developing world. The Butantan Institute in São Paulo and FIOCRUZ in Rio de Janeiro, Salvador, Belém and Belo Horizonte are the greatest vaccine producers in Latin America and are starting to expand and produce vaccines to other countries in Africa, like Mozambique. You might have heard of Oswaldo Cruz, whose last name was given to Trypanosoma cruzi by Carlos Chagas, to honor his master. Carlos Chagas not only discovered the Chagas disease but the whole cycle, vector and ethiologic agent, fact that was never repeated by another scientist. Although we still don’t have a cure for Chagas disease, just treatment. FIOCRUZ stands for Foundation for the Institute Oswaldo Cruz and their production of vaccines and also medications (like antiretrovirals) by the Fabrica de Medicamentos de Mozambique (Mozambique’s Manufacturer of Medications) in Africa will help reduce the costs of transports to that continent, making them less dependent on importation, money exchange and taxes related to the vaccine costs and will certainly impact the public health locally, turning the vaccines more promptly available for the people in need and also important, creating jobs because most of the workers are hired locally. More than that, FIOCRUZ will also teach Masters, Doctorate and Post Graduation courses in Public Health with the same infrastructure that already exists in Brazil, guided by the Farmanguinhos Institute of Technology on Drugs. So as we say in Portuguese, “it is necessary not to give fish to the poor people, but instead, to teach them how to fish”.
Thanks for your comments Joao. In the article, the point I was trying to get across is actually to get away from the point of view you’re proposing: that of wealthier countries “teaching” poorer countries “how to fish”. As I said at the end of the article, we need to think less of richer countries developing poorer countries and think more about codevelopment of richer and poorer countries together, learning from each other and sharing resources both ways.