Global Health

WORLDVIEW: If They Can Do It, Why Can't We?

Veronica Valdez — Thu, 09 Jul 2009 14:19:00 -0400

We often hear about the developed world assisting developing nations so it was refreshing to read the recent Wall Street Journal article that tells us it can also be the other way around. U.S. health programs are drawing lessons from medical practices in developing countries. When the AIDS clinic at the University of Alabama at Birmingham recognized that their patient no-show rates were growing, they looked far and wide for solutions. They found one in southern Africa.

Alabama's "Project Connect" has adapted a model developed in AIDS clinics in Zambia. Doctors see patients within five days of an initial call to clinic to gather psychosocial and medical history along with blood tests. A social worker also interviews new patients to try to identify and address issues (which often turn out to be complex and mutli-layered) that might prevent patients from coming back for ongoing care. The strategy is getting the job done. The Journal reports that "the no-show rate dropped from 31 percent in 2007 to 18 percent through June 2009."

I remember visiting an AIDS clinic in South Africa in 2004 and was shocked to see how empty it was. I asked a doctor why, and he said that they get patients in and out quickly by collecting all needed information before the patient actually saw a doctor. This was a stark difference from the AIDS clinic in San Francisco where my aunt worked, and where lengthy waits were the norm. I asked the same question many are asking today: "If they can do it, why can't we?"

Another program in Boston has cast its eye on Haiti of all places. The Prevention and Access to Care and Treatment Project (PACT) is based on the accompagnateur program in Haiti where a "domestic healthcare program trains and employs community members to check in on HIV patients on a daily or weekly basis, making sure they attend medical appointments, take their medications and have access to other essential needs and social services." Dr. Heidi Behforouz, who runs the Boston program, hopes it "will reduce rates of emergency-room use and hospitalizations, big drivers of health costs." It seems to be working. "According to data PACT collected, total medical expenses for 20 patients fell 40%," writes the Journal.

Not everything considered an advance overseas will be considered acceptable or suitable here. A recent paper by AEI states that "the developing world needs medicine, and it will seek out poorer alternatives if it cannot get high-quality Western medicines at affordable prices." Low-cost health technologies are easier to launch in the developing world where they are not subject to the same rigorous testing and legal barriers like the U.S. The Journal took Daktari Diagnostics as a case in point. The Cambridge, Mass. company "developed a hand-held, $8 device that takes a critical blood test in six minutes to determine when to start AIDS treatment...That is much faster and cheaper than the more sophisticated version of the test performed in the U.S., which can cost more than $50, requires an expensive machine and takes a couple of days to get results back," reports the Journal. This technology will be rolled out in several developing countries but not the U.S. The lower tech version is 90 percent accurate; the costlier U.S. one is 97 percent. Dr. Rodriguez (founder of Daktari) said, "In the developing world, people are willing to make the tradeoff in accuracy for simplicity and low cost. In the U.S., that kind of trade-off is a hard sell."

According to the Centers for Disease Control, an estimated 56,000 people become infected with HIV/AIDS every year in the U.S.-- a 40 percent increase over previous estimates. This means increased health care costs for communities and the nation and a decrease in available skilled and productive labor. We previously wrote on how every 9 1/2 minutes another person in America becomes infected with HIV but that a recent Kaiser survey found that the public's sense of urgency is down, even among some higher risk groups.The Journal states that in "In Alabama, the high rate of new HIV infections in rural parts of the state-estimated 1 percent to 2 percent annually -- is lower than in Zambia. But it is on a par with some African countries, such as Niger and Benin. And the challenges of poverty and stigma associated with AIDS are the same in rural Alabama as they are in parts of Africa." Stigma is one reason people don't seek timely treatment , and the delays can lead to more costly health interventions (and worse outcomes) down the line.

Mark Dybul, U.S. Global AIDS coordinator under President George W. Bush, quotes in the Journal, "We have learned from Africa that in a very resource-limited setting, you can do very effective chronic care delivery that doesn't have to be overmedicalized." U.S. health programs are following suit. It seems that reinventing the wheel and learning from cost-effective medical practices used in developing nations is paying off.

WORLD VIEW: The Weakest Link - China's Health Care Sector

Veronica Valdez — Tue, 19 May 2009 20:47:00 -0400

As a student at Peking University in Beijing in 2005-06—China's version of Harvard, without the Ivy—I was honored to be amidst some of China's best and brightest minds. I often wondered whether the person I was sitting next to at the school cafeteria eating noodles and baozi would be a future finance minister or a scientist that will cure cancer. I never once thought that some of these students would be unemployed. And uninsured. But in today's economic climate, some of them are.

After China's revolution, people got a basic level of medical care for free. That system was dismantled in the 1980s amid the economic reforms. Now China has gaps between the quality and access of care in rural and urban areas. And China has uninsured people—about 200 million of them. And costs are rising, as they are here. (NEJM had a great brief history of modern China's health system called "Privatization and its Discontents.")

So when the Central Committee of the Communist Party of China and the State Council, or the Cabinet, recently announced a three-year action plan on health reform (and a longer-term plan through 2020 as well), it brought welcome relief to many college graduates and millions of migrant workers in urban areas. This means job creation. It also means affordable heath care services for 1.3 billion citizens. Health care has become a source of tension in China today and often dubbed by the Chinese as its weakest link. Now health care will be thought of as a "public service."

Xinhua News writes:

The core principle of the reform is to provide basic health care as a "public service" to the people, which requires much more government funding and supervision.

By 2020, the world's most populous country will have a basic health-care system that can provide "safe, effective, convenient and affordable" health services to urban and rural residents, according to the tone-setting document.

This will be supplemented by a more detailed implementation plan for the three years until 2011. The plan has yet to be published, but the State Council announced earlier this year an investment plan of 850 billion Yuan ($124 billion U.S.) for the reform in three years.

See details on the plan here and here.

China's health care system has been strongly critiqued in the past for its increasing costs and poor coverage, driving many citizens to ‘alternative' treatments that are often illegal. "Medical care is a huge drain on every Chinese family," Wall Street Journal Asia writes. A Gallup Poll last November showed that the Chinese worried more about being able to pay for health care than about education, retirement or maintaining living standards. With little or no social safety net coupled with a global economic crisis, many families are driven to save more rather than spend more. That's a big problem for the Chinese government.

Like many of us here in the US, the Chinese believe that reforming health care will strengthen the economy and encourage growth. (We have written about this before). Health reforms in China may well provide opportunities for health-service providers, insurers, pharmaceutical companies and the IT industry.

While many in China are happy about this reform package, some are skeptical. It remains uncertain whether this package is enough to ease the financial burdens of 1.3 billion Chinese and get people spending again. But many of my friends, who are still living in China, tell me they are optimistic. And some hope that one day health care can change from being China's weakest link to its strongest.

WORLD VIEW: Taking Health Coverage for Granted in Australia

Veronica Valdez — Mon, 11 May 2009 15:39:00 -0400

Growing up in Australia and working there, I never really worried about health care. Sure, you had to spend some time in the doctor's waiting room (as we do here), but you were never turned away because you lacked insurance. Australia's Medicare health care system covers everyone (not just the elderly and disabled, as the US Medicare system does). Australia's Medicare, financed through general taxes, gives everyone in the country access to free or low-cost medical, vision and hospital care. It gives you free or subsidized care at the doctor's office and a discount on many prescription drugs. But we also had choices. We could get supplemental private health services and, in special circumstances, allied health services like chiropractors. That private option gives us services like dental work, emergency ambulance transfers (which aren't exorbitant there), a private hospital bed and so on.

As the Commonwealth Fund says, “The aim of the (Australian) national health care funding system is to give universal access to health care while allowing choice for individuals through a substantial private sector involvement in delivery and financing.” People buy insurance directly from the insurance company (not via an employer). Approximately 43 percent of Australians have private health insurance today. And if you do buy it, you receive a government rebate that subsidizes 30 percent of your insurance premiums, up to 40 percent if you are over age 65. There is a smorgasbord of private health insurance to choose from and it is relatively simple to compare options online.

I have lived in the U.S. now for nearly eight years and have experienced a wide range of health insurance—student health insurance, individual health insurance, and employer-based health insurance. By now, you'd think I would be an expert in getting health insurance and knowing what my policy covers. I'm not.

A recent report from the Robert Wood Johnson Foundation details the complex challenges people like me face when making choices about buying insurance (less so when I'm covered by a good work-based policy.) Trying to understand my health plan is akin to looking for a needle in a haystack. And when I do feel like I somewhat have a handle on it all, extra charges always seem to magically work themselves into the bill. Lot's of people living oustide the U.S. probably think we’re nuts.

Why can’t it be simpler? I do believe there is much to learn from other health care systems and I do recognize that the solution for the U.S. will have to be unique to the U.S.(Read more about some of New America's proposals here.) So when I hear my friends and family in Australia complain about health care, I kindly remind them that they should not take it for granted. You don’t know what you've got til it's gone.

WORLDVIEW: They Think We're Nuts

Joanne Kenen — Mon, 27 Apr 2009 18:38:00 -0400

Twice in the last couple of weeks I've had conversations with non-Americans about our complex and costly health care system that leaves 46 million people uninsured. To put a highly technical spin on their conclusions: They think we're absolutely nuts.

The other night I had dinner with two German students interning at their embassy. Both were excited to be here during the early months of Obama's presidency; one had been at the Brandenburg gate when he went there as a Democratic candidate last summer. Both were pretty sophisticated, and were able to discuss some of the long-term economic challenges of rising health care costs and technology throughout the world. But as one of the young women told me, "When my grandmother got sick and her treatment cost 150,000 Euros, we didn't have to worry, it was all paid for. But I heard it wouldn't have been in America." Well, it depends. If she was 65, she'd have Medicare, which provides great coverage for some things but can leave patients with significant out of pocket costs for others. If she was younger than 65, it would depend on what kind of policy she had, what kind of services it covered, what kind of monthly, yearly or lifetime caps. And forget about it if she were one of the 46 million uninsured or 25 million underinsured. The grandmother, incidentally, is doing just fine now.

The other conversation was with an Israeli occupational therapist (a relative by marriage) who works with children with what in this country it has become fashionable to call "issues." Israel has a hybrid system (which I'm not an expert on but you can read more here). The financing is single-payer, but the delivery system is a mix of public and private providers, and nonprofit "Sick Funds" that are roughly similar to big HMOs but with historical roots in the labor movement. Basic benefits are guaranteed, and people can purchase supplementary benefits. But even the basic packages covers OT for kids with learning challenges. I forgot how many visits she told me were covered, but it was pretty generous. She was stunned to find out that even really good employer-sponsored health insurance in this country might not pay for a single visit. Or pay for only a few visits, with really high co-pays. She was incredulous. "But what happens to the children?" she asked. Good question.

REFORM: Your Health, WHO Cares?

Hannah Graff — Thu, 28 Aug 2008 20:00:00 -0400

Your physical, cultural, and political environment has an unquestionable impact on your health and the course of your life. This is the clear and resounding conclusion from the World Health Organization's (WHO) Commission on Social Determinants of Health, which has released its final report, "Closing the gap in a generation: Health equity through action on the social determinants of health."

Not only does WHO make it clear that determinants of health vary from country to country, but there are vast inequalities within countries too.

"The development of a society, rich or poor, can be judged by the equality of its population's health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantages as a result of ill-health."

The commission lays out three recommendations for tackling this global phenomenon:

Improve Daily Living Conditions
Tackle the Inequitable Distribution of Power, Money, and Resources
Measure and Understand the Problem and Assess the Impact

While all of these measures are important, it's the first one which is most up our alley. For under "Improve Daily Living Conditions" there is an entire section on, you guessed it, Universal Health Care.

WHO recommends building health-care systems based on principles of equity, disease prevention, and health promotion —systems which provide universal coverage and financing that ensures the coverage regardless of ability to pay. The study defines universal coverage as a system which "requires that everyone within a country can access the same range of (good quality) services according to needs and preferences, regardless of income level, social status, or residency...." Almost all high income countries, WHO says, organize their health systems around this principle. The U.S. of course does not have universal coverage, and in nearly all of WHO's measures, ranks last among the wealthy countries. (Keep in mind here that universal coverage simply means covering everyone. It doesn't say anything about a nationalized health system.)

So for those who argue that insurance is the only thing that matters, and for those on the other side who argue that insurance itself doesn't matter very much at all -- we'll point you at WHO. A health care system is a social determinant of health — WHO says it and so do we.