Category Archives: Health Services

Here’s why developing countries should invest in health

20 years ago to this month, Rwanda was the reflection of humanities’ most self destructive instincts. Within a matter of 100 days in 1994, almost 1 million people – 20% of the population – were killed in an ethnic genocide between the Hutu and the Tutsi. Back then, when gory images of the genocide in Rwanda spread across the world, it was impossible to imagine that the country would one day in the future become some sort of a paragon for humanities’ instincts to nurture and nourish.
Yet Rwanda has done exactly that: from the ashes of the war, it has built a health system that is the envy of much of sub-Saharan Africa, and the rest of the world can’t help but stop and take notice. From having almost no health facility, public or private, worth the name at the end of the war, this nation of 11 million people has created a health infrastructure that has helped double life expectancy in almost 20 years.
Close on the heels of the genocide, as if the carnage left by the war were not enough, an epidemic of HIV usurped Rwanda much like the rest of sub-Saharan Africa. Scores upon scores of fathers, mothers, breadwinners were being wiped out, leaving behind all the but the dependents: children and the elderly. Things got so bad at one point, some people had the courage to suggest that the frail must be left to die, to enable a Malthusian purge and make way for a rejuvenation from the remains.
Better sense prevailed and Rwandans took to the onerous task of retooling and rebuilding their country. They came up with a “Vision 2020” that heavily stressed on making Rwanda a middle income country by the year 2020 and proposed that investing in health of the people as a major pillar of that strategy. Health was taken up as a rights issue and equity in health was thought instrumental in achieving the vision.
Their first battle in health care was HIV itself. With assistance from other nations and partners it heavily expanded HIV care, within the 10 years after 2000 the number of people in HIV treatment went up almost 100 fold. HIV rates have now fallen by a third, and facilities that were earlier on established to provide HIV care have now been expanded to provide integrated care.
Life expectancy has doubled from around 30 years in the mid-nineties.  Lesser number of children die today than they ever did, more than 90% of children get vaccinated, two-thirds of the mothers give birth assisted by a trained provider.  Rwanda remains one of the two African countries on track to meet the health related millennium development goals. A community health insurance scheme has been instituted, the poorest of people receive subsidies to participate in such insurance scheme.
Such health outcomes have had economic dividends for Rwanda. Per capita income has gone up three fold to $600 ($1300 in terms of purchasing power parity) in the last 20 years. The experience of Rwanda has but corroborated what has been felt all over the world in the recent times- that health expenditure is not just watering the quicksand, it can make way for real economic gain. Health expenditures have been known to provide at least 3.3 to 10 times the return on investment over a period of time. If the  moral or the legal argument for providing health care were not adequate enough, policymakers could at least pay heed to how it makes economic sense to invest in health care.
For developing nations that aim to rapidly steepen their arc of progress, investing in people’s health makes tremendous sense, not to mention the fact as Rwanda has shown, an equitable health care system helps bury the scars of a difficult past and make way for a new beginning. We would all do well to pay attention.
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Patient is the new kind of provider

It doesn’t take much effort to discern the fact that patient and provider dynamics are changing. People, especially physicians rue what they call was once a sacred relationship, that has now been overtaken by corporate interests, the government, overzealous hospital administration or even the annoyingly-attention-demanding radio-buttons and check-boxes in the EMR. These external forces are certainly influencing the way patients and providers interact with each other. But a more fundamental force may be turning the relationship on its head.

Traditionally providers have been called so because they bring two things to the table:  unique knowledge and know-how and the services they provide using that knowledge. When illnesses were short lasting, few-times-in-a-lifetime events this was largely true: providers saw a large volume of patients and overtime accumulated a wealth of information and experience that they used to the benefit of their patients. In fact this information asymmetry between the provider and the patient was and is exactly the reason physicians demanded such a premium in the health system.  However of late the nature of illnesses has changed.

Illnesses are now protracted and lifelong events that the patient has to deal with every single day. As a result not only does the patient have more longitudinal experience with the illness, he also has unique experience about how his body reacts with various therapies and treatment methods. This knowledge in very valuable especially given the individual differences in the natural history of chronic illnesses. True, specialist physicians are likely to bring in unique learning to the table but there is no denying the importance of  the patient’s learned knowledge, specially at a time when personalized medicine is the new rage in town. Oftentimes, young doctors to come across patients who have lived with an illness for longer than they have been in medical training and practice. Such patients are as valuable a source of learning to the doctors as any medical text.

Patients who live with chronic illnesses have to provide the majority of the services by themselves. They take their own medications, they work on a healthy way of life for themselves and they use their knowledge about the disease to manage through the course of the illness. It is not uncommon at all to come across a diabetic who correctly diagnoses their atypical hypoglycemia symptoms or a patient who points out he has only rectal pain with a Crohn’s flare. And since majority of the care in any chronic illness is delivered at the home itself than the hospital or the clinic, the patient, and may be his family, is suddenly the greater care provider!

Roles are changing. Chronic disease care providers now are more like a coach or a guide rather than the know-it-all Dr Welbys of yesteryear. As illnesses become more complicated, numerous professionals work with the patient, not very different from an athlete in an individual sport, a large team works in tandem but its finally up to the athlete to execute the game.

The current state of rueful confusion among care providers is representative of birth pangs of this new paradigm. Physicians and allied professionals however need not worry, there will always be more service needed than they can comfortably provide; they just need to recognize the fact that there has been some reassignment of the roles and designations.