Lord Crisp, Former Head of UK NHS, talking about sharing lessons across rich and poor countries regarding healthcare.
New York Times, Original Link Here
What We Can Learn From Third-World Health CareBy PAULINE W. CHEN, M.D.
The young doctor had just returned from a month working in a country in Africa, familiar to the rest of us only through pictures of its impoverished population and news reports of recurring natural disasters and political upheavals. "You must feel exhausted but great," a senior colleague commented. "You went in there and you really helped those people."
But my younger colleague felt neither exhausted nor relieved to be back home, she confided when the older doctor had left the room. She had cared for dozens of patients with abscesses and broken bones, tumors and arrow wounds, relying on nothing more than a single rickety X-ray machine, a handful of battered surgical instruments and the aid of one well-connected local nurse.
"We could get so much done with so little over there," she said. "It's like we're not doing something right over here."
Put another way, the American health care system has become the great international paradox, spending more but getting less.
With all the most advanced technology and equipment, spending far more on health care than any other nation - a whopping $2.6 trillion annually, or over 17 percent of our gross domestic product - the United States consistently underperforms on some of the most important health indicators. Our infant mortality rates, for example, are worse than those in countries like Hungary, Cuba and Slovenia. Our life expectancy rates are not much better; in global rankings, we sit within spitting distance of Cuba, Chile and Libya.
This quality conundrum dogs us, even as our best and brightest have tried to imagine a more cost-efficient system. Some have pursued the carrot-and-stick route, linking quality measures to reimbursement. Others have attempted to reduce quality to its most basic parts, creating checklists and to-do lists. And still others have rearranged networks of hospitals, clinics, physician practices and payments, conjuring up a breathtaking array of combinations, permutations and bundles of care in order to create more cost-efficient systems.
But, according to an essay published this summer in The Stanford Social Innovation Review, we might have saved ourselves the huge effort, the expenses and the disappointments of only marginally successful initiatives, if we had first looked to countries traditionally viewed as needing our aid and learned from their successes in facing challenges similar to our own.
In the essay, Rebecca D. Onie, a founder and the chief executive of Health Leads, a domestic health care organization; Dr. Paul Farmer, a founder of Partners in Health, a Boston-based medical nonprofit group; and Dr. Heidi Behforouz, medical and executive director of the Prevention and Access to Care and Treatment project, a community-based health care initiative in the United States that is part of Partners in Health, argue eloquently for "reverse innovation." They contend that for decades, several nongovernmental and nonprofit medical organizations have delivered high-quality care in some of the most challenging circumstances possible. Applying the solutions these medical organizations have already discovered could allow us to bypass or at least foreshorten what has become an interminable trial-and-error search for the answers to our country's health care woes.
Their own organizations offer several models of success. For nearly three decades, Partners in Health, for example, has delivered consistently high-quality care to more than 2.5 million people in a dozen countries like Haiti, Rwanda and Peru, places with widespread poverty, scarce numbers of providers and no health care infrastructure. But they have managed to achieve, among other successes, the highest rate of cure of multidrug-resistant tuberculosis in the world and better rates of adherence to treatment regimens and follow-up than in much of the United States.
The key to their success is an unabashed disregard for some of our most cherished assumptions about what constitutes good care. Instead of providing antibiotics, CT scans and high-tech interventions, Partners in Health considers basic necessities like food and housing as critical components of the group's medical work. Instead of asking patients to travel miles to the only clinic and see only the doctor or nurse, they train cadres of community health workers who can monitor, administer and advise in the heart of local villages and in people's homes.
Applied to organizations in the United States, this approach has proved startlingly effective, as the Prevention and Access to Care and Treatment, or PACT, program has demonstrated. PACT targets some of the poorest and sickest patients with H.I.V. and other chronic illnesses in the greater Boston area. Just like Partners in Health, PACT relies extensively on community health workers who are trained in tasks like helping patients take their medications and make it to clinic appointments as well as reviewing their pantries and teaching them to prepare healthy meals. Applying these broad definitions of care, PACT has significantly decreased the number of emergency room visits and life-threatening opportunistic infections, cut hospitalization rates by 60 percent and yielded a 16 percent savings for Medicaid.
Health Leads has stretched these definitions even further, giving the terms "provider" and "care" a millennial twist. Each year, Health Leads trains a selected group of technology-savvy and tenacious college students to staff "resource desks" in primary care and prenatal clinics in cities like New York, Baltimore, Boston and Chicago. With these Health Leads volunteers in place, doctors can, for example, "prescribe" housing assistance for a family whose child's severe asthma has been exacerbated by a cockroach infestation, healthy foods and nutrition resources for a man suffering from obesity, or transportation to a drugstore for an elderly woman who needs diabetes medications. At the resource desk, a Health Leads volunteer then "fills" these prescriptions by finding the best solutions for the problems at hand, whether that means tracking down the appropriate agency, navigating complicated online application processes or providing support as the patient makes the calls. In clinics where a single social worker may be responsible for as many as 25,000 patients, Health Leads volunteers have more than doubled the services provided.
The successes of PACT and Health Leads are no secret. But what does remain mysterious as our health care system threatens to implode is why more of us haven't done the same and rushed to apply the lessons learned and proved elsewhere.
"We keep trying to reinvent the wheel," Ms. Onie observed. "The humbling reality is that we are trying to recreate innovations that have been robustly developed in the developing world."
In other words, we have yet to deploy what could prove to be the most powerful weapon in the fight to contain costs and improve the quality of health care: our own humility.