Anne Winter: The drive for universal health coverage

anne_winterIn 2000, the whole of sub Saharan Africa had fewer telephone lines than Manhattan, and less than 3% of rural villages had access to land line telephones. Six years later, 45% had GSM coverage and connectivity is now a given across the continent. So it may be with healthcare.

As momentum gathers around efforts to achieve universal access to healthcare and countries across the world embark on healthcare reforms, there is a real opportunity to bypass conventional approaches—often based on Western models that are ill adapted to other contexts and needs—and to adopt new ways of delivering healthcare that can offer better value to users.  

At the same time, mature health systems can learn much from providers in low and middle income countries who, frequently out of necessity, have devised highly innovative ways of delivering services under severe resource constraints. Many are now leading the way in developing new models of healthcare that deliver high quality care at low cost.

Last week, a meeting hosted by the Dartmouth Center for Health Care Delivery Science, the World Bank Institute, and the Salzburg Global Seminar brought together some 60 leading international healthcare experts from 20 countries to share their insights on how health services can be redesigned to enhance value for patients. The sessions did not disappoint.

A panel of medical entrepreneurs in India demonstrated how specific process innovations can not only lower expenditures, but at the same time significantly improve quality. Trained at Guy’s Hospital in London, Devi Shetty has been called the “Henry Ford” of heart surgery. At his flagship 1000 bed hospital in Bangalore, 30 day post surgery mortality rates for coronary bypass procedures are lower than those averaged in a sample of 143 hospitals in Texas, and the cost of open heart surgery is 4-18% of that of comparable procedures in the US, after adjusting for salary differentials. Aravind Eye Care System, which treats over 1.7 million patients a year and now undertakes more eye surgeries than anywhere else in the world, has funded its growing number of hospitals from its own profits despite the fact that two thirds of its patients receive care free of charge or at subsidised rates. How do they do it?

According to research carried out by Dartmouth College, three process innovations are at the heart of many of these and similar successes. First, they are based on a hub-and-spoke architecture, in which “spoke” facilities undertake routine treatment in relatively far flung areas while channelling patients to urban “hubs” for more sophisticated procedures and surgery. Secondly, they have taken task shifting to new levels—creating, on the one hand, new categories of low cost healthcare workers and, on the other, highly focused specialists. Thirdly, they focus on cost effectiveness, rather than cost cutting.

In a presentation highlighting how critical lessons can be learned from one’s own and others’ mistakes, Bob Drake of the Dartmouth Psychiatric Research Center noted that the average length of stay of mental health patients in institutions in the US was 40 years in the 1960s, today, it is seven days. He cautioned against separating mental health services from primary care and counselled that most people with severe mental illness are best helped by finding them jobs and integrating them into their communities.

The potential of involving patients and communities in healthcare solutions and investing in new approaches to primary care was indeed evident across the sessions. With the support of the World Bank, lessons learned from involving communities in tackling multi drug resistant tuberculosis in Peru are now being applied in South Africa, which has faced an intractable problem of TB in the gold mining industry for decades. In Rwanda, the extensive use of community health workers has brought services closer to communities and empowered people to participate in their own healthcare and development. And the transformative potential of shared decision making and efforts to elicit patient preferences in terms of increasing patient satisfaction, developing doctor-patient trust, and informing policy priorities was enthusiastically endorsed by participants from widely different contexts.

Prevailing models of healthcare have yielded systems that are relatively inefficient and ineffective—incurring up to 40% waste of resources and, worse still, risking harm to users—as well as levels of expenditure that are increasingly unsustainable. At last week’s conference, there was perceptible excitement among participants as traditional ways of delivering healthcare were challenged and new approaches to tackling common problems were shared.

In the drive to deliver better healthcare across countries, there exists a critical mass of providers and practitioners with the knowledge, commitment, and inventiveness to radically transform systems and accelerate change. But for them to be able to succeed, it is essential to tackle the inertia created by vested political and financial interests that arguably now represent the biggest obstacle to achieving the high value health services that people need and have a right to expect.

I declare that I have read and understood the BMJ Group policy on declaration of interests and I hereby declare the following interests: strategic advisory role on global health advocacy to the Dartmouth Center for Health Care Delivery Science.

Anne Winter is a consultant in strategic planning, advocacy, and health and development communications on behalf of governments, non-governmental organizations, United Nations organizations, foundations, and academia.  Her work also focuses on public affairs and reputation management.