Richard Smith: Leapfrogging to universal health coverage

richard_smith_2014Low and middle income countries have the chance to create health systems that will perform much better than those in high income countries. Copying health systems that look increasingly unsustainable would not be wise. Instead, low and middle income countries can “leapfrog” to something better, and the World Economic Forum has a project to make that happen. I heard about it in New York last week.

A plot of health adjusted life expectancy against the health expenditure of individual countries shows a plateau in the late 1960s at an expenditure of about US$500 per head adjusted for purchasing power. Yet most high income countries are spending more than US$2500, with the US spending US$8000. To be blunt, these high expenditures don’t look like “value for money.”

But even if low and middle income countries wanted to copy the health systems of high income countries, they lack the resources, capacity, and time to do so. For example, Nigeria in 2012 had 67 doctors for every 100 000 people, and with current capacity it will have 94 for every 100 000 in 2030. But to reach the OECD average it would need 794 for every 100 000, 12 times more than is currently expected. The cost would be US$51 billion, 10 times public health expenditure in 2012, and with current training capacity it would take 300 years. (There’s also the problem that the doctors cluster in cities and emigrate.)

The optimal health system improves health outcomes equitably, is financially sustainable to both individuals and governments, and provides individual satisfaction, including easy access. There are naturally trade-offs, and no health system is perfect.

Leapfrogging can be defined prosaically as “accelerating development through cost effective and scalable solutions.” The great example is mobile phones: most people in low income countries have mobile phones, and there has been no need to put in cables all across the country. But leapfrogging is not all about technology: there can be leaps in operating models, policies, behaviour change, almost anything.

The World Economic Forum has looked for possible leapfrogging projects (both the projects and their owners are now called leapfroggers) in technology, operating models, and behaviour change in all aspects of health systems (prevention, delivery, products, workforce, information, financing, and leadership/governance), and found many examples for all of them.

Unfortunately—but unsurprisingly—leapfrogging is much easier to do at a smaller scale, with thousands of people rather than millions, and leapfrogging a whole system would at least be complex, unpredictable, and long term—and quite probably impossible. So the World Economic Forum is proposing to countries that they select a group of leapfroggers and try to implement them. The group might be aimed at one target, perhaps reducing maternal and child deaths.

The New York meeting heard from three leapfroggers, all using different models and at different stages.

Mothers2mothers began in South Africa in 2001, and is trying to respond to the shortage of health workers and the stigma associated with HIV by identifying mothers living with HIV and training them to educate and support other mothers. The programme starts with mothers already infected, but extends to mothers who are not infected.

Funded by donors such as USAID—but also by Johnson and Johnson—Mothers2mothers has reached 1.2 million mothers in nine African countries. In some countries the programme has been incorporated into the local system, an outcome to be wished for. The programme might now extend to other diseases, such as malaria and tuberculosis. Long term success has depended on adapting the programme to local circumstances.

Sproxil is a system of countering the US$200 billion counterfeit drug market. The company puts codes onto packages of genuine drugs, and patients can verify the code by using an app, phoning, or going to a website. It is being used in Kenya, Nigeria, India, and Ghana. It’s free to patients, with funding coming from the manufacturers or their local representatives. There is evidence that use of the code increases sales of genuine drugs, so the manufacturers can benefit—and the counterfeiters end up paying for the service through reduced sales, which is satisfying to everybody (except the counterfeiters). There are also problems with fake seeds, fake fertilisers, indeed, fake everything, so there is ample room for growth.

The founder of Clinicas del Azúcar was prompted to start the company, which he describes ironically as “the McDonalds of diabetes care,” when his Mexican mother developed diabetes and faced substantial bills. Mexico has one of the highest rates of diabetes in the world: 14 million people have diabetes. By using technology and providing a one stop shop, Clinicas del Azúcar has cut the costs of routine care by 75%. There are currently only four working clinics, but the aim is to have 200 by 2020—and there might be extensions to other conditions like hypertension.

These are only three examples, but there are potentially thousands if not tens of thousands. None of them on their own will enable the rapid achievement of affordable universal healthcare in low and middle income countries, but when combined they could well help to build health systems that will perform better (higher quality, cheaper, more equitable, accessible, and sustainable) than those in high income countries.

Richard Smith was the editor of The BMJ until 2004. He is now chair of the board of trustees of icddr,b [formerly International Centre for Diarrhoeal Disease Research, Bangladesh], and chair of the board of Patients Know Best. He is also a trustee of C3 Collaborating for Health.

Competing interests: RS had his expenses paid by his employer, UnitedHealth Group, for attending the meeting. UnitedHealth Group is a member of the World Economic Forum. Just before leaving The BMJ, RS became a media fellow of the World Economic Forum, attended the annual meeting in Davos, rubbed shoulders with the likes of the King of Jordan, the founders of Google, and other luminaries, and wrote the first ever blog in The BMJ. Since then, I’ve attended the occasional Forum meeting, but never again in Davos. I did make it, however, to the Africa Forum in Cape Town, where I was the only person among about 500 who put health as my main interest.