Friday, Nov. 26, 2010

Healthcare in Asia: A Roadmap for the Next Decade

It was the winter of 1777. Soldiers of the newly formed continental army under George Washington had encamped at Valley Forge. Over the next four months, typhoid, dysentery and small pox swept through the camp decimating an already weak force. Washington and his medics decided to act on a rumor that small pox could be prevented. They decided to rub the pus of already affected individuals into wounds of unaffected men. Of the men inoculated, only a small number went on to develop the disease but the rest were rendered immune for life. This along with measures to improve sanitation with a dedicated corps of doctors and nurses helped the army recover and reengage the British with new confidence, eventually winning independence.

History is replete with such instances where health was often the decisive factor in shaping events. In the turmoil following World War II, when Asian nations took the form they have now, healthcare was acknowledged as an important factor in the road to prosperity.

In the year 2000, The World Health Organization (WHO) conducted its first-ever analysis of the health systems of 191 member states. The top 50 included 12 countries from Asia. But a disproportionate number among those — nine — belonged to oil producing nations. The subsequent decade played host to numerous stories of Asian nations coming into their own with robustly growing economies weathering the global economic storm, and yet there has a been a sense of disquiet when it comes to healthcare. Despite noises made at the beginning of the millennium, expenditure in this sector by governments across the region has often been seconded in preference to measures that reaped quick rewards, such as physical infrastructure and arms, in terms of economic growth and a greater diplomatic punch. As a result, Asian countries continue to lag behind in healthcare as can be seen by the dreadfully high numbers in infant mortality in South Asia — 52 per thousand in India alone.

Another worrying trend is the paucity of healthcare professionals. India has approximately 70,000 doctors, working out to 7 per 10,000 people, and 1.5 million nurses and technicians for her 1.2 billion strong population (WHO data). Compare this with countries with strong healthcare satisfaction levels which average above 25 doctors per 10,000. Within the WHO list, Singapore was the highest ranked Asian country at 6, while Myanmar brought up the rear at 190. China came in at 144 and India was placed at 112. Contrast this with the size of their economies. China is the second largest economy in the world and India the fourth largest. Yet, the investment made in this sector has a lot of catching up to do.

Why is it so important for healthcare to refine its act?

In 2003, a paper by David Bloom and his team highlighted that one year's improvement on a population's life expectancy could result in a 4% increase in output. Illness and disability reduce hourly wages earned, an effect especially seen in developing countries. It's imperative therefore that a nation looking to move forward also allocates resources to ensure that her people can function at their best. Interestingly, the success of the existing system in reducing mortality due to infectious diseases with a changing lifestyle means that Asian people have a greater life expectancy and in turn have begun to face a new spectrum of chronic disorders.

To illustrate the changing spectrum of healthcare needs using China as a model, currently 6% of her population is diabetic, 20% hypertensive and 25% overweight. Topping this, 30% of the population continue to smoke (WHO). A population cohort with the above problems will require several multi-disciplinarian visits over the next 20 years, dealing with the problem in itself and other clinical offshoots. For example, being a diabetic increases a person's risk for cardiac and renal disease over a period of time, thus placing a strain on other branches of the health system. Combine this need for chronic care with a vastly undermanned system and things do not look too good. South Asia also offers similar challenges, with chronic diseases a priority in urban centers while infectious diseases remain a scourge and the main killer in the rural hinterland.

"Confounding the obvious state of under-preparedness the sector faces, is the financial model countries in the region employ to pay for healthcare. The Middle Eastern countries employ a mix of public (funded by petrodollars, heavily subsidized) and private sector hospitals (paid for by insurance or direct fees) to take care of their health systems. Other nations like Singapore, South Korea mandate universal insurance cover for everyone, paid for by varying degrees by the individual, the employer and the rest subsidized by the government (40-60% depending on country). The government also has healthcare safety nets for those who cannot afford insurance.

Looking at South Asia and India in particular, the scenario suddenly turns very bleak. India currently spends 4% of her GDP on healthcare of which government spending accounts for a measly 19%. Compare this to France where 11% of her GDP is on healthcare, of which government spending is 79% (World Bank data). France of course has the highest satisfaction rates for her health system. In some areas of India, especially the rural sector, health spending can form a disproportionate figure of up-to 18% of income. In addition there is a huge manpower crisis in the existing network of primary care facilities with 15.1% shortfall in doctors and up-to 56.8 per cent in Multi health workers (Bulletin on Rural Health Statistics 2008). This of course is not including the large rates of absenteeism and the already existing shortfall in required number of primary health centers.

China to start with had an excellent network of rural practitioners (barefoot doctors) and a centralized healthcare system which made tremendous gains in life expectancy, by a series of public health measures including sanitation, immunization and control of disease vectors. With Deng Xiaoping's revolution in the early 80s, the apparently successful model of health was dismantled overnight without an adequate replacement. This happened through a reduction in funding from the central government for hospitals, in which the onus was placed on the province. There was also a change in pricing policy which enabled hospitals to make huge profits on new procedures and drugs. The commune system which had served most of rural China was also dismantled overnight and the public health system was decentralized, partially privatized (Blumenthal NEJM 2005).

All this contributed to creating a system that was ranked 188 among 191 nations by the WHO in the year 2000. Subsequently, however, massive government spending ($125 billion from 2009 to 2011) promises to alleviate the situation with an aim to cover 90% of the population with insurance by 2011 and universal health care by 2020. This of course does not address the basic problem of high drug costs and lack of accessibility of quality care for all.

Therein lies the next problem. An increasingly affluent population has come to expect the same level of service in healthcare as they would in other sectors. The inadequacy of the system to match up to expectations of service levels and an unrealistic expectations of a quick cure leads to great levels of dissatisfaction. Match this with a belief (true in many cases) that doctors indulge in a system where expensive investigations and drugs help line their pockets through a 'cut' system and suddenly the sector seems to be in turmoil. Recent reports of increasing levels of violence against healthcare workers in China and India illustrates this problem."

To summarize, the two big engines of economic growth in Asia (South Asia and China, mainland SE China) have healthcare systems that are fragmented, suffer huge deficits of manpower and facilities and a potential flashpoint of anger to a young population that is increasingly demanding the best possible care. Further complicating the scenario is the presence of traditional systems of medicine which often operate in unregulated areas without proper checks and controls.

This brings us back to the root question: why didn't anyone think about this ten years ago? Simple: quick returns. Build a road or an airport, investment flows into the region and in a few years, the whole region gets transformed. Healthcare however with its long training periods (6-12 years for a doctor and 4-8 years for allied professionals), takes a much longer period to show any tangible benefits, often up to a generation.

What's the Solution?

The most successful and effective health care systems around the world like Cuba, France, and Japan place strong emphasis on community based health care programs. Effective care at the community level and a well stratified system of referral means resources get allocated to people who need it the most and at the same time ensures that high-tech health care can still be practiced. To illustrate this with an example, a person suffering from acute diarrhea does not need to consult a gastroenterologist with 12 years of medical school behind him to get a simple course of antibiotics.

This is exactly what post-revolution China pursued so effectively and India tried to implement after its independence. Subsequently, though, in one case the system was dismantled without an effective alternative in place, and in the other, there just wasn't enough investment in manpower and resources. Other nations in Asia all have systems based on the above model and work quite well within the constraints of resources.

Just like any system, healthcare too depends on the triumvirate of manpower, infrastructure and finance. Governments across Asia have recognized this and have allocated resources or planned to do so for the same. Nations like Singapore and South Korea have invested heavily, looking to transform themselves to the forefront of medical research and healthcare (indirectly attracting medical tourism dollars). Of the south Asian nations, India has been mulling over the creation of a new cadre of health workers to support and serve the rural areas in addition to the creation of multiple institutions dedicated to super specialty care and cutting edge research.

All these reforms would be pointless if the common man for whom all this is meant, can't access or pay for it. Once again, governments have been proactive in this area. Most Asian countries have an existing network of insurance or fee based healthcare and only have to ramp it up. China has spent $120 billion in the last 3 years to try and achieve 90% coverage of its citizens. In India, several states have launched insurance schemes and the central government bankrolls 75% of the National Health Insurance Scheme which aims to help households living below the poverty line with liabilities arising from hospitalization. For a nation that has only 15% of its population insured, this scheme has helped cover 55 million people or another 5% gain access to healthcare. But most importantly for India, it is the poorest of the poor that gets covered.

The only 'catch' with all this action is that it is designed to bring the existing health system to levels that would have been acceptable or excellent at the turn of the century. What it does not do is create the framework needed to help push the frontier of medicine, cement Asia's place at the forefront of new development and at the same time provide effective, quality healthcare to the man on the street. To draw a corollary, Healthcare today, as a system, is where computing was 30 years ago, a series of standalone mainframes which one went to in order to get a process done. What we need in health is a paradigm similar to the IT world today. A world where a search result is tailored based on past search patterns. A networked, integrated world where processes are fine tuned to deliver maximum efficiency.

I believe that while governments are ramping up infrastructure projects to meet demand, it makes sense to also create a backbone of IT enabled services and use it to enhance the experience of the 'art of medicine'. Around the globe and in almost every other field, IT is used to integrate systems and connect people. An executive sitting in an office can track events at a plant on the other side of the globe. The health system unfortunately has nothing similar at the moment as it operates as a standalone system. Patient records are kept in an office, if the patient decides to switch doctors, all that is provided is a summary of the previous hospitalization. In the process, vital and potentially life saving information is often missed.

Imagine a system that is digitized. Patient data is collected, stored into a centralized server. If he should go to another doctor, the other provider will still be able to access previous heath history from the cloud servers. This way, healthcare providers also get a clearer picture of the disease process, information does not get missed, duplicity in investigations gets avoided, potentially increasing efficiency and thus delivering cost savings. The patient could be identified with a unique id number (similar to the UID project in India) with a smart card, which will carry details about insurance providers, blood group, organ donor details. The possibilities are limitless.

In any field, measurement of data is the single most important method to see if a process is working. Any company will be able to give a person real time data of how they are performing. Take a car company. Quarterly, sometimes monthly sales reports, profit reports etc can be provided. Healthcare however takes an enormous time to measure the few numbers that it does (e.g. infant mortality rate). Providing data on number of patients visited or surgeries done etc is never really done due to the sheer absence of a system to measure data. Being able to measure data could potentially influence policy decisions tremendously.

What is more important however is the kind of opportunities this could open up for public health. Take clinical trials for example. Having a centralized system recording clinical events eliminates the need for teams of people following patients and collecting data. All it requires is a person with a computer at the other end evaluating data. What's more this also means data gets disseminated faster. That is, the time from introduction into a trial to actual use gets reduced tremendously due to the time savings involved. In addition, this provides healthcare workers with a network that allows them access to the latest in evidence based medicine, flags that go up for potential adverse effects with drugs helps enhance patient care and decreases the number of iatrogenic events that could happen.

Just to illustrate how having greater connectivity could transform the way medicine is practiced, take the field of microbiology. Antibiotic resistance suddenly seems to be on everyone's radar. With increasing medical tourism, the possibility of super bugs crossing continents and flourishing elsewhere suddenly seems a very real possibility. Antibiotic resistance occurs due to indiscriminate and inadequate use of existing drugs. Having a central system allows information about community based susceptibility tests to be disseminated to all practitioners. Physicians prescribe only what is recommended and follow the protocol strictly. Reports of drug resistance are followed up immediately by the national equivalent of a CDC and quarantined.

Even in the case of emerging viral illnesses (e.g. SARS or H1N1), the only tool we have is the speed with which index cases are identified. In this age of just-in-time logistics, does it make sense to hang on to antiquated methods of reporting? Can we really afford the delay in recognizing the emergence of new pathogens? The only way is to act faster and the best way to make sure that happens is by having an effective reporting system.

Applying the same principle of data mining could potentially revolutionize fields like genetics which need a huge database of people to be screened before an association between a gene and a disease can be made. As we begin to understand the increasing complexity with which our environment influences all aspects of our health from our genes to the way we age, having a comprehensive database will be an enormous resource in picking out potential cause and effect relationships in addition to highlighting new areas of research. The embryonic field of environmental medicine would gain an enormous fillip.

Traditional systems of medicine in Asia have always stressed the impact of our surroundings on us. The systems as we know today are riddled with several problems. For one there is no authority overseeing and enforcing a minimum standard of care. Second, traditional medicines often have high levels of heavy metals. Creating a local equivalent of the FDA dedicated to ensuring the drugs used adhere to strict manufacturing standards and regular toxicity screening would increase transparency in this sector. Third, integration of the system along with allopathic medicine in the above proposed IT speedway. This would ensure accountability and unlock potential applications in research.

Effective medical care today requires a multi disciplinarian approach. Having a multi-tiered system of referral ultimately provides the best results. In the future however, with the emergence of a rapidly ageing population, geriatrics and hospice care will undoubtedly gain prominence. Integration of these disciplines into grass roots primary healthcare will become essential to help people live their lives with dignity. To sum up, sustainable prosperity is virtually impossible without a strong health system taking care of every citizen's needs. The healthcare system in Asia, (barring some countries) is one of massive disparity, gross understaffing, underfunding, corruption and creaking inefficiency. The good news is, with Asia's new found economic might, an overhaul of this sector is very plausible. A process which in itself will provide the impetus for growth in our economies that will propel and cement us in our rightful place as the centre of the world.