Viral fever and dengue patients at the Noida District Hospital in India
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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.