Delivering health and hope: A volunteer with the Bangladeshi Rural Advancement Committee (BRAC) dispenses antibiotics to infants. (© Karen Kasmausk i/Corbis)
Simple Solutions For Global Health
As anyone over 50 knows, deteriorating close-range vision is a universal symptom of middle age. The cheapest solution? Dime-store reading glasses. But for people living in developing nations, glasses are neither affordable nor easy to obtain. Without them it’s difficult to do essential daily activities such as reading, sewing or sorting seeds for planting.
In Bangladesh, one of the world’s poorest and most densely populated countries, the nongovernmental organization BRAC (formerly known as the Bangladesh Rural Advancement Committee) and a New York-based nonprofit called VisionSpring teamed up to solve this problem by sending an army of "vision entrepreneurs" into the countryside to sell inexpensive reading glasses. It’s not uncommon for a customer to burst into tears after trying on a pair for the first time. Some 500 women have already been trained in how to prescribe the $2 glasses, and each has received a special briefcase containing the tools of the trade and product samples. The women keep a portion of the revenues and use some of the money to pay back small loans that cover their training.
"Reading Glasses for Improved Livelihoods" is just one of many simple but innovative initiatives sponsored by BRAC, which reaches more than 92 million Bangladeshis through its network of 68,000 volunteer healthcare workers—mostly poor, rural women. Besides prescribing reading glasses BRAC volunteers sell medicines, make home visits, vaccinate children and collaborate with the government on programs to improve sanitation and combat tuberculosis and malaria. BRAC even runs its own school of public health, as well as a dairy and a chain of handicraft stores. By taking a holistic approach that combines health programs with economic development and education, BRAC has evolved from a donor-funded organization into one that is 80 percent self-supporting—and so successful that it has expanded to Afghanistan, Sri Lanka, Tanzania, Uganda, Pakistan and southern Sudan.
As this shows, sometimes low-biotech can improve lives and even save them. Likewise innovation does not always come from a lab bench. Moreover the best plans need not be the most expensive.
It’s surprising to find a model healthcare program in a nation where per capita income is less than $40 per month. But when it comes to health, you don’t always get what you pay for. As poor nations struggle with how to provide quality care on a shoestring budget and rich nations attempt to rein in runaway costs, governments and charitable organizations throughout the world are searching for ways to reform healthcare. "We’re finally at the point where the entire world is in a health crisis," says Laurie Garrett, senior fellow for global health at the Council on Foreign Relations and the author of Betrayal of Trust: The Collapse of Global Public Health.
Best Of Times, Worst Of Times
It’s not all bad news. By some measures, the world is healthier than ever. Compared with 50 years ago, average life expectancy at birth has increased by almost 27 years in Asia, 23 years in the Middle East, 21 years in Latin America, 14 years in Oceania and 11 years in sub-Saharan Africa. Infant and child mortality have also improved: Even though more children are born today than in 1960, the numbers who die before age 5 have been cut in half.
"There have never been more resources available for health care than now," according to the World Health Organization’s World Health Report 2008. Even after adjustments for inflation, global health expenditures grew by a whopping 35 percent between 2000 and 2005.
Unfortunately the rising tide of money has not lifted all boats. "Today the gaps in health outcomes, both within and between countries, are greater than ever before in recent history. Differences in life expectancy between the richest and poorest countries exceed 40 years," said Margaret Chan, director-general of WHO in a February 2009 speech at a global health forum hosted by Italy’s Aspen Institute and Japan’s Health Policy Institute. A boy born today in Swaziland will probably not live long enough to see his children graduate from high school, while a boy born at the same time in Japan is likely to know his great-grandchildren.
Each year about 10 million children under the age of five die, according to WHO, and almost all of them could survive with better access to healthcare. More than half a million women die annually during pregnancy or childbirth, and most of these deaths are also preventable. And despite major progress in the prevention and treatment of HIV/AIDS, it remains the leading killer of adults in Africa.
Focus On Primary Care
To tackle these enormous challenges, governments and organizations around the world are developing blueprints for better health systems. Virtually all of these plans emphasize the importance of primary, preventive care. WHO, for example, is using Millennium Development Goals adopted in 2000 to guide its actions. Among the health-related objectives: reducing worldwide deaths during pregnancy and delivery by three-quarters between 1990 and 2015, and achieving universal access to reproductive healthcare by 2015—both of which will require training more workers.
Health workers need not be doctors or even registered nurses. In Rwanda, for example, community health workers called "accompagnateurs" make home visits to administer drugs and check on patients with HIV and tuberculosis. Using this rudimentary health-delivery system, together with programs to fight poverty, Rwanda hopes to provide basic healthcare for the entire country by 2011 at a price tag of only $200 million. The Global Health Delivery Project (GHDP), co-founded by Kim and Harvard Business School professor Michael Porter, did a case study of this grassroots approach and found that it improved health outcomes and lowered costs.
Comprehensive care emphasizes disease prevention and healthy lifestyles, rather than the treatment of specific diseases. For communicable diseases like malaria and measles, that means preventive care such as insecticidal bed nets and childhood vaccinations.
Although communicable diseases are often the focus of international efforts, chronic non-communicable diseases such as heart disease and lung cancer are already responsible for 60 percent of deaths worldwide, and 80 percent of these deaths occur in low- and middle-income countries, reported a team of 19 global-health researchers in a November 2007 paper in the journal Nature. "With concerted action, we can avert at least 36 million premature deaths by 2015," they noted.
The researchers compiled a list of the top-20 policy and research priorities for chronic non-communicable diseases. Some of their recommendations are as simple as "increase the availability and consumption of healthy food" and "promote lifelong physical activity." WHO estimates that at least 80 percent of deaths from cardiovascular disease and strokes could be prevented through healthy diet, exercise and the elimination of tobacco use—which is high in many countries.
Better health systems are not necessarily expensive. While the U.S. might offer the best care available if you need a complicated surgical procedure, its citizens do not, on the whole, enjoy longer or healthier lives than people in some less well-endowed nations. Costa Ricans, for example, are as healthy as people living in the U.S.—in spite of spending one-tenth as much on healthcare on average.
Something as simple and inexpensive as a sheet of paper can produce major improvements in health outcomes. In one recent pilot study, a safety checklist developed by WHO lowered deaths and complications during surgery by a third. (See sidebar "Safer Surgery.")
However, some essential medical technologies and pharmaceuticals—such as vaccines to immunize children against bacterial diseases—are expensive and time-consuming to develop. One possible solution now being tested offers vaccine makers a guaranteed market in exchange for advance funding. (See sidebar "A Promise to Buy.")
Meanwhile new challenges have emerged: Urbanization and globalization make it easier for communicable diseases to spread. Aging populations are facing chronic non-communicable illnesses such as cancer and heart disease. Climate change is aggravating health problems, such as heat stroke, asthma and waterborne diseases.
The biggest challenge of all is the "delivery gap," says Jim Yong Kim of Harvard Medical School’s department of global health and social medicine. Despite unprecedented financial investments and medical advances, care often does not reach those who need it most. Bureaucracy and corruption siphon money, and programs sometimes reflect the interests of donors rather than the needs of recipients. Even when needs and funding are aligned, there is a crucial shortage of doctors, nurses, pharmacists, dentists, optometrists, lab technicians and other workers.
An estimated 4.2 million health workers are needed worldwide to bridge the gap, according to the Global Health Workforce Alliance. "We’re not going to be able to fill that void in our lifetime and probably not in our children’s lifetime," Garrett says. "It takes a long time to train doctors and nurses, and as fast as they are trained, they are recruited to the rich world." Even there, supply is not keeping up with demand.
Health Entrepreneurs
Market incentives might also be the key to attracting and retaining healthcare workers. Many countries currently rely on volunteers to provide basic healthcare, and these workers get discouraged when they don’t have the skills and equipment they need, much less a salary. "Franchise" models such as the VisionSpring reading-glasses initiative provide volunteers not only with training and tools but also with an opportunity to earn money providing health services to others.
Garrett developed a similar franchise model, called Doc-in-a-Box, with architects at Rensselaer Polytechnic Institute. Doc-in-a-Box is a shipping container retrofitted to serve as a ready-made primary-care clinic. At such a clinic, workers could examine patients, dispense drugs and administer vaccines and screening tests. The workers running the clinic would charge for their services and would quickly make back their initial investment in training and equipment. "The average poor person in the third world is an instinctual entrepreneur," Garrett says. Tapping into that motivation could create an army of healthcare workers dedicated to their jobs.
In the end, only a combination of approaches can provide healthcare around the world.
Safer Surgery
Of the 234 million major surgeries performed annually around the world, an estimated 7 million or more result in complications—half of which are preventable. To improve the safety of surgical care, the World Health Organization (WHO) developed a checklist that can be used in any operating room. Tested at eight hospitals in different regions, the Surgical Safety Checklist reduced surgery-related deaths and complications by one-third, according to a study published in January in the New England Journal of Medicine. WHO hopes to have 2,500 hospitals using the checklist by the end of this year.
The checklist requires surgeons, anesthesia providers and nurses to pause at three points during an operation—before inducing anesthesia, before cutting into the patient and before the patient leaves the operating room—to answer a few questions. For example: Does the patient have a known allergy? How much blood do we expect him or her to lose? Are we missing any instruments or sponges?
Short, simple checklists could improve healthcare in other specialties too, says Atul Gawande, who led the international team that developed the surgery checklist. "They could become as essential in daily medicine as the stethoscope."
A Promise To Buy
Developing new vaccines and bringing them to market in developing countries can take more than 15 years. The GAVI Alliance—a partnership that includes governments, the World Health Organization, UNICEF, the World Bank, foundations and pharmaceutical companies—is testing a way to accelerate this process. Governments and private-sector donors make an Advance Market Commitment (AMC) to purchase a vaccine at a guaranteed price if it is successfully developed. That gives the pharmaceutical company an incentive to invest in researching and manufacturing the vaccine.
The pilot AMC—launched two years ago with $1.5 billion donated by the governments of Canada, Italy, Norway, Russia and the U.K., along with the Bill & Melinda Gates Foundation—is for a vaccine that targets pneumococcal disease, a major cause of pneumonia and meningitis, which kills as many as 1 million children annually. By January 2009, the GAVI Alliance had approved support for introducing the pneumococcal vaccine in 11 countries, mostly in Africa. Rwanda and Gambia are expected to receive the first shipments later this year.
