A Difficult Week

The 118th Boston Marathon is coming up in a few weeks, and I’ve heard that many more runners (35,000) and spectators (1 million plus) than in previous years are turning out, in part to refute the tragedy of last year.  I will be doing my refuting with my community response team, by setting up runners’ aid stations along the part of the course that passes through our town, and with my biking group on a predawn route ride if cycling is allowed as was in the past.  The preparations reminded me of a posting from last spring and I thought it was worth reposting.

Health Care for All

Last week was a difficult one here in Boston.  It’s really a small town and many people, me included, although not injured or killed in the bombing or the manhunt mayhem, are one or two connections removed from people who were.  Trying to make sense of the tragedy, I realized those connections are needed in healing us after episodes of hate-fuelled violence and also in preventing them.

Also last week, I attended a conference sponsored by the Harvard University Program in Ethics and Health and Harvard’s Global Health Institute on “Universal Coverage in Developing Country Health Systems:  Ethical Dilemmas,” the “universal coverage” here meaning that all citizens have access to a country’s health care system (Conference website).  I tend to stay away from these types of meetings since the participants are usually not practitioners of global health (e.g., government officials from ministries of health or health care delivery NGOs) but rather researchers and analysts whose studies may be used to make or “inform” policies of the practitioners.  However, given my interest in universal coverage (UC) in developing/emerging countries as a potent “pull” mechanism for global health businesses and in the new approaches governments and NGOs are trying to achieve UC (see my posts tagged “delivery” and “international development”) and my realization that a couple of speakers were from the developing/emerging world, I attended and am glad I did.  The conference helped me understand the philosophical, political, and practical underpinnings of UC.

The co-chairs started the by positing that UC is based on the idea that health is important to the well-being (physical and economic) of a society and countries and therefore its provision should at least be overseen, if not managed or even provided (the US not withstanding), by governments.  Then the idea is complicated by three serious questions:  who is covered and when (women and children first or those with ”curable” disease or in the government and military?); what gets covered (maternity, public health, catastrophe, and not what happens when we chose to something?); and how to pay (out of patients’ pockets, insurance premiums, general or special taxes, as a benefit of employment?).  And then underlying answering these questions are ethics, what we as individuals and a society believe is the right and just thing to do, and social equity, how a society distributes its always scarce resources to benefit its members.

The next speaker was Julio Frenk, dean of the Harvard School of Public Health, who described his experience as the minister of health for Mexico in designing and implementing the latest version of that country’s health system.  I was deeply impressed not only by his clear and thoughtful delivery but also by the politically efficient way the country addressed achieving UC (especially compared to the fractured and inefficient method in the US).  The starting point was an employment-based system (health care as a benefit) that only covered half the population of 100 million, the other half either not working, working for themselves, or employed part time or in small companies, and the explicit statement in the Mexican constitution that health was  social right.  The first step was a national debate at all levels that led to the conclusion that, since people have little control of their health (this is true on an individual level, e.g., not all smokers get cancer and some marathoners have heart attacks), everyone should have equal access to health care, and that to make this happen, each person will contribute according to his/her capacity to do so and receive services based on need.

Next the health ministry identified specific goals to be achieved (incidence of disease, infant mortality rates, longevity, etc., I think) and then what interventions were needed and been shown to be cost-effective in reaching those goals.  Dean Frenk said the ministry came up with 260 interventions and/or services that addressed 95% of the need and 67 low incidence but high impact interventions, like cancer chemotherapy.  Next was the hard part, convincing the finance minister that the UC implementation was not going to bankrupt the country and getting his backing to gain legislative approval.  The health ministry won by presenting the details on cost and advocating for a multi-year allocation, but not the number of years, hence not asking for a blank check to be spent each year on whatever the health ministry wanted, but an annual and predetermined amount to be spent as directed by the goals and interventions.  This approach worked (along with putting in place a system of accrediting health care providers to assure quality) and now, after a commitment of 1% of GNP over seven years, 52 million previously uninsured are insured and can access heath care.  For details, Dr. Frenk referred to an article he co-authored published in Lancet last year (Frenk et al. 2012) and I noted a nice summary in Nature (Nature news).  My thought was, could this multi-year effort be replicated elsewhere (like in Massachusetts)?

While I learned something from each of the subsequent speakers and discussion, I’ll skip to those who spoke on my interests, that is, what is being tried and what works (if one is interested in the rest of the conference, the organizers will up a video version in May at PEH).  Here is a short recap:

Lisa Hirschhorn spoke about Rwanda from her experience with the NGO, Partners in Health, and noted that an national insurance program, implemented 2000-2008, has achieved 85% coverage for basic and catastrophic care but that the health care is still a major out-of-pocket expense for the poorest.  She also noted the UC plan includes direct financial assistance to pay for health-related expenses like better food and transportation to clinics and the training of heath care workers to do tasks they were previously not “qualified” to do, so called “task sharing” but its utility had not been determined.

Emanuela Gakidou of the University of Washington described measuring health outcomes in Zambia where a concentration on maternal and child health has decreased child morality by one-third in eight years but infectious disease mortality has not budged despite efforts like increased bed net use for malaria prevention, use of regional hospital rather than clinics, and access to anti-viral treatment.

Richard Levins, a Harvard ecologist and self-described third-generation Communist, spoke glowingly about Cuba where health care is integrated with other social services, is community-based (one clinic per 1000 people), and has achieved some of the best measures of health in the Western Hemisphere.  He also noted a shortage of toilet paper in the hospitals and a need to import 30% of the country’s food.

Peersapol Sutiwisesak of Thailand’s National Health Security Office (NHSO) noted that Thailand undertook a forty-year UC effort, that UC was achieved in 2003, and now, in addition to overseeing the system, his office is offering guidance to other countries interested in the Thai approach.  I wasn’t clear on the details (which can be found at NHSO) but understand it is insurance-based with two tiers of costs/benefits, emphasizes rural capital investments (I guess it assumes that for-profits will concentrate in the cities), is audited yearly by the inspector general, uses a mix of payments methods (e.g., fee-for-service and capitation), and has incentives to providers for improved quality.  The Office also has pooled procurement for medical devices and group that evaluates the cost-effectiveness of new interventions.  I think I noted that he said this combination had significantly decreased the cost of dialysis and led to rejection of the new HPV vaccines since the group and the pharma companies could not agree on a price (I think they did not try hard enough).

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