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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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).

This Little Piggy

As a former biotech/pharma business development guy and now amateur observer of global health matters, I am out of my depth when commenting on the economics and policy of health care provision and financing.  But I try to do it anyway, primarily because, from my naïve view point, a potential and potent first step to achieving better health among many of the world’s citizens is the creation of markets.  Markets are where the needs of consumers and buyers of health care services and products are collected, described, and priced so that providers of services and products can gauge demand and figure how to meet it.  Through the magic of economics and human society, the market works and providers compete to meet the need by being inventive, improving efficiency and creating new products, and ultimately proving affordable products and services.  That’s the theory anyway.  Also part of the theory is that government’s job is to figure out ways to prod, steer, and regulate the market so that it evolves in the right direction and their constituents are happy and healthy.

Along those lines, I noted an interesting blog posting last month by Adam Wagstaff, a research manager in the Development Research Group of the World Bank, entitled “Health reform: A consensus emerging in Asia?” (Wagstaff post).  Typically, I steer clear of health policy blogs and articles since they are written by specialists for specialists and I quickly get lost in the arcanery (an exception is the analysis put out by the Kaiser Family Foundation on US global health policy at kff.org).  Adam caught my attention by starting his posting with “my sense is that while we health-reform aficionados are berating one another in the blogosphere, policymakers in Asia are quietly iterating toward something of a consensus on a whole swathe of key issues on health reform.”  His point is that a significant part of the population of six Asian countries, about 1 billion people, are part now participating in government programs that, while differing in detail, have a number of common elements and that these programs are meeting the health care needs of the participants regardless of their ability to pay out of pocket.

My rough summary of Adam’s “emerging consensus” is:

  • governments (via their tax revenues) are subsidizing insurance programs to achieve universal coverage with the net result that 20 to 70% of these countries’ citizens receive free or almost free care;
  • governments are using intermediary insurance management departments to pay for the insured care through performance-based payment systems, such as fee-for-service or per capita; and
  • governments are moving away from providing care through government-run hospitals and clinics and are using a range of providers, including no/low/for-profit companies as well as non-profit NGOs, and using bidding and contracts to create competition.

Of course, there are substantial problems to manage:  corruption, lack of information needed by users to make informed decisions, possible mis-incentives, and unaffordable patient costs, to name a few.  But Adam concludes:  “So, while we aficionados have been debating health reform passionately among ourselves, Asia’s policymakers have quietly got on with the business, and have come up with a rather interesting model.”

So to tie Andrew’s points back to my interest, developing global health businesses, I see these programs as a starting point for providing the market that businesses need to understand and meet demand.  The standard refrains from the global health activists is that “the market has failed” and from the companies is that  “there’s no market.”  But I think there can be a market and if one looks hard enough is one emerging now, and Adam’s view point is heartening.  From another direction, I note that the US is the world’s wealthiest country and we, the over-consumers that we are, have evolved an expensive and inefficient system (that finally most everyone agrees needs to be fixed) and we who care about global health need to show the players in our system, the insurance, drug and device companies and health care providers, how to scale their businesses to meet the basic needs of many people at low cost.  And those slimmed-down little piggies need to get to market.

I refer those enquiring readers who may be interested in my past posts on the topic of providing affordable care to my posts of 10/14 and 10/28/10.  In the former I tie the growing generic drug and bio-similiar industry in the developing world with the growth of micro-insurance programs, and in the latter, I summarize an article about the many roles of the private sector to deliver health care in the developing world.  For those readers who wish to dive more deeply into these topics, the WHO recently released a report on health systems financing (WHO report) (that I think is deficient in covering the role of private companies), and the Brookings Institution Press just published a book on health insurance programs in low- and middle-income countries (Escobar et al. 2011).

Affordability Revisited

Two postings ago (October 14), I noted that Cipla, the billion-dollar Indian generic pharma company, is developing affordable versions of biological anti-cancer drugs and that it likely assumes there will be some type of scheme to pay for the drugs.  [Sidebar:  Pfizer closed a multimillion dollar deal for diabetes bio-similars last week with another Indian company, Biocon (WSJ article).]  I then wrote about micro-insurance provided through governments, NGOs, and companies as one scheme for the delivery of affordable health care.  Not surprisingly when I did additional research, I found many, almost overwhelming, sources and viewpoints on this topic.  To start this revisit of affordable health care, I extracted a few (clearly debatable) points.

First, most of the world’s poor live several days’ walk from a public sector (government- or NGO-run) clinic or hospital and typically rely on self-diagnosis and medication purchased from a local vendor or on a local private practitioner, either credentialed or not (i.e., a traditional healer).  Second, most of the aid money donated for health care has gone to pubic sector agents, primarily governments, and not to private (for-profit) sector providers.  Third, the effectiveness, as measured in terms of people actually treated or other outcomes, has not been well-studied by the donor or recipient organizations, and when it has, has been found wanting.  For a well-reasoned summary of this perspective, I refer to a 2008 report by Philip Stevens of the International Policy Network (2008 IPN Report).  The report noted health care aid has increased as portion of overall aid since 2000 to a total of about $14 billion in the last year studied, 2006, but that, by the WHO’s own accounting, progress toward meeting the heath-related Millennium Development Goals has been lacking (2009 WHO Lancet article).

What has been tried and what may be done in improving the delivery of heath care in needy countries?  Turning to Mr. Stevens and the IPN again, I found his recent report, “Delivering medicines for chronic diseases in low-income countries:  Lessons from the response to HIV/AIDS” (2010 IPN Report), to be informative.  In it, the author summaries the literature on governments’ and aid organizations’ use of the private sector to deliver health care as a possible alternative to addressing current and  projected need.  Here is my (brief) synopsis of the described alternatives:

Franchising: “in which different independent health providers are commissioned to provide services under an established, unifying brand at specified prices and standards;” there are some examples of success, but high start-up costs and the difficulty of offering a wide range of services at a low price limit this approach for low-income groups.

Performance-based contracting:  in which “ministries of health contract private sector operators and NGOs to deliver defined and measurable services to local populations;” several countries have used this approach, the most successful being Cambodia since 1999, and, if done with transparency and strong evaluation mechanisms, is promising.

Public-private partnerships:  in which for-profit companies contribute money and expertise to a care delivery project; many examples in  HIV treatment are given; the most successful, but expensive (more than $100 million), to date has been in Botswana involving the government, Gates Foundation, and Merck Co.; the country was the first to  provide free HIV care to all its citizens.

Workplace treatment:  this approach harkens back to cradle-to-grave services provided by the early industrial age corporations and has several examples of success, primarily in south Africa with its large number of multinational companies and in HIV treatment with its unfortunately high prevalence and devastating effects.

Traditional healers:  although many people receive the majority of their care from this source, the few studies that have been done indicate a lack of trust or interest by the healers in adopting, non-traditional, evidence-based treatments.

Health equity funds:  are government- or donor-subsidized, but independently managed, programs that act as a health insurer for qualified, low-income participants; again Cambodia leads in trying these and had 26 funds operational in 2006; drawbacks include the need for substantial subsidy and experienced management.

Microfinance:  many examples exist in which small-scale lending is used by private health care providers to improve their services.

Community health insurance:  are like health equity funds but require some level of premium payment; there are successful programs in  Africa but they have suffered from fluctuating participation and lack of regulation.

Private health insurance:  the report only mentions the role of private insurance in providing HIV treatment and care in southern Africa where several attempts by companies have had mixed results (he cites  Feeley et al. 2007) but also notes that insurers in Ghana and Namibia are offering HIV/AIDS coverage.

So lots of examples of alternatives to the current (and not effective) donor-to-government-to-public provider system exist, but there are no obvious solutions.  Is there a solution to finding solution, or at least best practices?  Possibly, when I remembered my posting of September 7, 2010 (“Market Tested but Not Yet Approved”) in which I wrote about the Center for Health Market Innovations (CHMI), a Gates- and Rockefeller-funded program that is administered by a Washington, DC-based international development consulting firm called Results for Development Institute.  CHMI is building a database of programs that are operating through out the world to improve health care in low-resourced regions and gives details on each (there are about 400 now) and data on their performance.  My comment then was “so far, so good” with the caveat that they need to beef up their performance evaluation process for the database to be really useful.  And to which I can now add, CHMI’s mission of finding solutions to affordable health care delivery will be helped if it includes the programs cited by Stevens (his report includes reviews of 24 of the studies he cites) to the database, too.

Affordability

At the August annual meeting of Cipla, a major India-based generic drug company, YK Hamied, the chairman, noted the company is extending its generics business model to biological drugs, aka  “biosimilars” or “bio-betters,” in part through a $200 million dollar investment in building a biologics plant (Business Standard article).  Further he said, “We believe this activity is also humanitarian and like our crusade on the HIV/AIDS front, we will attempt to make a similar contribution in the sophisticated cancer market, reaching one and all cancer patients with valuable drugs at affordable prices.”  Of course, the company’s HIV/AIDS crusade drew the wrath of the major pharma company competitors whose drugs were being pirated (at the time the drugs were not patented in India nor the countries where they were sold) but brought the cost of annual antiretroviral therapy (ART) down from $12000 to $300 (it’s under $100 now).  Subsequently, or consequently, the company is now providing the drugs for about 40% of all ART.  And, although many companies, including the big pharmas, are developing a biosimilars business (c.f., Bloomberg article), their products are intended for the well-reimbursed high-income country markets.  Cipla, a major generics company with annual revenues in excess of $1 billion (2010 Annual Report), apparently believes there will be a market for treating “all cancer patients with valuable drugs at affordable prices.”  However, unlike the ART market where the meds are purchased through government-backed programs like the US’s PEPFAR (PEPFAR) and the Global Fund (Global Fund), cancer, while a major killer in many rest-of-world countries (IPS News article), has no donor country-funded market.

My guess is that the Cipla and other generics companies that are developing biosimilars are thinking that patients in the developing world will pay for their cancer therapy the same way those of us in the developed world do now, through private health insurance.  Such plans exist and are part of the “microinsurance” industry, a relatively new approach that has the attention of the international development community as well as businesses.  The basic idea is that people with incomes under $2 per day already put a significant part of their income into health care and therefore can afford to put small sums into policies to cover injury or illness needing hospitalization (Epoch Times article).  A 2007 survey found that 78 million people in the world’s 100 poorest countries have some type of micro-insurance, the most popular by far being for death/disability (more than half), followed by property loss and lastly, health (about 10%)  (MIC Landscape Study).

The interest in the microinsurance concept is shown through international conferences on the topic (e.g., next month in the Philippines, 6th International Microinsurance Conference), advocacy groups like the Microinsurance Center (MIC), and at least two on-line resource centers (Microinsurance Network and Microfinance Gateway).  Even the Gates Foundation is involved through its support of the  Aga Khan Development Network’s Microinsurance Initiative which started pilot projects in Tanzania and Pakistan in 2009 (AKAM Initiative).  Not surprisingly, the insurance industry sees a business opportunity in providing low-cost insurance products.  The 2007 survey reported that more than half the coverage was provided by for-profits, and a recent report by Lloyd’s, one of the largest insurance companies, called microinsurance a “win-win situation” (Lloyd’s report).  There is even a $100+ million fund, Leapfrog Investments (Leapfrog), that specializes in investing in developing world insurance companies.

However, the wider adoption of health insurance faces several barriers; for example, insurers need to be fiscally sound.  A 2008 report by Oxfam notes that, of the approximately 35 million people in all countries who are covered by micro health insurance (90% of whom are in Asia and 9% in Africa), most have it through private entities such as insurance companies or microfinance institutions and the small size of these organizations and lack of government regulation may lead to their failure (Oxfam report). One of the largest (300,000 beneficiaries) and longest running (since 1996) programs in Asia is provided by Grameen Kaylan, a division of the Grameen Bank, and is still working towards being self-supporting (Microcapital article).  Another program in Kenya has had success by pairing microlending with a requirement to buy health insurance, at cost of about $15 per year (San Mateo Journal article).   According to a recent review of microinsurance, designing the right product to address local market risks, convincing the customer of value, and building a large client base are critical for success but the authors also note that microinsurance is becoming a “boardroom strategy” (Knowledge Wharton article).  It looks to me that, to meet the huge needs in the developing world, some drug companies and an emerging mix of government, not-profits, and for-profits payers are working on the affordability problem with some success.  Maybe there’s a lesson here for the big pharma companies and the US health insurance industry.