Public insurance option – Not a magic solution.

There has been much debate regarding health care reform and the inclusion of a public option to provide needed competition to the private health insurance industry.

While conceptually this sounds like a reasonable idea there are some potential flaws to this model that need a closer look.

1) Who would use this plan?

For most America’s currently using private health insurance, there is little cause to believe they would switch to a public health plan. Most of the costs of health insurance and payment to providers is not taken up by the patient, rather it is assumed by a third party (employer). Thus unless an individual or family is faced with a sudden loss of insurance due to unemployment or rise in premiums, most America’s that are currently insured will not switch.

2) Subsidy for the Private Insurance Industry

There is a real possibility that the public insurance plan will become a haven for persons or families that simply are unable to qualify for private health insurance. This would include the sick, elderly or uninsured. If the basic premise of the insurance industry is to pool risk, the outcome will be even higher profit margins for the private insurers because they can knowingly exclude unfavorable risky persons with the knowledge these ‘high risk’ populations can go to a public health plan. Thus the average premium under the public plan may be a great deal higher for individuals than under private insurance due to this ‘higher risk’ pooling. That is unless the government (taxpayer) subsidizes the average premium under the public option.

3) A reasonable alternative?

The status quo is no longer acceptable. Too many families are excluded from basic coverage do to a flawed system that is focused on profit maximization and not the provision of community wellness or disease prevention services that reduce costs. This system stymies workforce innovation by restricting workers from changing jobs or becoming self employed to simply retain health coverage for their families. However creating a public option that provides greater profits for the private insurance industry through a publicly available safety net does not seem like the most efficient solution. Essentially, this is the equivalent of a federal stimulus for the private insurance industry on an annual basis.

A more reasonable solution would be to develop legislation that creates incentives for the development of insurance collaboratives to further pool risk, consolidate administrative waste, and mandate coverage for the poor, underinsured and uninsured while ensuring high quality standards for health care service delivery.

Pooling risk, not further subdividing insured populations will most likely reduce overall costs.

4) A way forward for health reform in America

Re-shaping the American health care system into one that is more equitable, expands access to care, maintains quality, and contains costs poses a great challenge, but also a remarkable opportunity.

But there are no ‘shotgun solutions. Thus whatever investments we make in the short term should be seen as a flexible, supportive of innovative ideas, and a series of quantifiable experiments that can be revised over time. Establishment of comparative effectiveness programs at the national, state, and county levels will jumpstart a long overdue process of evaluating what works and doesn’t work specific to health care delivery.

But comparative effectiveness must not be solely focused on health care delivery. These efforts must look at the entire health care value chain and associated stakeholders. The value chain includes both supply and demand side causes such as medical education, medical technologies, research systems, and patient care. Stakeholders must include training institutions (colleges and medical schools), insurance companies, medical and device manufacturers, clinicians, and the patient.

Unless we start a process by which we look to evaluate and improve upon the entire value chain in health care, we will continue to develop piecemeal solutions that will have limited impact.

Most importantly, while thinking nationally or even regionally, it is important to act and create local solutions.

Gawande and the NYT – A way Forward

Dr. Atul Gawande (The Cost Conundrum, New Yorker Magazine, June 1st 2009) and New York Times (Editorial “Doctors and the Cost of Care”, June 14th 2009) provide very insightful, critical, and constructive commentary on what is potentially wrong with the US health care system. Primary reasons allude to overutilization that has created waste with questionable quality and impact.


In other words we have not had very good bang for the buck.

Dr. Gawande well known for his insightful essay’s and books on quality of health care points out through vivid testimonial accounts that there are vast discrepancies in health care costs within the US, even after taking into account differences such as severity of illness. Some of these discrepancies have been known for over the past decade. For example the work of Professor Don Berwick and colleagues is seminal. The Institute for Healthcare Improvement (IHI), since 1991 has highlighted how inefficiencies in health care cost billions of dollars and thousands of lives each year in the United States.

Looking closely at Dr. Gwande’s article there are several subtle hints that are made that point fingers towards the advent of ‘profit centers’ and ‘maximizing revenue’ practices for artificially driving up health care costs. These buzz words allude to how the ‘business’ of health care has created the ‘high cost’ and questionable quality of health care service. We need to ‘avoid looking at fragment quantity driven systems.”


Dr. Gwande further suggests that potential answers to the existing problem are to “reward doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, under treatment, and sheer profiteering. Under one approach, insurers—whether public or private—would allow clinicians who formed such organizations and met quality goals to keep half the savings they generate.”


As compelling as this analysis is, these recommendations assume that a) maximizing revenues produces an inefficient health care system and b) large hospitals and physician groups will naturally induce incentives and goals to provide high quality health care while reducing costs.


While these are important assumptions, there are some other assumptions and questions worth highlighting.

1) While there is plenty of evidence that an unregulated fee for service system produces over utilization of health care resources, there is also evidence that maximizing revenues and promoting competition provides strong incentive to reduce overall operating costs.

In the US health care system the consumer (patient) does not typically assume the full cost of service. Thus the insurer (typically the government and ultimately the tax payer) may assume the brunt of these costs and while the patient may not be any worse off (though there is an alarming rate of medical errors, that could be caused by over utilization of services), we have a system that has differences in utilization of health care resources for questionable/debatable return. What is needed as Dr. Gwande suggests is cost effectiveness and delivery consortiums that will support national, state, and local level evaluations, best practice identification, and as needed operations research to examine cost, quality, and effectiveness of health services and procedures.

However, how much power the outputs will have over reducing health costs is to be seen. Ultimately unless there is a pay for performance/pay for quality incentives created for multiple stakeholders (patients, insurers, and doctors) these studies will have little influence on reducing overall costs in the US health care system.

2) Is there strong evidence to suggest that non-for profit health care systems reduce costs and promote higher quality any better than a for-profit model?

Currently, many of the higher cost and cutting edge technologies and procedures that are introduced into our system have originations from non-profit systems. The results of controlled clinical trials are typically written up in the most prestigious scientific journals and have influence on driving health care practice for millions of Americans. Concentrating the power of providing health care services into non-profit organizations and local communities to self regulate quality is not the full answer. Monopolies or oligopolies can drive up costs regardless of for profit or non-for profit structures. Thus, laws in various states have long safe guarded against collusion and price fixing.

To assume that physician or hospital groups will entirely focus on quality and reduce costs when faced with limited local market competition is not an entirely plausible outcome. This sort of self regulated market place has failed in the past. Just look at the recent wreckage of the financial sector to see the latest evidence of what relying heavily on self regulation can do. There needs to be a cost effectiveness and quality improvement mechanism that can positively influences what services are paid for based upon evidence/outcome.

3) What defines ‘high quality service?’

Quality to this day means many things to many people. Thus, there still is much debate regarding how to standardize quality for specific procedures. There needs to be more effort to establish minimum ‘quality’ standards for specific procedures. This may include mortality, morbidity, length of stay, quality of life, and patient satisfaction statistics. A significant challenge is that the large gap in knowledge and often paternalistic nature between the physician and patient. If a patient is facing a life threatening or terminal illness, how many families would argue with the doctor for less service and procedures?

4) Dr. Gwande’s article states no one teaches you how to think about money in medical school or residency? What about student debt?

There are estimates that the average debit of students upon completion of undergraduate college and medial school is over 200,000 USD. Having personally taught courses at Harvard Medical School the past 10 years, many students are shaped by the type of practice they go into because of the debt they are saddled with or the sincere desire to work with the most cutting edge and often expensive technological advances to save lives.

5) While utilization disparities are inherent in our system, a related factor is the impact of expensive medical technologies that drive up health care costs.

Without a strategic look at investment in health care technologies and services that promote preventive home based services and introduce lower cost devices and personalized medicines, the system will continue to spiral upwards.

6) Leadership, quantitative analyses to establish organizational control systems, quality of service, and maximizing customer satisfaction are tenets of good business practice.

These certainly can lend value to help improve quality and reduce unnecessary costs. Let us not forget that a significant problem that contributed to the high cost of health care has been the government’s reimbursement to providers that has used the fee for service model of service delivery. A former Professor of mine, William Kissick from the Leonard Davis Institute at the Wharton School used to compare this system to giving a credit card to your teenage son or daughter hitting puberty and saying spend as much as you want and do not worry about the tab. Essentially, we had supported the system with unlimited rocket fuel, without thinking much about the price of the ride.

7) Most physicians in general will do as much as they can to benefit their patients.

The majority of doctors want to do no harm, yet provide maximum service. Isn’t that the type of doctor we all want if we are sick? Who wants to hear, “you have a 10% chance of survival, there is an experimental therapy available, but sorry scientific studies have proven it is not very cost effective.” The fact that for-profit and non-for profit entities have learned to leverage the system to maximize revenues based upon these inherent principles of personal self interest to live as long and healthy life as possible should not surprise anyone. These principles have led to the discovery and usage of some of our most promising therapies.

8) Who speaks for the uninsured?

Our country has over 40 million unisured, over half are estimated to be children. Will reducing overutilization of services support coverage to the uninsured without shifting the incentives to do so? The answer is no. One way forward will be to form a public and private partnership to pool clients and provide basic health services as well as a reasonable safety net for those unemployed and looking for work.

Personal Reflection - Strengthening Health Systems

In Tanzania, I have had the privilege of working with the public and private sectors to develop strategic recommendations on how to improve patient care for infectious (HIV/AIDS, TB, and Malaria) and non-communicable diseases such as diabetes and heart disease. What is required to complete this activity is a detailed analysis of the entire health care value chain. This involves an understanding of factors and stakeholders that influence supply of demand health services that impact delivery.

Supply factors include; cost of medical education, clinician decision making, medical technologies, and public private partnerships, demand includes; patient driven demand, financing, as well as societal values and context for expecting health services. A common flaw in trying to assess a health system is isolating specific components without taking into account the entire value chain. Thus while overutilization of services make compelling news stories, these are symptoms of a more complex value change and production process that needs a closer examination.

The rising cost of health care has been an issue for over 40 years, especially since the establishment of Medicaid in 1965. The problems are not new. These include the introduction of live saving yet expensive medical technologies, limited cost effectiveness data for services/technologies/procedures, a focus on illness and not wellness/prevention, and inconsistencies as well as misalignments between the demand (patients), payment (insurers), and supply (physicians) for health service delivery.

What is required is a national, yet decentralized office for health care quality/delivery improvement tasked to develop a series of pilot initiatives that examine current best practices and support new practice models across the value chain. These would include both short term and longer term evaluations. We cannot afford to wait ten years for longitudinal results before taking action. Some evaluations could also be performed using simulations and forecasting models that use existing evidence for specific components of the health care value chain. S

Evaluations might include 1) bulk purchasing of primary care services for the uninsured to reduce overutilization of emergency room visits, 2) opinion survey’s regarding affects of reducing the cost of medical education on young MD decision making, 3) providing quality reports directly to consumers to help make difficult decisions regarding expensive/low yield procedures, 4) create research and development incentives for low cost diagnostic technologies to replace high cost/high margin services, 5) reimbursement models that use pay for quality report cards. These can all be evaluated to determine areas for savings in costs and while either maintaining or possibly improving health services.

Asante Sana Dr. Gawande for your insight and commentary.

Why the world and America needs Paul Farmer

I remember very clearly in March 2004 arriving into Kingston Jamaica. I was just tapped to be a Volunteer Country Director for the Clinton Foundation. The task was to work closely with a team of clinicians, business personnel, and ministry officials to help finalize the HIV/AIDS treatment and scale up country proposal for the Global Fund.

I remember during the first week on the job driving past a local prison. Our guide described the prison as a place where only ‘The Lord” smiles upon. It was known as a place where HIV/AIDS was rampant from drug use and unsafe sexual practice. However, for a variety of reasons was a population where no one cared to provide access to treatment.

It seems everyone has an opinion about Dr. Paul Farmer. The Far right question America’s role and tax payer dollars to help in the fight against poverty and strengthening health care abroad with over 40 million uninsured in America. The left promote Dr. Farmer as the world’s ambassador against poverty and disease. But without question, quite simply, Dr. Farmer has dared to go to those places where only ‘The Lord” smiles upon.

Paul (Dr. Farmer prefers both strangers, myself included in this first category, and close colleagues to avoid formal titles) has dedicated his life to improving the lives of those forgotten in the global economy. Regardless of whether you support his work, one cannot deny him full respect and admiration. He will be the first to admit he is not someone to be worshiped. Just a doer, who loves to do. Through his actions and doing, Paul and Partners in Health have directly impacted the lives of millions around the globe.

The world is a much better and enlightened place because of Paul and his ability to inspire many to think less about themselves and more about how they can help others.

Currently the Obama administration is working to convince Paul that he should become their global health ambassador. If this ultimately becomes reality, let us all be thankful. Because not withstanding the inevitable political minefields that await and budget battles to be fought, Paul will assuredly exponentially raise America’s stature in the world as a serious advocate for human rights, poverty reduction, and global health.

Happy Mothers day and Reflection

We wish you a very happy, wonderful, and happy mothers day.

Appropriately Mr. Nicholas Kristof from the NYT has given us a gift of reporting on a condition that effects both mothers and children, yet remains largely under funded with few direct advocates. Mr. Kristof reports that childhood pneumonia is an illness that is easy to treat, yet more than two million children die each year in developing countries. Thanks again to the herculean advocacy efforts of Lance Laifer the world is becoming better acquainted with a condition that Mr. Kristof states will kill almost twenty children in the five minutes it will take to read his column or my blog.

Though we are reminded that part of the challenge of advocating for childhood pneumonia is typically the condition can be a secondary infection caused by a primary underlying condition such as upper respiratory disease, HIV, malaria and malnutrition. Actually many scientists and health officials will argue that malnutrition or under nutrition and health illiteracy by parents are the biggest root causes of disease.

This highlights the challenge of advocating for a disease versus channeling the energy and funding dollars to strengthen health systems and increase health literacy to improve primary health care services and tackle root causes of disease. Otherwise, if we target a specific disease, yet do not thoughtfully look to apply needed attention to strengthen the health delivery system, we may get a disproportionate investment in treating one disease versus improving overall health services for mothers and children.

For example I’ve worked with local health workers in Tanzania to help develop primary prevention programs to eradicate rheumatic heart disease (RHD) over the last 5 years. RHD is thought to be an entirely treatable and preventable condition (it was a leading primary and secondary cause of cardiovascular death in the US prior to the discovery of penicillin), yet we have millions of children and adults in the developing world suffering from this disease. However, my colleagues and I have learned that the root cause and treatment for RHD goes beyond screening for streptococcus A and handing out penicillin. The inability to eradicate RHD in the developing world also has also been effected by traditional focusing on disease specific programs versus strategic strengthening of systems to detect and prevent diseases among infants and children.

Lance and Bill; We know your reporting and advocacy work are making an amazing difference for mothers and children the world over. The world needs more people like you bringing attention to these conditions. Lets hope that the tremendous advocacy and resulting funding dollars are spent wisely to also focus on root causes of disease and strengthening primary care and prevention services. Otherwise, the world will continue to follow the treatment of one disease at a time strategy versus creating a system that promotes wellness and health for an entire community and village.

Happy Mothers Day to all!

Beware of the Elephants – Common Sense guide for International Social Impact Field Projects

In the last several years there has been an exponential increase in the number of graduate and undergraduate students working on social impact projects in developing country settings. Many of these programs are short term engagements that last between 2 – 8 weeks over winter, spring, or summer intersession. Often times many of these students have never traveled to the destination site and are unaccustomed to the local cultural differences. While setting up a field program, a successful project is best driven by an experience field based mentor and supervisor. However the following are some tips for the traveling student to avoid unnecessary delays or impediments to having a successful experience:

Do not be a hero

If in an area that is endemic for malaria, TB, or other infectious diseases, do not hesitate to contact a local health worker or go to the nearest health clinic. Delaying care by a few hours can cause serious consequences. Before leaving for your destination make sure you have some form of international health insurance plan such as iSOS. Also, it is very important to remember to continue taking your malaria prophylaxis medications after your return from your destination as indicated by your prescription.

Your time is short, you can never plan enough

Do your best to gather as much information as possible to understand the context of the local problem and key stakeholders on the ground. Try in advance to schedule site visits and interview schedules before your arrival date. Be absolutely sure you have all the appropriate permissions and authorizations to collect and publish results.

Expected the unexpected, be flexible

The reality on the ground in global health is that most staff from junior to senior clinicians and administrators are over worked and have little extra time for new projects, regardless of the priority or importance. Often times an unexpected situation may occur. This might be work related – critical care emergency, or act of nature – heavy rains, flooding, or infrastructure related –email is not available, massive traffic congestion. Try to remain calm and work within the system. Use your mobile phone and SMS in advance to confirm appointments and maintain follow-up. Do not rely upon email as a primary tool for communication. Always have a back up plan.

Humility is critical

Too often I have see students intentional or not discussing details about an upcoming safari or upcoming job offers including salaries from summer internship positions. Remember in most instances one is working in an environment where there are vast structural differences and limitations to both educational and employment opportunities. Be appropriate and think before speaking. Remember that most of the professionals you are working with are mostly constrained by context, not by intellectual capacity or desire for advancement. If local partners sense you are insincere or in-country for a resume building exercise then the chances of accomplishing your goals for your project will be greatly limited.

Be smart, use common sense

When in doubt, don’t do it. Things that are most common that cause serious illness or worse include: 1) Eating or drinking from unsafe sources of water or uncooked food, 2) Traffic accidents. If the care or transport looks unsafe or the driver seems incapacitated due to alcohol or something else, just say NO!. It is better to be late than the alternative. 3) Unsafe pursuits. Most places of travel are endemic for HIV/AIDS. Unprotected sexual activity is playing Russian roulette. Also do not rely upon local safety standards for national parks and extreme sport activities. Double check all rented equipment, terrain vehicles as well as arrange activities through a recommended local travel agent. Saving money by seeking out unverified deals can cost you dearly beyond a hit to your savings account.

Create a weekly reporting system with interim and final deliverables

As described under the ‘humility section’ most officials you will be working with on the ground are extremely busy. Also chances are that most principle investigators or faculty members from your home institution will also be very busy with many other responsibilities. Manage both yourself and your ‘boss’. Prepare in advance meeting agendas that outline critical issues as well as a weekly summary of accomplishments, upcoming activities, and challenges or bottlenecks for action. Unless you carefully document your experiences and communicate effectively and concisely both accomplishments and challenges on a weekly basis, chances are that when your stay is over and you will have missed accomplishing many important milestones.

Health Communications 101 Part Deux: Swine Flu - Separating evidence from the fear factor.

Not sure about you, but I’ve been a little bit on edge recently with all the announcements of swine flu and media sound bites using outbreak, epidemic, and pandemic. Over the last few days there has been a wide range of news coverage of the Swine flu outbreak. Responsible coverage has provided factual information regarding what is influenza and has distinguished between pandemic and seasonal (non-pandemic) flu. I would also consider part of responsible journalism to include a discussion on why in 2009 the United States and the global community is better prepared to cope with an influenza pandemic than at any time in modern history. This includes wide availability of antibiotics that are used to treat secondary infections caused by the flu virus. What can be deemed as less-responsible journalism, has unnecessarily stoked fears of a Stephen King, “The Stand”, super bug, without a scientific review of facts and safeguards in place to avoid such a scenario.

The CDC has a Q&A regarding flu. For example did you know that it is estimated that over 36,000 Americas die each year from seasonal (non-pandemic) flu? However, it is acknowledge these statistics are somewhat inaccurate and possibly under reported for several reasons: a) it is not required to be documented for persons older than 18 years of age, b) the life of the virus is short, thus detection of the virus of a primary cause of illness is not always possible, and c) many persons who many die from flu like symptoms or secondary complications are never tested for the virus.

A scientific peer reviewed article by Peter Doshi (May, 2008) in the American Journal of Public Health provides a critical review of mortality related deaths due to pandemic and non-pandemic influenza since 1900. The article provides an assessment of the topic and concludes with a section entitled “Explaining the Gap Between Evidence and fear.” Due to copy write restrictions I am prohibited from posting excerpts from the article. However it is available through Medline or other online full text journal portals at your local library for individual use.

What we have seen in recent days is an alarm over a possible pandemic. But let us not forget that due to advances in health care infrastructure and modern medicine we are better equipped to handle such responses to ensure that the public is well protected. While there are still many gaps in our public health infrastructure, lets us also be confident and not cause undue panic before we have all the appropriate facts and evidence. Precaution is good. Wash your hands frequently, especially when in public places. If prone to upper respiratory infections, especially the young or elderly, consult a doctor if you may have symptoms of the flu.

In closing, an area that is of great need is strengthening our public health infrastructure in the United States to include the uninsured. In the United States, it is estimated in a recent institute of medicine (IOM) report on the uninsured that over 45 persons are without insurance. Thus for any minor or potentially significant health aliment these persons will most likely seek care and treatment at the local emergency room. In times when a flu pandemic is feared, the weaknesses of our public health infrastructure are most exposed. This will surely translate into unnecessary costs associated with inappropriate care and treatment at emergency rooms that could have been better served in a community health clinic. 

Health Communications – Swine Influenza or Malaria. Is there a way to integrate competing health messages?

By late morning of Saturday 25th April there were some ecstatic messages by World Malaria Day advocates that said. “Malaria is number one search term on Twitter.” But that lasted a very short while. By mid afternoon the media started to pick up on a new announcement by WHO regarding an outbreak of swine flu that claimed the lives of over 80 persons in Mexico City and the possibility of spread to the United States, Europe, and Asia.

Quickly the attention of World Malaria Day was now turning towards a flash outbreak message by WHO regarding a potential new killer pandemic. One colleague described this day of competing messages as, “while I totally understand the reasons, it was a bit deflating. We worked very hard to get out the message regarding malaria and all of a sudden it seemed we were drowned out.”

In the statement released by the WHO Director General’s Office on Saturday 25, 2009 regarding Swine Influenza, there was no mentioned of World Malaria Day. This statement was picked up by major news outlets around the world in a matter of hours.

What is your opinion?

Do you believe this could have been an opportunity to educate the public about the urgency of the outbreak of Swine Influenza while also bringing the world’s attention to a disease that is reportedly responsible for the deaths of over one million adults and children a year?

Observing World Malaria day (Saturday April 25th 2009) - what would Paul do?

Thanks to herculean efforts by mainstream advocates such as Lance Laifer and his many colleagues, the generation X and post X are becoming much more aware of a deadly disease that takes the lives of over one million adults and children every year. What makes this infectious disease particularly frustrating is that experts, clinicians, and field workers agree that many of these deaths are preventable and unnecessary.

However as awareness is increased and monies are raised to eradicate malaria deaths in resource poor settings, I choose to honor my colleague Dr. Paul Ambrose, whose death on 9/11/2001 left the public health community a gaping hole and the world without one of its brightest stars. To emulate my colleague Paul’s exceptional mind and inquisitive nature I pose some questions for us to ponder on the World Malaria day:

1. Why has a disease that kills over one million persons a year been neglected? What incentives have been lacking and how can we structurally change these incentives?


2. Can old technologies such as DDT be re-formulated to maintain their effectiveness to kill malaria infected mosquitoes while avoiding harmful side effects on humans?


3. Is money the only missing ingredient to eradicate the disease? What are the other issues such as political, social, and bureaucratic that have led to problems in the field?


4. What existing versus emerging technologies are most cost effective for prevention versus treatment; bed nets, vaccines, etc.


5. Should donors focus on the local production of bed nets versus importing foreign made bed nets to sustain and build local industry?


6. What do the local African Leaders have to say about existing efforts to date for malaria control? What have the successes been, where have we failed, how do we move forward? Can we invite these leaders to the US and speak to us about the challenges they face?


7. How can new technologies such as web casts and twitter stimulate direct dialogue with field workers to help them be more effective through existing efforts?


8. What strategies can we develop specific to discovery, development, health delivery, and primary prevention that complement other existing priority global health problems without creating health worker brain drain and maximize allocation of scarce human and financial recourses.
   
   As a global community we can work together to achieve greatness. By asking the difficult questions we can provide effective solutions to eradicate this dreaded disease while also being thoughtful about other existing problems in global health.
   
   Paul, thank you. Your shining light and inquisitive mind continue to spur us to new heights.

HST939 Update – The Fight against MDR-TB. Example of Public Private Partnership Collaboration.

Dr. Gail Cassell, Vice President for Scientific Affairs and Lilly Research Scholar for Infectious Diseases, Eli Lilly and Company was our distinguished guest today in HST939. Dr. Cassell is heading up the Lilly initiative to fight the spread of multi-drug-resistant tuberculosis (MDR-TB). The genesis for this program stems from a conversation that Dr. Cassell had with Paul Farmer and Jim Kim of Partners in Health fame. To Lilly and Dr. Cassell’s credit they embarked upon a path to develop new therapeutics to treat this deadly form of TB.

MDR-TB is defined as TB that is resistant at least to the two most powerful first line anti-TB drugs. MDR-TB has been on the rise and the WHO reported in 2008 that there are nearly one half million new cases per year of the estimated 9 million total new cases of TB estimated per year. WHO further reports that extensively drug-resistant tuberculosis (XDR-TB), a virtually untreatable form of the respiratory disease, has been recorded in 45 countries.

It was recently estimated that worldwide approximately 450 million USD was devoted towards treatment, discovery and diagnosis for TB globally. To put this in perspective it is further estimated that 1 Billion USD is required to develop and bring a new product to market. Thus as with most neglected diseases, there is a great short fall in global industry and public sector monies to tackle this disease.

The MDR-TB effort at Lilly is an example of a successful public and private collaborative for neglected disease and reportedly one of the largest philanthropic industry efforts to date. However there is much more that the global community has to do. It certainly cannot be left up to the private sector to subsidize research and development for neglected diseases in the developing world. The internationally community must come together to develop policy that incentivizes private sector partners to develop products and extend IP to ensure that the most in need receive life saving medicines.

This is arguably one of the greatest opportunities and challenges our generation has to tackle in addition to global warming and poverty; the development of capital markets that incentivize private industry to serve the world’s poor. The answers are not hard to find. Combinations of tax incentives, patent protection, subsidizes to spur innovation coupled with strengthen of quality assurance and health delivery systems can help eradicate/reduce disease burden in developing countries as well as resource poor settings within the united states, Europe and Asia. Within this context it is critical to develop an overall global health investment strategy that focuses on health systems to avoid targeting simply high profile diseases.

Re-thinking incentives

In an article written by Richard Stevenson of the New York Times, a discussion of re-thinking the current predominate economic model for the US economy is presented. Mr. Stevenson points out that, “In the two decades since the fall of the Berlin Wall, the American model of capitalism, largely unchallenged by ideological alternatives and increasingly dominant around the world, drifted toward what conservatives viewed as a more pure form of economic liberty and what liberals came to view as misguided free-market fundamentalism.”

Furthermore Mr. Stevenson states, “But now, as the United States and other nations look for lessons in the wreckage from the excesses of that period, political leaders are confronting uncertainty about what economic structures and values should define capitalism’s next chapter.” This article provides some fuel for discussion not simply on the US economy, but also the global economy. For example, currently over 90% of the worlds research and development budget for medical devices and pharmaceutical products is targeted towards 10% of the world’s population. Chaos creates opportunity.

While the existing political will and policy tools might not support a board re-shaping of how the US and European countries incentivize corporations to develop life saving medicines and products for the world’s poor, it is time to start re-thinking how best to create incentives to do so.

Microfinance: Banking for the world’s poor. Separating success from faux

Micro lending or banking for the world’s poor has been made especially famous by Professor Yunus. Professor Yunus and the Grameen organization have paved the way for new lending practices to reach millions of persons living in developing countries to help break the vicious cycle of poverty.

Given the recent problems and blatant examples of corruption exposed during the recent financial crisis in the developed world, I became curious about what safeguards are in place for the multitudes of expanding micro lending programs in developing countries.

An informative beginners article on the subject entitled Delivering microfinance in developing countries: Controversies and policy perspectives (Bhatt, 2001) provides an overview of vehicles, technologies, and performance assessments for financial service delivery to the world’s poor. Bhatt points out that absolute poverty is 75% lower in villages with Grameen programs than in villages without such programs (Khandker, 1996). However as a word of caution Bhatt further mentions that performance of other programs has not been as encouraging. Other programs have been plagued with such problems as high default rates, inability to reach sufficient numbers of borrowers, and a seemingly unending dependence on subsidies.

Given the recent implosion of the financial services industry in the developed world, particular attention should be made towards safeguarding lending practices to the world’s poor. We cannot afford for a scandal to erupt in the micro lending that would discredit an industry that has helped millions of people escape poverty. This is an area ripe for opportunity for organizations such as FINCA, Grameen, BRAC, KIVA, as well as independant agencies to further develop international standards and monitoring practices to ensure maximize outcomes and reduce corruptive influences.

HST939 Update – Clinton Foundation – Tackling Drug Supply to Increase Access to Treatment for HIV and Malaria

Today was another special day for our HST939 course. Inder Singh, Director of Drug Access for the William J. Clinton Foundation was kind enough to take time out of his busy schedule and chat to our class about his teams experiences. Inder and his team at the foundation have done extraordinary work on the supply side to help reduce costs of anti-retroviral therapies (ART) for persons living with HIV/AIDS (PLWHA).




Under his leadership an interdisciplinary team of scientists, business professionals, clinical, and public health professionals have helped to reduce the cost of ART as well as combination therapy for malaria medicines. In a few short years this team has worked to remarkably increased access to life saving medicines for pediatric AIDS patients around the globe. Another very impressive accomplishment for this team has been the 50% reduction of Malaria medicines for the world’s poor which has led to a doubling of access to life saving drugs.

A key question raised was, “How does one reduce the cost of life saving medicines for developing world markets?” A short list of answers ranged from negotiated price reductions, high volume advanced market commitment agreements, support lower cost local generic manufacturing, and price subsidies. However beyond these mechanisms, scientific and discovery ideas were also discussed. These include reformulation, harmonization of raw material supplies to help reduce risk as well as prices for manufacturers.

The Clinton Foundation is a shining example of innovative business practice. Personally, I worked with the foundation in 2004 as a country director for Jamaica. So I learned up close the workings of this extraordinary organization. I learned firsthand how one can apply business skills to tackle problems in emerging and resource poor markets. This experience has carried over and provided me great confidence that by working on a focused, no nonsense agenda with stakeholders from public health practice/NGOs, industry, public and private sectors innovative solutions can be created for seemingly impossible obstacles in global health. The motto that I still carry with me that exemplifies my experience is the Harry S. Truman Quote; “It is amazing what you can accomplish if you do not care who gets the credit.”

It is my personal belief that we have only begun to scratch the surface on supply side solutions. I also believe that innovative incentive and business models for pharmaceuticals, medical devices, and diagnostics will emerge over the next 3 – 5 years. These models will support rational design for emerging and resource poor markets as well as strengthen in-country testing capabilities that are a necessity to further the discovery and design sciences that meet these unique market needs. This is an area of great personal passion and I encourage others who may read this blog to contact me directly if interested in furthering the study and implementation of these models.

Open Source Clinical Systems and Global Health– Barriers and Opportunities

Open source for global health is an area of great strategic importance in the international community. The promise of open source projects in global health is to facilitate the implementation of interoperable platforms responsible for storing and sharing electronic health information to improve quality of health care delivery. Pioneering organizations and champions in this area include the OpenMRS Team, Google and Partners in Health. These organizations and numerous others from around the globe have been championing the cause to improve the quality and access to health information systems in developing countries. The dedication of these professionals must be applauded for their selflessness to save lives and reduce human suffering through the advancement of open source electronic medical records.
Deploying medical records systems has historically been challenging even in developed countries. For example in the United Sates, less than 50% of clinicians have adopted EMRs.

Similarly, deploying medical record systems in emerging markets and developing countries has its many challenges. Issues related to limited availability of computers, sporadic internet access, inadequate storage, intermittent power and infrequent access to in-service training all can reduce the speed of adoption of clinical management systems for global health. Other issues facing adoption of medical records in developing countries include lack of proper motivation and incentives for staff to use medical records and other critical information systems for health. This is a critical issue because there are many existing legacy systems in developing countries. However these systems often do not have adequate numbers of technical support staff to provide necessary training or report writing capabilities to motivate workers at the point of care to enter quality data into the system.

In countries where there are extreme human resources for health (HRH) crises (inadequate trained medical staff, poor retention and motivation for existing staff) there is a vicious cycle; Too few staff to adequately treat clients and poor adoption of information management tools that could improve efficiencies to improve client care by the existing health work force. Yet adoption of information systems to help improve quality of care through outcomes and resource utilization reporting is critical to maximizing the potential of human and capital resources in developing country settings.

A way forward for Open Source in Global Health

Advocates of open source development have implemented an impressive distributive programming team that engages the brightest minds from around the world to lead the development of novel medical record technologies that can be applied to improve efficiencies, while reducing the rate of unnecessary medical errors. Without a doubt the implementation of novel, low cost, easily scalable and user friendly systems to improve clinical, financial, and outcomes reporting will provide a much needed tool kit to the existing human resources for health crises that faces much of the African Continent and other emerging settings. However, one must consider the limitations of deploying open source health records if they do not look to improve the existing incentives for health workers to adopt these systems. Another critical area for expansion it to promote a sustainable local business environment that can create a vibrant home grown technology sector to maintain and expand these systems. Fortunately the trend to foster local capacity is becoming more main stream and a focus of attention.

Happy Easter and Time for Reflection

Happy Easter Sunday. My wife Michelle and I sincerely hope and wish you all a wonderful and happy holiday.

Holidays are a time to reflect, appreciate the gift of life, but also the possibilities of how we can extend ourselves to helping others in need.

Today’s New York Times has an article entitled, “States Slashing Social Programs for Vulnerable” by Erik Eckholm. This article reports upon the recent slashing of budgets for programs by a majority of states that serve the most vulnerable of populations. These include the elderly and high risk sub-populations prone to child abuse.

While in the short term cutting these programs can help balance state budgets, slashing such budgets will disrupt critical preventive efforts that would save money and reduce human suffering over time.

The United States has been facing rising health care costs for many decades. Slashing of prevention programs targeted at the most vulnerable populations is politically expedient to cope with short term budget deficits. However, in the intermediate and longer term cutting these programs will adversely impact overall health care costs for state and federal programs in years to come.

A way forward would be to complete a thorough due diligence to estimate the short term budget savings while accounting for the longer term adverse impact on human health and forecasted cost burdens to the state. Only by factoring both indirect and indirect costs into a thoughtful review of proposed reductions in social programs will policy makers be able to ensure fiscal discipline that does not forsake the overall physical and financial health of our country.

My grandmother used to say to me as a little boy, “we are only as strong as our weakest link.” To cope with the current budget crisis we can surely find ways of meeting budget shortfalls that do not slash serves for our most vulnerable populations.

Tackling Malaria - Challenges and Opportunities

Recently, there has been a surge in awareness and action in recognizing the horrible toll malaria has on the developing world. From mainstream advocacy by groups such as 'madness for malaria' and less publicized day-to-day field worker initiatives, the battle to saves lives is taking place every day.

In Tanzania, malaria still accounts for the highest all cause mortality among children. Reasons for this are complex. These include cultural, political, biological, and economic.

For example there has been important progress in Zanzibar over the years in combating the disease among children and adults. Yet despite these efforts, success has been more challenging on the mainland. Some of this was due to ineffective policy that had prohibited private sector facilities from procuring preferentially priced pharmaceuticals, creating an undue tiered system that created inequities in access to life saving medicines. Other reasons include resistant strains of the malaria parasite, inadequate distribution of bed nets, and mainstream beliefs that inhibit widespread prophylaxis.

A cautionary tale is while currently there is hundreds of millions of USD invested in the search for a malaria vaccine, it is critical to appreciate that barriers to effective treatment are multi-factorial and no magic bullets exist. New microfluidic diagnostic tools will also allow for large low cost panels to screen children and adults for dozens of infectious diseases, including the malaria parasite, within minutes. But diagnosis must also be accompanied by affordable access to life saving medicines. Even with an effective vaccines and/or diagnostic tools, public health innovation must also be achieved in policy reform that streamlines procurement and distribution practices between both public and private stakeholders for eradication strategies to be effective.

Tackling Diabetes for Worlds Poor and at Home

Diabetes is increasing faster in the world's developing economies than in developed countries. Seven out of ten countries with the highest number of people living with diabetes are in the developing world. With an estimated 35 million people with diabetes, India has the world's largest diabetes population (http://www.worlddiabetesfoundation.org/).

Unfortunately, due to lack of access to proper medicines and staff trained to diagnose and treat diabetes many persons in the developing and resource poor countries die prematurely. Type I diabetes (juvenile diabetes or insulin-dependent diabetes) is often misclassified and is an immediate death sentence for many because of lack of access to Insulin. Type II diabetes (adult-onset or noninsulin-dependent) is on the rise due to changes in lifestyle, poor diet, and urbanization of populations.

But the problem of diabetes is felt very much in the United States and developed countries. For example in the US, one out of every five health care dollars is spent caring for someone with diagnosed diabetes, while one in ten health care dollars is attributed to diabetes (http://www.diabetes.org/).

With much of the world’s attention focused on common infectious diseases such as Malaria, TB, and HIV/AIDS, non communicable diseases such as Diabetes have been forsaken.

But with evolving innovative global health partnerships with private (http://www.sido.co.tz/aphta/index.html), faith based, and public leaders in health care in developing countries the challenge is starting to be addressed.

Diabetes is a perfect example of how working in setting up a development partnership to service the bottom billion can help create cost effective design and products for the developed world. What is needed are innovative financing mechanisms to stimulate industry to design diagnostic and therapeutic products for low resource poor settings. These products and services can have great impact on reducing costs for our own health care in the US, Europe, and Asia.

For individuals and organizations interested in learning more about how to partner or learn about specific projects (http://www.bienmoyo.org/), please contact us @ info@bienmoyo.org.

Importance of Development Partnerships

Recently there has been in influx of interest in the development of low cost medical devices for resource poor and developing country settings. This has spurned a great deal of passion and interest by students, faculty, and partners to develop prototypes and send teams for short stays to document future requirements as well as tweak existing designs. Examples of ingenious devices/products from the fruits of many hours of careful design and development have ranged from pill boxes to urine strips for monitoring ingestion of life saving medicines.

However, it is critical to incorporate these activities into a framework for proper testing and evaluation to ensure safety and efficacy of programs prior to human subjects testing. A challenge in developing markets is porous oversight, especially in rural communities to monitor pilot programs and report on results. Additionally, while international standards exist for good clinical practice, the cost of adhering to such standards is not tenable in many developing markets without further direct investment.

The good news is there are some world class clinical and laboratory infrastructures in place that have been developed due to large investments from organizations such as the National Institutes of Health (NIH) and center for disease control (CDC). However these structures have primarily been focused on infectious diseases, vaccine development, and surveillance activities. Rarely have these existing platforms been available to the social entrepreneur trying to innovate.

New methods for partnership and investment are required to transform the existing landscape to better serve the bottom of the pyramid. Such investment will create a platform to support the development of a well vetted pipeline of innovations in global health practice.

THE WAY FORWARD: PARTNERSHIPS AND INNOVATION - AMNH

It was a thrill to participate in the recent Spring Symposium at the American Museum of Natural History on Exploring the Dynamic Relationship Between Health and the Environment. The conference was hosted and organized by the Center for Biodiversity and Conservation's Fourteenth Annual Spring Symposium.

I have the privilege for speaking on the final panel that focused on a way forward for strengthening collaborative projects and partnerships in global health.

http://symposia.cbc.amnh.org/health/index.html

Bottom line (audio to be released shortly) is while much has been accomplished to support research and activities for infectious diseases, we are far from a comprehensive or strategic approach to integrating non-communicable diseases (NCDs). Given the existing limitations that are related to human resources in health in developing countries, it is critical to look at cross cutting health systems strengthening areas that can improve ID and NCD integration.