Towards The Grand Convergence and Universal Health coverage – A panacea

by Titus Ngeno, Josh Rivenbark

As countries transition from millennium development goals (MDGs), and focus on implementation strategies for sustainable development goals (SDGs), healthcare remains a primary concern in bridging the gap between developed and developing countries. It is represented in Goal 3: “Ensure healthy lives and promote well-being for all ages.” Under this goal, one of the overarching targets is attainment of universal health coverage (UHC).

The concept of UHC is not new and has been growing over the course of the past two decades. In 2005, the World Health Organization (WHO) member states committed to develop their health financing systems to ensure access to services for all people. The countries also committed to ensuring that the people do not suffer financial hardship in paying for health services. This is the spirit espoused in universal health coverage and is envisioned to reduce the gap in health care between rich and poor countries.

Unfortunately, there is no “one shoe fits all” solution to establishment of universal health coverage. The concept represents a convergence of perspectives on what attainment of health is. In addition, implementation of universal health is undertaken under disparate governance structures. The resources with which to develop universal coverage, as well as pre-existing levels of coverage, also vary greatly from country to country. The 2010 WHO report on health systems financing highlighted three main barriers to achievement of universal health care: availability of resources; overreliance on direct payment at the time of need; and thirdly, inefficient and inequitable use of resources. The report noted that there are also several other factors influencing health, which lie outside the primary realm of the health sector and administrative dockets. These areas, such as education, housing, food, security and economic growth, are inter-linked with health outcomes and influence attainment of universal health.

Furthermore, as countries work to achieve UHC, it is not yet clear how progress will be tracked. Measurement is a critical factor in goal setting, and the goal of UHC presents unique challenges to measurement. According to the WHO, UHC is “ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.” As was alluded to in class, there are a LOT of aspects of this definition that would need clarifying. For example, what exact services are included? Is it the same package in every country, or should it account for the resources of a given country? And how is financial hardship defined? Clarification (and arguments about definitions) will likely be needed before a specific measure is adopted.

Nevertheless, UHC is not just a utopian fantasy. Bridging the healthcare gap between developed and developing countries is achievable, albeit slowly. Countries such as Chile, China, Costa Rica and Cuba have demonstrated that this is feasible in a 21 year period by scaling up health sector interventions as reported by the lancet commission on investment in health. Increasing capacity for universal health coverage has also led to improved health outcomes such as infant and under-five mortality in Tanzania. In Estonia, life expectancy has increased by about 10 years. In India, where the concept of UHC dates as far back as 1946, good access to preventive and curative health services has been achieved even though financial coverage is still lacking for most services (as surveyed by Devadasan et al).

Going forward, in order to attain universal health coverage, development of health insurance and health provision industries should occur in tandem with strong backing from policy makers and stake holders (Jane Doherty et al). The global call to focus on the SDGs is an opportunity to echo the 1990 MDG call, and to rally governance sectors and the wider society to embark on attainment of universal health coverage in order to ensure healthy lives and promote well-being for all ages.

FINDING ALTERNATIVE FUNDING FOR THE ONE FAMILY HEALTH INITIATIVE

 Chelsea Swanson and Caesar Lubanga-kene

The One Family Health (OFH) model is a phenomenal response to the health care worker shortage which is a perpetual challenge to the health care system of Rwanda. The model is well-thought out, effective, and requires comprehensive cooperation from a number of players both in the private and public sector both locally and internationally. OFH has adapted its practices to offer healthcare under the Mutuelle insurance, obtain essential technologies like Lifesense, and train its employees in quality treatments and additional skills like human resource, financial and supply chain management, while offering a sustainable plan.

However, despite all of these progressive and impressive qualities, OFH may be on the verge of a downward spiral. The recent withdrawal of Glaxo Smith Kline (GSK) a major partner from the financial support of the model is calling into question whether OFH can continue to be an effective player in the health care worker shortage and continue operations to improve health in Rwanda.

GSK, as the main funder, was a backbone for the OFH model. It gave the Rwandan government and local banks faith in the program. The loss of GSK as a funder may mean the loss of faith from the local government and local banks that deemed loans to the local enterprise to risky to provide loans a gap that GSK had well covered. It is a domino effect that is in urgent need of saving.

But how?

First we ask why GSK dropped out? Well, according to them, they felt the risk was too high, and that they would lose more than they gained. Next we ask what could have been done differently when recruiting and obtaining funders for the program?

Here is where some of the problem solving can begin. The back bone is made up of vertebrae, but with GSK as the backbone funder to OFH, there is no smaller vertebra to fall back on. By starting out with more investors and venture capitalists, the likelihood of failure due to one investor pulling out is much smaller.  There are many investors willing to invest small sums and if pooled this could incrementally fill the enormous funding gap left by GSK.

Another potential solution would be a government intervention through a co-operative incentive scheme. This would be where the government offers money to a group of health clinics at once. The goal of OFH would be to recruit and stratify the health clinics, possibly by geographic location like a district, and conform them into an association that the government can support financially. While governments in Africa have limited funds, the successes of the OFH model in strengthening the health system, demonstrates both the need and worth of funding.

This might also be a productive way to gain local support for the health clinics within each community. The combination of social support and accountability make it harder to misuse the money from the government to the association other than individuals.  

In sum, OFH still has time to find funders and hopefully get back on its feet in the wake of GSK’s exit. Government support and a multitude of smaller private investors are two potential solutions to the problem in order to sustain the model of OFH keeping its public private partnership goodwill while maintaining a source of health care workers and supply providing quality health care for the people of Rwanda. 

Picture: Rwandan health workers preparing for a ward round.

Source: www.mhtf.org

Medical Technology in Global Health

by Denali Dahl and Rosa Castro

In his engaging presentation last Tuesday, Dr. Robert Malkin introduced us to a shocking reality: most of the medical equipment donated to the developing world ends up being a burden. Donors might have good or bad intentions but the reality is that most donations are ineffective, troublesome, and often cause more harm than good.

The accumulation of ineffective technology in low and middle income countries is due to the lack of spare parts and the technical knowledge, which lead to an inability to repair or maintain the donated medical equipment. Without the capacity to fix technical equipment, the devices intended to improve access to quality medical care end up “parked” in a hospital, taking away space rather than helping anybody.

Donors are more excited to donate different pieces of equipment rather than fundraising to provide spare parts or money to maintain the medical equipment they have dumped in another country. This fundamental flaw in the system must be addressed for donations to become sustainable solutions that have provide long-term improvement.

3D printing technology has the potential to create new materials and parts on large and small scales with a wide variety of applications, a concept that has revolutionized the engineering world. The question becomes, can 3D printing extend beyond the laboratories and be applied to improve the donated medical equipment problem?

3D printing can generate spare parts and consumables without having access to large-scale manufacturing facilities. With thousands of pre-programmed designs at hand, using a 3D printer is becoming more user friendly everyday. All the user has to do is load their material--usually a plastic polymer--select design specifications, and watch while their creation comes to life.

Technology like 3D printers has the potential to provide low and middle income communities with ways to build products for themselves, especially small parts to repair the larger medical equipment constantly being donated. In Haiti, 3D printerswere recently used to help Haitians build their own umbilical cord clamps. The ability to 3D print the necessary items empowers hospitals and clinics by giving them a tool to become more independent, instead of having to rely on donors or the government to provide everything.  

Image credit: Makezine.com

The main drawback is, what happens when the 3D printers break and need their own spare parts? Would donating 3D printers along with medical equipment be helpful or harmful? Would the 3D printers be another sophisticated device “littering” the developing world? 

Source: http://www.scientificamerican.com/article/medical-equipment-donated-developing-nations-junk-heap/

3D printers have the potential to alleviate the disparity between having and using medical equipment, but to be effective technology in any form must be donated in a sustainable manner to ensure long-term benefits to the selected communities. 

Filling Healthcare Gaps with Tumeric and Mushrooms?

by Matt Boyce

After our lecture from traditional medicine experts Dr. Boyd and Dr. Stanifer last Thursday there were two points that really resonated with me:

(1) That traditional medicine places a special emphasis on the difference between being cured and being ill.

(2) That traditional medicine should be viewed as a tool in a multi-disciplinary health arsenal, not an alternative to modern medicine.

Keeping these things in mind, it seems, to me at least, that there is a very clear and practical role for traditional medicine in current treatment practices. And after spending some time trying to wrap my head around an example of where I saw an application of traditional medicine in this way, I finally settled on a current event...

Does the name Martin Shkreli ring any bells? Yes, of course it does. Just last month he raised the price of Daraprim, a 62 year old medication commonly used to treat parasitic infections in immunocomprimised patients, from $13.50 a pill to $750 a pill. And in doing so became the Scrooge of the pharmaceutical industry by hoarding wealth and exploiting the poor, drawing condemnation of humanitarians, politicians, and pretty much anyone with a moral compass and internet access.

Meanwhile, another pharmaceutical competitor has stepped up to challenge him, announcing that it will now offer a version of Daraprim for as little as $1 per tablet. But what if there were other alternatives? Enter traditional medicine.

Ok, before I lose you, I do recognize that’s a bit dramatic. I’m not about to argue that traditional medicine should replace a highly effective drug. The development of modern medicine, that is the development of antibiotics and vaccines, is one of the most important scientific developments ever. However, I do feel that “Traditional Medicine: Novel Treatment for AIDS and Cancer Patients” would make one hell of a newspaper headline, and that there is a place for traditional medicine in our current Daraprim predicament.

Let’s begin with focusing on turmeric, one of the first few examples of traditional medicine that was presented to us. As alluded to in our lecture, turmeric may be one of the most beneficial spices in the world, owing largely to the fact that it contains a compound called curcumin. Curcumin has many health benefits, including promoting brain function, protecting against depression, and delaying aging (all of which I hope we can all agree would promote a “sense of overall wellness”). But quite possibly the most important benefit is it’s potent natural anti-inflammatory attributes. While acute inflammation is great and all, as it helps fight pathogens and helps repairs damage, chronic inflammation has been shown to be really bad for our bodies. So bad that some researchers believe it may play a role in heart disease, cancer, metabolic diseases, and a handful of other chronic, Western diseases. As such, any compound that can suppress chronic inflammation, including turmeric, may be viewed as a potential therapy or even prevention of disease, which also happens to be what cancer researchers have to say about the spice.

To shift our attention to another example of traditional medicine, let’s focus on mushrooms. Mushrooms, especially shitake and button varieties, are excellent sources of vitamin D. And why exactly is consuming vitamin D so great? Because while our bodies naturally produce it when exposed to sunlight, many of us are still deficient in vitamin D levels. This could pose a problem, or at least warrant concern, as vitamin D has been shown to help prevent chronic illness, and also helps regulate cellular growth, reduce systemic inflammation, and fight a whole slew of infectious diseases.

The micronutrient’s therapeutic properties have long been recognized, and some recent studies even go as far as to allude to antibiotic like properties being associated with it. In fact, in the pre-antibiotic era, physicians realized that both sun exposure and cod oil could play a protective and therapeutic role against TB. And while the two treatments have their obvious differences they have one thing in common: active forms of vitamin D. So I’ll propose the following question: is it really that far of a stretch of the imagination to think that vitamin D could also help prevent or treat illness in these immunocompromised individuals?

While I personally do not believe that making sure to eat mushrooms sprinkled with turmeric is remotely close to a means to replace treatment by Daraprim in these patients, I don’t think it could hurt to at least acknowledge the health benefits that may be achieved by incorporating these traditional medicinal foods into their diets. Especially if we put the time and resources into understanding the metabolic pathways that underlie their therapeutic properties.

So, to offer a brief summary of what we’ve covered here: We first established that Shkreli is a goon who has put a lot of people in a bad situation. Next, tumeric, in addition to promoting a general sense of wellness may play a role in decreasing the risk of disease and decreasing the risk or progression of cancer, one of the immunocompromised populations that frequently uses Daraprim. We followed that up by covering that mushrooms containing vitamin D could act as a potential therapy to counter infection, much as Daraprim is used as a therapy to counter parasitic infection. Ultimately, combine the two (in the albeit oversimplified scenario I just presented) and you get a one-two punch that could compliment other therapies, or help fill the gaps left by the actions of Shkreli.

Farming for Child Health: A Pilot Project to End Hunger in Hospitals

by Emily Esmaili

The Ministry of Health of Rwanda recognizes the persistent problem of child malnutrition and its contribution to child morbidity and mortality. As such, it has put into place the National Food and Nutrition Strategic Plan (2013-2018), which aims to eliminate malnutrition in every district in the country. Huye District (Butare) is one with higher levels of poverty and food scarcity than other districts: The Integrated Household Living Conditions Survey (EICV4) carried out in 2013-2014 indicates that Huye district is 8^th poorest among the 30 districts in the country (with 32.5% of the population considered as ‘poor’ and 5.7% as ‘extremely poor’). Along with widespread poverty, Huye has exceptionally high rates of child malnutrition and stunting as compared with other districts. It happens that this district also houses the country’s largest university and medical school, as well as one of the largest teaching hospitals.

Centre Hospitalier Universitaire de Butare (CHUB) is the main referral hospital for southern and western districts in Rwanda, as well as one of the two main teaching hospitals in Rwanda. I was stationed at CHUB from February 2014—August 2015, working as Pediatrics Faculty with Yale University and Rwanda Ministry of Health, through a program called Human Resources for Health. Due to the aforementioned high rates of poverty in our catchment area, the majority of our patients were not only malnourished, but also could not afford sufficient food during their hospitalization, which (predictably) hindered their ability to recover and cope with their illnesses. Despite providing the best medical care we could, patients could not meet basic daily nutritional requirements and therefore often had prolonged hospitalizations and difficult hospital experiences.

Children are especially vulnerable to the long-term impacts of malnutrition. Poor neurodevelopmental outcomes are closely linked to early nutrition—starting in the womb. On our wards, manifestations of malnutrition ranged from frustratingly slow recovery from basic childhood illnesses such as pneumonia, to more chronic cases of rickets, to wasting in premature babies from inadequate breast milk (because mothers were themselves too malnourished to produce milk, and could not afford formula).  Treating children, and teaching students and residents about pediatric medicine, was exceptionally challenging when such basic needs were not being met.

Overview, Goals, and Objectives

In response to this dire situation, we developed a nutrition program to address nutritional needs in a comprehensive and sustainable way, through a program originally called Farming for Child Health (F4CH). This multi-component program involves providing food for malnourished pediatric patients, breastfeeding mothers, and now surgery patients as well; growing crops and livestock to supply some of the food; and family education about sustainable farming, hygienic food preparation, and healthy, affordable nutrition.  The program officially began in May 2015, and owing to its huge success, is now expanding to include patients in Internal Medicine and Obstetrics and Gynecology wards as well. Our ultimate goal is to replicate the program in hospitals throughout Rwanda, pushing towards the goal of eliminating malnutrition through education and self-sustainable agriculture.

Program Details

F4CH quickly grew into a larger organization, now called Kuzamura Ubuzima (KU), or “Growing Health.” We have partnered with a local NGO, Agaseke k’Urukundo, who farms a large portion of the land surrounding the hospital. The Director General of the hospital granted us ample land to start planting our crops, in partnership with Agaseke. We selected seeds for foods with the highest nutritional value and local availability for cultivation, emphasizing dietary diversity as much as possible. For livestock, we began with pigs, who could recycle the kitchen scraps, produce manure for fertilization, and be sold for additional income—and perhaps eventually supply manure for biofuel as well. In the next few weeks, we plan to bring in dairy goats, which each produce up to 3 liters of nutritious milk, with much less upkeep than cows.

In the hospital’s on-site wood-fueled kitchen, our cook (with the assistance of patients’ families) prepares two meals per day largely from the farm yields: one meal of high-energy porridge (Sosoma, comprised of soy, sorghum, and maize), and one well-balanced lunch (including vegetables, greens, protein, starch, and fats). A typical meal includes rice or potatoes mixed with tomatoes, carrots, onions, peanut powder, and small dried fish; a green leafy vegetable; a boiled egg; an avocado, and a banana. Food staples such as rice, salt, oil, etc. are purchased from local markets.

Beneficiaries are identified by nurses and our project manager, as those with the highest degree of food scarcity. Narrowing the list of those in most need is the project’s most difficult task. We currently feed 30 pediatric patients and 40 surgery patients, and will soon include Internal Medicine and Obstetrics and Gynecology patients as well. We soon plan to conduct a baseline survey to assess the prevalence of food scarcity and malnutrition among hospitalized patients, as well as the impact of hunger upon hospital length of stay. We also plan to conduct ongoing surveys for monitoring, evaluation, and program adjustment as needed.

We have partnered with a Kigali-based NGO called Gardens For Health International (http://www.gardensforhealth.org/) as well as the Catholic University of Rwanda School of Public Health and Human Nutrition, to assist with nutrition education and teaching demonstrations, emphasizing hygienic and nutritious food preparation. In addition, BIOCOOP Rwanda (http://www.biocoop.rw/) supports our agriculture and “farm to fork” activities. We have also partnered with Veterinarians Without Borders (http://vsf-belgium.org) for technical support on best livestock practices. We hope that through these partnerships, patients and families can engage in experiential learning activities to encourage healthy eating and sustainable family farming. Ultimately, we hope to foster long-term behavior change and improved well-being overall.

While initially dependent on private donations, the ultimate goal is for surplus crop and livestock production to generate enough income to meet the costs of farm and program maintenance. Eventually, we hope the farm will be able to feed patients with minimal financial input. Until we reach this goal of self-sustainability, our operating expenses run entirely on donation.

Directions ahead

Though still in its nascency, KU has relieved the hunger of numerous patients. Children have been recovering from their illnesses and getting discharged home more quickly, and mothers have once again been able to produce breast milk. Caretakers no longer have to choose between buying medications and buying food. Families and hospital staff have been able to watch the seamless flow from cultivation, to preparation, to proportioning of whole, nutritious foods, meeting a very basic—and vital—need. Many of these successes are owed entirely to team on the ground—especially our Program Coordinator. While her skills range from orchestrating and meticulously documenting all program activities, to rearing piglets and growing mushrooms, the job is quickly growing too large for one person to manage. We are seeking more managerial support as the project continues to expand and flourish.

It was completely gratifying to watch our seedlings grow into food on patients’ plates, and to see a simple warm meal transform a listless child into a lively one. However, what would be even more gratifying would be to know that this modest project, in this one corner of the world, has sown seeds for an enduring solution to hunger in our hospital—and perhaps in other hospitals like ours.  We hope that Kuzamura Ubuzima continues to grow, flourish, and thrive—along with the patients it will feed. 

Pollution and Global Warming: Can you smell the inevitability?

by Shem Opolot

Stop smoking and you will lower your chances of getting lung cancer; drink less and more often than not, your liver will stand the test of time; practice safe sex and hopefully you won't get AIDS. In a simpler world, simple behavioral changes such as these would alleviate most of the ailments that plague our existence. But what do we do when the very air we breathe will kill us if we're exposed to it long enough? Where do we run? Air pollution is a difficult problem to solve for several reasons:

We've caught on very late in the game. In the times of the London smog, during the boom of the industrial revolution, we were none the wiser to the price we pay for "progress". All we saw were bigger engines, and faster cars; bigger buildings and huge clouds of smoke signifying the fruits of our labor as we inched towards the modern era. It has taken several years for global warming and its causes to become a mainstay in our media and research, and despite the overwhelming evidence of global warming out there, we still have several skeptics. And unfortunately, some of  these skeptics are tax payers and legislators, who are serious impediments to the mission to create policy that can protect our world.

The negative consequences of the pollution problem are experienced disproportionately around the world, hence it has been difficult to prioritize attempts to abate the issue. For example, per the National Resources Defense Council (NRDC), the United States is the largest source of global warming pollution- emitting more carbon dioxide than China, Japan, and India combined. However, the crux of extreme global warming effects are being experienced outside the borders of the United States,  like the scorching heat waves in India earlier this year. As polar bears lose their homes in  the polar regions of the planet, or people's houses get wrecked by floods in Asia, others burn fossil fuels and manufacture cars with in-built software to cheat on emissions tests (yes Volkswagen, I'm talking to you). We willfully suspend our concern for these tragedies and our roll in them only until we have to tweet #PrayForCountryX, or until we have an excuse to go serve overseas,  whenever our guilt and compassion meet  opportunity.

How can we get ahead of this trend? Who polices the police of global greenhouse gas emissions? Should some countries start demanding reparations from the developed countries that produce much more emissions? Also, have we really failed to engineer and distribute clean energy? Or are we simply complacent? Or are our hands tied by the powers that be-the large corporations with lots of money that continue to benefit from burning coal fuels and other activities that are harmful to our environment? This issue is reminiscent of the battle that raged on over the banishment of the usage of  lead in gasoline for cars in the 1980s. I hope the implementation and translation into policy of the scientific evidence available now can result in swifter action to preserve Mother Earth.

Air Pollution: Do We Have A Panacea?

by Yudong Qian

In Dr. Zhang’s lecture, he introduced the history of global air pollution in developed countries and offered solutions for the air pollution burden developing countries are suffering right now. The insight he has put into this global burden is inspiring and evokes some of my own experiences and thoughts.

When you talk about air pollution, what do you think of first? Will you come up with the picture of cities with endless obscure smog and people wearing masks? Or will you think of the related diseases such as chronic obstructive pulmonary disease (COPD), acute lower respiratory illness (ALRI), cerebrovascular disease (CEV), ischaemic heart disease (IHD) and lung cancer (Lelieveld, 2015)? Not surprisingly, these phenomenon and diseases are really happening in the world everyday. One week ago, the number of PM2.5 in Shenyang - a city in Northern China - broke the threshold and reached to 1400mg/m³, which resulted in the overload of patients in respiratory departments of the city hospitals. This February, a documentary called “Under the Dome” about the air pollution in China has drawn global attention. The documentary was filmed and self-financed by Chai Jing, a former China Central Television journalist, who said she felt dangerous for her kids to live in a city like Beijing with 175 days/year under pollutant air.

While China is suffering the unprecedented outdoor air pollution, people in Africa are under the exposure of indoor air pollutants. In Sudan, low respiratory infection is the top one risk factor for disability-adjusted life years (DALYs) (Institute for Health Metrics and Evaluation,2010). Biomass fuel remains the primary energy supply and the indoor smoke caused by biomass burning is responsible for 2.7 percent of the global burden of disease (WHO, 2010). The distinction between China and Sudan reflects the relationship between economic development and air pollution: in middle-income economies, outdoor air pollution is the prevailing pattern while in low-income economies, indoor air pollution is the prevailing pattern.

Air pollution is no longer a new global issue, but why are the people in developing countries still suffering from it? Dr. Zhang explained this by using some examples of developed countries. The accidents happened in London and Los Angeles were the consequences of rapid industrialization. He then provided a formula for the solution in developing countries: Legislation + Technology + Enforcement == Clean Air. From this we can see the main factors preventing developing countries from getting access to clean air. To fix the air pollution problems, the first step is to enact environment protection law and enhance public dissemination. Next, for different countries there should be different strategies to tackle air pollution. From my experience, the biggest problem in China is the lack of enforcement to implement environmental protective regulations and green technologies. However, in Africa like Sudan, the imperative approach should be introducing environmental friendly fuels for the households.

1. Lelieveld, J., Evans, J. S., Fnais, M., Giannadaki, D., & Pozzer, A. (2015). The contribution of outdoor air pollution sources to premature mortality on a global scale. Nature, 525(7569), 367-371.

2. Institute for Health Metrics and Evaluation (2010). GDB: Sudan. Retrieved from

http://www.healthdata.org/sites/default/files/files/country_profiles/GBD/ihme_gbd_country_report_sudan.pdf

3. World Health Organization (2010). Sudan: WHO statistical profile. Retrieved from

http://www.who.int/gho/countries/sdn.pdf?ua=1