Archive for February 2007
I attended a very interesting event yesterday at the Woodrow Wilson International Center for Scholars on nanotechnology and global health. I will blog on that later this week/weekend. Today they have another event that might be of interest to those in the DC area. They also have a free live webcast (that can also be viewed later):
February 28 2007, 12:00 p.m. – 2:00 p.m. (FREE)
Alternative Health Financing in Low- and Middle-Income Countries
Woodrow Wilson International Center for Scholars
Pablo Gottret, Senior Health Economist, World Bank;
Marty Makinen, Vice-President, International Health, Abt Associates; and
Hugh Waters, Assistant Professor, Johns Hopkins Bloomberg School of Public Health
Due to the generally unpredictable nature of illness and the burden of high health care costs, risk-pooling is beneficial to cover the needs of those who become ill. It allows populations to make contributions to a central fund in times of good health and/or relative resource abundance in order to cover the health needs of the community-whether that entails preventive medicine, maternal healthcare, sick visits, or catastrophic coverage. Ideally, these central pools would finance services for the poorest and provide the entire group with financial protection and improved health care. However, many different health financing schemes have been used in developing countries, with varying degrees of success.
On Thursday (2/22/07) I had the pleasure of attending the newly formed IPEG DC chapter meeting. IPEG is the International Private Enterprise Group started by a couple of Columbia students. The DC chapter is hosted by NextBillion and they do a fantastic job of putting it together. IPEG is an opportunity for professionals interested in business and development to network and exchange ideas. You can read more here.
This meeting was focused on success in the health sector. Beth Boomgard from AED discussed her group’s work (Private Sector Health Initiatives) in the area of anti-malarial bed nets. Unfortunately I did not get to hear her full discussion, but you can read more about the NetMark project here.
Based on the case study we wrote, I was able to share my ideas about Aurolab and the Aravind Eye Care System. Both are phenomenal organizations that offer many lessons. The Aravind clinic started in 1976 in a 11 bed rented house and today is probably the largest eye care system in the world. Their mission is to eradicate blindness in developing regions, which is primarily due to catarcts. Aurolab is the non-profit medical device and pharmaceutical manufacturing arm of Aravind. For a quick overview on Aravind see this Wall Street Journal piece or this Fast Company article and/or check out this video if you have time (35 min, Link). Basic facts about Aravind & Aurolab:
– 2/3rds of patients receive some sort of charity care, 1/3 pay above cost
– 250,000 cataract surgeries per year
– 5 hospitals across the state of Tamil Nadu, over 1000 beds
– 1300 community eye camps
– 2 Million outpatient visits
– Export products to over 120 nations
– Reduced price of synthetic lenses (IOL) for cataract surgery to under $10
– FDA compliant facility
– IOL, suture, pharmaceutical, spectacle and hearing aid divisions
– Globally unique due to scale and non profit status
Blindness due to cataracts is a substantial problem in developing countries. Aravind and Aurolab managed to build infrastructure, systems and manufacture core medical technologies at the local level that allowed them to chart their own course. Instead of relying on a non-sustainable donor model, they decided to build their own system and self-manufacture their own technologies and still manage to make a substantial profit. Some of the questions I received Thursday night revolved around replicating and expanding the model:
1) What other disease categories can Aurolab tackle – what other low cost medical technologies can they make?
2) How did they achieve remarkable success? How do we replicate this model?
Regarding the second set of questions – in a nutshell, it comes down to solid management, charismatic leadership, clear socially driven mission and unwavering persistence. Of course there are many other factors, see our case study for more information on how they built partnerships, transferred technology and charted their own direction. Finally, one very important ingredient, is that it takes time (see historical milestones). Aravind was started in the mid 1970s and Aurolab was founded in 1992. They faced various challenges, learned from their mistakes and over the course of 3 decades built a world renowned system. As far as replication, I argued that you do not need a non profit manufacturing facility in every country – for example, Aurolab through NGO partners distribute their synthetic lenses (intraocular lenses) to over 100 countries and have 5-10% of the global market. On the hospital side, Aravind has consulted with over 100 hospitals worldwide to set up clinics and systems to improve their capacity to offer care. For more on that see their “consulting” arm – LAICO. The last thing I will say is that there is not a one size fits all solution, but people really should study the Aravind Eye Care System to see what lessons they can apply to their particular case. As far as the first question, I will have to tackle that in another post.
A couple of days ago I posted on the “flags as social art” exhibit. I did say in that post that I was unable to verify the numbers or sources of data, even though the official website for the art states “We used real data taken from the websites of Amnesty International and the UNO.”
I apologize for being in a rush with that post because I did go back and take a look at the stats for one flag which seemed a bit far off. Somemone may also want to let WorldChanging know that some of these representations seem inaccurate (see their post from Jan 5, 2007 which I just spotted).
The Angolan flag indicates that half the people in Angola are infected with HIV and half with malaria. Two separate sources indicate this is not true:
When looking specficially at Somalia, the flag may be accurate – UNICEF says that in the country – “Female Genital Mutilation (FGM) has a prevalence of about 95 per cent” (Link). So I am not sure what data was used to make the flags or how the artist arrived at these conclusions. I have not had time to check stats on the other flags and there may be something I mis-interpreted, but perhaps the artist should be more transparent. This concept is a very interesting way of getting across ideas, its a shame that some of the flags may be inaccurate.
I watched a fantastic presentation by the folks at the Department of Medical Informatics & Clinical Epidemiology at Oregon Health & Science University (OHSU). They have an online journal “On Informatics” where they have a recent video presentation titled “Cuba’s Medical System: A Public Health Paradox?” (The video is below)
If you want to learn something about a very interesting health system and how they are using ICTs/medical infomatics I highly recommend watching it. The focus of the video is on Cuba’s national health information portal, INFOMED, which on paper sounds amazing. I have posted some bullet points directly from the video below in case you want the “cliff notes” version. Additionally last week there was a major conference on medical informatics in Cuba. Check the posts on this blog from 2/13/07 – 2/16/07 for their notes directly from the conference. If you are not familiar with Cuba’s healthcare system, it is a fascinating case of what happens when a country devotes massive investment in health. To be sure there are some criticsims, but you can get a general idea of how well Cuba seems to have done with population health under extreme political and economic duress. The graphs give you some basic aggregate facts (figure credit: BBC News) on Cuba’s health system, which speak for themselves.
Cuba has made investment in their primary healthcare a system a top priority (funded in part by gutting their defense budget). So when they had a severe economic crisis in the 1990s, population health did not plummet as much as would be expected. They are not allowed to import US made medicines and medical supplies (such as pace makers, mammogram film and medical textbooks) due to the economic embargo, consequently they have had to innovate to take care of their population. One other noteworthy fact is their susbstantial biotechnology sector.
This video is a presentation of their health system, the major challenges they face, and the phenomenal informatics infrastructure they have. Here are some highlights and thoughts from the video:
1) There is a doctor and sometimes an associated nurse living in every neighoborhood/local area (known as a Consultorio) which is the base of their health system. The implications include a strong infrastructure and systems in place (exactly what Laurie Garrett is advocating) along with:
- Quick determination of an outbreak because there is a medically trained person in every neighborhood
- Strong knowledge of available resources AND local habits that may have caused outbreaks
- Years of excellent medical records that can be mined and tracked
- Consultorios have strong communtiy civil groups for education, women’s groups, etc. and the doctor is involved in these groups
2) Availability of longitudinal medical history with consolidated information systems. Cuba doesn’t have much in the way of EMR’s due to economics and patient privacy issues, however, the have –INFOMED:
- Serves as center and backbone of national medical informatics
- Is a central repository for clinical practice guidelines, link to the cochrane collaboration, virtual library, and more
- Every neighborhood clinic is supposed to have a computer with access to INFOMED
- Used for telemedince and continuing education
For more information on INFOMED see this 2006 article: A Case Analysis of INFOMED: The Cuban National Health Care Telecommunications Network and Portal by Ann C Séror, PhD. LINK
As I commented at the OHSU On Informatics online journal, it might be difficult for other developing countries to learn from Cuba’s experience precisely because they do not have such an organized model, infrastructure, or I am assuming a similar investment in health. However, on a community or hospital system scale, perhaps lessons can be applied. The Aravind Eye Care System in Tamil Nadu, India has developed an excellent health system and this has allowed them to utilize the power of ICT in several ways. So perhaps best practices can be developed and then shared on a case by case basis.
Last reference, check Steven Mansour’s site for someone who works on ICT in Latin America and has been to Cuba.
Two weeks ago Indonesia announced that it would no longer provide samples of the H5N1 (Avian Influenza) virus to the World Health Organization (WHO). The decision by Indonesian Health Minister Siti Fadilah Supari was based on reasoning that commercial entities would use information derived from freely donated Indonesian samples to develop vaccines that would not be accessible to most Indonesians.
Indonesia is faced with with various challenges (world’s 4th most populous nation, 6000 inhabited islands) to dealing with a human epidemic, should one occur. And should one occur, Indonesia is a likely to be hit hard – currently 38% of mortalities worldwide (63 out of 167) have been identified in Indonesia (source: Wikipedia).
Instead of providing the viral samples with the WHO, Indonesia’s plan was to share exclusively with Baxter HealthCare (USA) in exchange for technology to develop the vaccine domestically. This arrangement has met with considerable sympathy (The Lancet), but the WHO was of course very interested in continuing to receive samples.
More recently, Indonesia has agreed to “resume sending avian flu virus samples to the [WHO] as soon as it is guaranteed access to affordable vaccines against the disease” (source: Indonesia Offering Samples of Bird Flu, NY Times).
One Indonesian reporter’s view is in agreement with Indonesia’s position, but in more direct language (source: RI must stay angry, but temper its anger with wisdom, The Jakarta Post):
Treating poor countries as Petri dishes for the robust growth of diseases so pharmaceutical companies can produce vaccines, and perhaps life-saving drugs, only for countries able to afford them is obliviously discriminative.
There is a local saying cacing pun marah ketika diinjak, literally translated as even a worm gets upset when stepped upon. This must seriously be pondered upon by those with greater power to review their initial righteous intentions of creating a better world.
Indonesia has made a bold, but necessary, move on behalf of itself and other developing countries. Upcoming developments will tell how much of an impact such an action can have.
UPDATE – There is something a bit funny about the use of stats in these flags, see latest post. What a shame because it is an interesting idea.
An artist friend just sent me this site of flags. Apparently these flags as social art made their debut a couple of years ago, but now they are making the rounds again. The flags use real data to “populate” the colors, however I was unable to verify this. It is never-the-less a very interesting concept, enjoy:
Icaro Doria, Brazilian author/artist: “We started to research relevant, global, and current facts and, thus, came up with the idea to put new meanings to the colours of the flags. We used real data taken from the websites of Amnesty International and the UNO. The idea was to bring across the concept that the magazine offers profound journalism about topics of real importance to the world of today.” More flags here.