Where to intervene to deliver better health care?

by Anjali Sastry on October 2, 2009

We explored an unavoidable question: where, in the system, should we aim to intervene in order to deliver better health care? To students of public health, this is a well-known question; for students of management and engineering, guided by a trauma surgeon, the discussion was a rich one and led to ideas and questions that gave us new perspective on the question of how we can help deliver better health care. At the end, we left with new questions about health systems and the interrelationships between interventions tackling poverty, access to services, information sharing, linking formal and traditional approaches to health care, and much more.

We’d already touched on the prevention-vs-treatment question in our HIV wargames discussion last week, but this time we expanded the boundaries of our analysis further. We imagined the case of Jose, a hypothetical but representative patient who presented at a tertiary-care hospital in Angola. Jose had a distended abdomen which surgery revealed was the result of multiple bowel perforations and which the team repaired as best they could. After the operation, Jose spent a week in an ICU but did not survive.Angola ER from Riviello

Where should improvement efforts focus if we want to avoid cases like Jose’s? The ICU needs to be better equipped, for sure. Staffing levels and nurse training need to be improved. We traced Jose’s journey to the hospital, mapping multiple points where the system failed to deliver the care he needed, and learning about the implications of his family’s poverty, lack of access to information, and poor transportation. We looked at the cause of his ills: typhoid. How could it have been addressed? At the district hospital where he went before the tertiary-care hospital? By improving water sources and sanitation? By stocking rural health posts with the appropriate antibiotics? Better diagnostics? Better pay for health workers? Valuing primary care more?

We couldn’t answer these questions, of course, but we did lay out an approach that I’m hoping orients us all towards finding the solutions that help to address multiple issues at once: delivering health care while also reducing poverty and protecting the environment, for instance. We can’t assume that such solutions always exist, of course, but in searching for them, perhaps we can get a little closer towards making the system better.

A final couple of notes: regarding primary care–we examined a few readings before class. One addressed the definition of primary care and others presented the basic idea behind the WHO’s call for primary care for all, issued over 30 years ago (see this issue of the Lancet for more). If primary care were delivered as advocated by the Alma Ata declaration, would Jose have avoided getting sick?

Recent attention to the link between water, sanitation, and health shows why ensuring clean water in resource-limited settings is crucial:

Worldwide, over one billion people lack access to an adequate water supply; more than twice as many lack basic sanitation. Areas without adequate supplies of freshwater and basic sanitation carry the highest burdens of disease which disproportionately impact children under the age of five. The lack of access to and availability of clean water and sanitation has had devastating effects on many aspects of daily life. While poverty has been a major barrier to gaining access to clean drinking water and sanitation in many parts of the developing world, access to and the availability of clean water is a prerequisite to the sustainable growth and development of communities around the world.

For more–an executive summary, or the entire book–please refer to the
recent publication by Eileen R. Choffnes and Alison Mack, Rapporteurs (Forum on Microbial Threats, Institute of Medicine), Global Issues in Water, Sanitation, and Health: Workshop Summary–it explains how sanitation and water are linked to health, describes waterborne diseases, and lists needed improvements.

And a huge thank-you to Dr Robert Riviello for leading us in this discussion and teaching us about some of the challenges he and his colleagues face.

{ 1 comment… read it below or add one }

admin October 3, 2009 at 1:33 pm

Posting on behalf of Josh Gottlieb, a student in this year’s GHD class:

I’d like to briefly explore the Alma-Ata declaration, and emphasize through specific comments that while I think it was a hugely commendable statement in galvanizing world healthcare focus, I also believe it was significantly flawed and may even be said to represent an effectively missed opportunity in reforming and directing healthcare efforts going forward.
The Alma-Ata declaration was adopted at the International Conference on Primary Health Care in September, 1978. It contains 10 points focused on energizing the world community to pursue healthcare goals for all of Earth’s denizens, and particularly to focus on “primary health care” for all. While I once again wish to affirm that I believe it has had a very positive impact on the development of global health services, I also believe that it was flawed in several essential ways, a few of which I’ve outlined below.
The first point focuses on the “universal right to health care”, as expressed not only as absence of disease, but also involving social and economic wellbeing. Several points here are lacking clarity. For one thing, many of the most developed nations on Earth very clearly do not believe that people have a right to healthcare, and much of the debate over healthcare reform in the US, for example, can be traced, I firmly believe, to just this discussion. Additionally, pointing out that social and economic sectors must be involved is important, but not defining specifically which services are included in defining an individual’s “rights” versus those which are just nice to have sorely degrades the power of the statement, as it immediately removes all hope of measurable goals for the endeavor.
Points six and seven suffer from more of the opposite problem. These sections attempt to define primary health care in terms of scope, participants, and continuum of care. Unfortunately, while a plausible definition may be found in point six, “It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process”, the remainder of these points extend the definition to be as broad as possible, including education, food and water, public works, sanitation, and treatment and prevention of ALL infectious and endemic diseases. This type of far-reaching declaration has little chance for success. More effective would have been to segment primary healthcare into levels, and create much more attainable goals in stages (i.e. level 1: improve child mortality rates by 30%, basic sanitation/clean water; level 2: education programs on preventing diseases, better sanitation, and food for the poor; level 3: targeting more difficult diseases such as HIV, etc). Instead, the declaration effectively obviates the possibility for measurable progress, and simply outlines an amalgam of all that is wrong in the developing world.
Finally, point ten emphasizes the goal of “an acceptable level of health for all the people of the world by the year 2000”. This statement to me is both noble and, quite frankly, absolutely ridiculous. While the Millenium project clearly failed to articulate appropriate goals and metrics to meet, Alma-Ata set the tone for this by providing absolutely no concrete measures of success, either as waypoints toward a goal, or in measuring the goal itself. This deficiency, more than any other, makes the declaration more of a “feel-good” message for member nations than an effective charter for delivering quality healthcare in the world.

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