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.
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.