Thursday, May 21, 2009

"Lest they be forgiven"

Mar 4:10 And when he was alone, they that were about him with the twelve asked of him the parable. 11 And he said unto them, Unto you it is given to know the mystery of the kingdom of God: but unto them that are without, all [these] things are done in parables: 12 That seeing they may see, and not perceive; and hearing they may hear, and not understand; lest at any time they should be converted, and [their] sins should be forgiven them.
Lest? What do you mean “Lest…their sins should be forgiven them”? Doesn’t He want their sins to be forgiven. Jesus seems to be saying something very not-PC in Mark: that He doesn’t make parables clear for the purpose of people not believing in Him. The blow is softened in Luke’s account (so most Christians just skip over Mark’s “lest” and go on to a more comfortable Luke).

For those that do exposit this verse, it is generally taken to mean that Jesus is creating an insider group, separating those who would believe from those who would not. This has been taken as a verse in support of a Calvinist view of the world where those who are inside were predestined to be there and that’s the way God wants it; parables may even be a way of limiting the accountability of those who are going to be damned anyways. And though Calvinism is always tough to swallow, expositionally it’s usually a safe bet (and the side of the argument I usually find myself on).

Today in my Bible study, we went back and looked at where Jesus was quoting from:
Isa 6:9 And he said, Go, and tell this people, Hear ye indeed, but understand not; and see ye indeed, but perceive not. 10 Make the heart of this people fat, and make their ears heavy, and shut their eyes; lest they see with their eyes, and hear with their ears, and understand with their heart, and convert, and be healed.
Pretty much the same thing (once you pass it through the Septuagint). First note the context: this is the first message given to Isaiah, immediately after his commissioning.[1] So the context makes this into a pretty important message. And what’s the message? Israel will not listen. But Isaiah isn’t satisfied with his commission. He asks God, “Lord, how long?” (Isa 6:11)[2]. And God tells him, “Until the cities be wasted without inhabitant…” and then goes on to describe exile and a remnant.

When did that happen? From the writing of Isaiah to the present, the desolation of the cities of Israel was either by Nebuchadnezzar (586BCE) or by Vespasian (70CE … :P Just fooling. Anno Domini 70 [3]). But if you look at Jesus’ words, He seems to be applying God’s words to the present situation; He seems to be claiming His parables are the fulfillment of the first part (“lest they see…and hear”). It would follow that the prophecy of desolation is Vespasian’s.

Look closely at the Isaiah passage. The word that caught my attention was: “until”. The implication of ‘until’ is that this blindness is only temporary. Where do we hear about “blindness until…”? A BLB search yields one result:
Rom 11:25 For I would not, brethren, that ye should be ignorant of this mystery, lest ye should be wise in your own conceits; that blindness in part is happened to Israel, until the fulness of the Gentiles be come in. 26 And so all Israel shall be saved…
In this part of Romans, Paul is talking about Israel’s role in God’s plan. Here he describes how Israel’s disbelief benefits the Gentiles: “…through their fall salvation [is come] unto the Gentiles…” (Rom 11:11). In other words, if Israel did not fall, the Gentiles would not have had the chance for salvation. If the Jews would have accepted Jesus as King, they would have set up His throne in Jerusalem and kicked off the Millennium in 32AD; His crown would not have been of thorns and the fealty paid by the Romans would not have been in jest. But Eternity would have been empty save for a few million Jews, peppered with Gentiles like Melchizedek and Rahab.

Why doesn’t Jesus want them to be forgiven in Mark 4? Because if the Jews to whom he preached believed, then multitudes of Gentiles would not be saved. It wasn’t that Jesus didn’t want the Jews to believe in Him; He didn’t want them to believe in him yet. By keeping the Kingdom of God a secret, by encoding it in parables and telling only His closest disciples, Christ was preparing the way for His own crucifixion. By keeping His identity a secret from those people who he loved most, by allowing his beloved ones to suffer from blindness, he made salvation possible for billions. His secrecy made possible a world where He would pay for the sins of the world, and a world where those few disciples to whom he told these secrets would then go out and preach Salvation to all tribes, tongues, peoples and nations.

What sounds like an elitist Jew speaking secrets to an inner circle, actually is a daring and heroic plan to save the world.

[1] In my book, Isaiah in this scene wins the “Best possible direct response to God” award: When God asks in His throne room (filled with recently-described super angels screaming to each other "Holy, Holy, Holy") “Whom shall I send?” Isaiah has the balls (faith) to shout “Here am I; send me.”

[2]This, by the way, is also pretty insightful/ballsy
God: “I’m going to crush them.”
Isaiah: “Yeah I know you’re saying that, but, come on, they’re your people. I know you won’t forever. So, how ‘bout it? When are you going to give up and bless them again like you always do?”

[3] I think I’m going to start saying the full translated phrase from now on. “When were you born?” “In the year of our Lord 1985.”

Friday, May 8, 2009

Equity or Efficiency in Global Health?

A dollar spent in the US buys orders of magnitude less health than one spent abroad. It turns out that for most questions, the equitable and the efficient are often the same. Kenya has a lower life expectancy and a lower GDP (it’s more equitable) AND a dollar spent there will save so many more Disability Adjusted Life Years (DALYs[3]) than a dollar spent in Japan. So to a first order approximation, this ethical dilemma is only theoretical.

As a second consideration which must be addressed before the question directly. Serving the poorest has more broad-reaching effects than simply an increase in DALYs (which is usually optimized in cost effectiveness analysis or CEA). An intervention that allows a poor person to escape poverty had long-reaching effects on that person, their children and their society. Saving a man from premature death by AIDS does more than help him, it allows him to contribute to his community. Getting people onto the proverbial ladder of development, putting them in a position where they could begin to climb up and improve their situation, is an important consideration beyond strict CEA.

Nevertheless, there are times and places where you can help people more effectively who are better off, or you can less effectively those who are worse off. All other things being equal (particularly the Development value discussed above), I value efficiency over equity.

There is certainly an argument to be made for serving the poor. You have to try really hard to find a philosopher or religious teacher who teaches against this (perhaps Ayn Rand, but I think even she may see the value of Global Health as a piece of International Development). To most (including myself), it seems to be a Good which is self-evident. But in much of global health, everybody’s poor. If I could bring 10 years of added life to 1000 people making $2/day or to 500 people making $1/day, I’d choose to help the richer and so save more people.

As I’ve written elsewhere[1], where Kantian ethical statements are satisfied, (i.e. One ought to help the poor), Utilitarian ones should pervade (“Greatest good for the greatest many”). I disagree with the argument that is made that achieving ultimate equality in income is a moral imperative (this argument is frequently attributed to John Rawls, though I admit I’ve only had secondary exposure to him). I reject a morality whose end is the homogenization of income; I disagree that the lack of equality (e.g. Capitalism) is inherently bad, and I do not think that the logical end of this, Communism, is even a good place to be (see Harrison Bergeron[2]). I fail to see equity as an independent axis of the Good; it certainly correlates to the Good. Often those who are poorest are most oppressed. Those who are weak are enslaved. So I agree that injustice is committed against the poor, but as we all know, correlation is not causation. The badness is in the injustice, not the disequilibrium of money.

Truly it is moral to serve the poor for reasons of mercy and compassion. Suffering is indeed evil that should be fought against. But I cannot see a universal moral reason why some people can’t drive Hondas and others Acuras.

Fortunately, this theoretical situation is not that big a problem. It’s clearly moral to help the poor. And the poorest and the easiest to help are often the same people. When they’re not, most of those remaining could be helped in escaping povery by Global Health. When they can’t be, we should consider showing the greatest good that we are capable of. We can discuss these minor points of philosophy (and really should), but it’s not where we, as a society, are failing. I hope that one day we’re having this very debate broadly: “Should we save the really really poor? Or just the really poor?” Unfortunately, we’re still at the, “Should I buy a third car? Or a new TV?” phase.

[1]Carreon, David. “To Promote the General Welfare – Why Utilitarianism Works Better than Kantianism in Government.” 28 Apr 2009. <>

[2] One of my favorite short stories and a powerful argument against the ethics of Equality. It opens thus,
“THE YEAR WAS 2081, and everybody was finally equal. They weren’t only equal before God and the law. They were equal every which way.” Vonnogut, Kurt. “Harrison Bergeron.” 1961.


Saturday, May 2, 2009

The Importance of Perspective in Development CEA

“Why Helping Working People Keep Working Is Really Important”
· The costs of missing work for treatment and because of illness should be considered.
· Pneumonia sucks and worsens life by 27.9%.
· It is important to have the right perspective in addressing health problems and if our goal is development, we should approach problems with the good of the whole community in mind.
· Doing an analysis from a societal perspective suggests that we should prioritize working adults in pneumonia treatment.

Note: This also is technical. Sorry to my non-nerd readers if you do not find this interesting.

The following thought just occurred to me in thinking about my previous article: opportunity cost has been ignored. When we normally think about the ‘cost’ we think about it in terms of dollars spent on treatment, and the ‘benefit’ as being years of quality life lived[1]. In my own analysis, I didn’t discuss the difference in opportunity cost. This will be especially important to development.

If we want a society to develop, a large part of that must be in improving income generation. Any health care analysis cannot ignore the impact it is having on the ability of people to generate income. Ultimately ‘sustainable’ means that people can earn enough money themselves to not need outsiders.

Pneumonia Sucks [9]
So let’s return to our question. Pneumonia (my new favorite developing world illness) has some pretty serious complications. The World Health Organization rates diseases based on how much they suck[2]. And pneumonia sucks pretty hard. The DALY weight is 0.279[3], putting it equal to having an amputated arm or being deaf over the period that you have pneumonia. Another way to put this is that it’s better to live three years without pneumonia than four years with it. That’s how bad it sucks.

The burden of disease (roughly “how bad it sucks”) is not the same thing as the cost. It is essential to determine who is spending the money when considering in the cost. In my previous analysis, I was incorrectly considering the patient perspective.

In my previous (conceptual) analysis, I ignored the cost of visiting the doctor and loss of productivity at work. This will be a huge driver of the overall cost, particularly when considering disease in working-age adults. Not being able to breathe sucks for a child, but it doesn’t affect as directly the income generation of the family. And this is a critical consideration in development. Health, at least at this stage of development, should be a means to the end of self-sufficiency. Time is extremely valuable, especially when a person’s time is worth $1 a day.

Simplified, Make-Believe Analysis
Warning: Math approaching. For those who have had severe allergic reactions to math in the past, it is recommended that you skip to the “Discussion” section. But it shouldn’t be all that bad. There's nothing but the four basic operations[11].

Let’s get back to pneumonia. Imagine Abasi, a 30 year old Kenyan man with a wife and a 5 year old daughter named Sakina, coming down with pneumonia. He’s sick and he’ll stay sick until he gets treatment which costs $4.00 (and we’ll assume that it’s perfectly effective). Abasi will die five years after getting pneumonia if it remains untreated. Let’s also say that he’s only able to work at 75% capacity because of his difficulty breathing. The clinic is far away, so it takes a full day to walk to the clinic, get treatment and walk home. In that day, he loses $1.00 worth of productivity. But every day, he’s losing $0.25 because he can’t work. Healthy, Abasi can look forward to 33 more years[4]. Sick, he only has 5 (and that with a lowered productivity). The ICER can be calculated as follows:

This means it is cost-saving. In the long-run, Abasi saves money by getting treatment. This is superb. In a sense, it is literally an investment ($5 initial investment to save $312 which is a 6200% increase in 5 years; that’s what I call an ROI).

If the analysis were repeated from the perspective normally taken (the “provider” perspective), it comes out costing money. Repeating the analysis above from a provider perspective (ignoring ignoring the value of Abasi’s time and lost wages), it comes out to costing $0.14/DALY.
Now imagine his daughter, Sakina, comes down with pneumonia. She should be able to look forward to 56 more years of life and has the same five years to live if she doesn’t get treatment[4]. The difference here is that she doesn’t help generate income for Abasi, so the major economic impact on Abasi drops out of the equation. He still has to take the day to travel to the doctor, pay the same amount for the medication, and (for the sake of this simplified analysis[5]) have the same discounted DALYs. From Abasi’s perspective, the ICER for his daughter is:

ICER = [($1.00+$4.00)-$0.00]/(56-3.6) = $0.10/DALY
Note that this is now positive; when Abasi spends money to save his daughter, it is not cost-saving. Nevertheless, if Abasi values a year of his daughter’s life at something more than $0.10, he should buy the medications. The provider perspective (which doesn’t care that Abasi took a day to travel) is $0.08/DALY.

One more exercise. Imagine we took the societal perspective, concerning ourselves with the overall wellbeing and costs to society. And imagine we were concerned about only a five-year window rather than the lifetime of Abasi and Sakina. With smaller windows, long-term goods are washed out, but it’s a conservative assumption that is verifiable. Would this be cost effective for Abasi’s pneumonia? Sakina’s? Repeating the analysis from a 5-year societal perspective shows that it is cost-saving for Abasi and cost-effective for Sakina ($3.57/DALY) [7].

Cost saving
5-year Societal[10]
Cost saving

So as you can see, the only perspective where treatment of Sakina is more cost-effective is in the provider perspective. Which helps explain why we are so concerned about saving the children: from our perspective (that is, one only concerned with health and not development), it’s a better idea to treat kids before adults. But if you are Abasi, or if you care about the immediate development of the society he lives in, then you ought to prioritize him.


What’s my point? First, these numbers should wake us up: 8 cents for a year of healthy life[8]. I don’t bother to stop and pick dimes up off the street. And yet it is for want of this that people like Sakina are dying[6].

Secondly, these numbers should be translated from Imagination Land to reality. I made all this up out of thin air. I think in this easy case (pneumonia treatment), I’m probably right in recommending emphasis on treatment of Abasi. But there are many questions which are not so easy. Most treatments are not extremely cheap, extremely effective and most diseases do not have the morbidity profile of Pneumonia. Even in Pneumonia, if treatment was not close to 100% effective as I assumed, or if there were significant side effects, or the costs were more than $4.00 (which is certainly possible), these conclusions do not stand. Most work in this area is either not applicable; treatment costs and regiments in the developed world are perfectly irrelevant to the developing world. It would be quite useful to compare the cost effectiveness of various developing world interventions from a societal perspective, side-by-side, using local prices. If such a model were constructed well, the details could be adjusted (i.e. Penicillin here costs $3 instead of $1.50 in Kenya) and the conclusions, recalculated.

Finally, it is very important to consider our perspective and our goal. If we don’t care about development and our goal is simply to extend life, then paying for Sakina is the best idea. But if we are concerned about the societal costs, more emphasis should be placed on Abasi; his pneumonia will cost society more than Sakinas in the short term. If we are concerned about development, we cannot just look at saving Sakina. She is truly the future of Kenya, but Abasi is the present. And it is he who must build the future. He must have an income to support Sakina, pay for her school, and tear off the shackles of poverty. And health interventions ought to aid him.

This analysis shows that it is extremely important to care for those who are the ones developing. Mercy compels us to care first for Sakina; prudence reminds us to care for Abasi first. It is the same thing that they tell you on airplane safety videos. While mercy compels us to put the oxygen mask on our children first, prudence (and the video) reminds us to put it on ourselves first so that we can be able to help our children. Let it be so in Kenya.
If our goal is five-year development, the healthcare should focus on Abasi. But I pray to God that we can find the eight cents to save Sakina.

[1] I’m sure this thought has occurred to someone; it may actually be taken into account in the calculation of DALYs. In a brief review of DALY definition (Drummond, et al “Methods for the Economic Evaluation of Health Care Programmes” Third Ed. p 187), it did not seem to include lost wages. I’m fairly sure that ‘cost’ of lost work should be counted separately. This does need outside confirmation, however as I’m not certain.
[3] I have found this table at long last! WHO did not make it easy.
[4] Life Tables, Kenya.
[5] As another simplifying assumption, I assumed 0% discounting.
[6] To cover my bases, we can’t just spend $0.14 cents and save someone practically. Health and social systems have conspired against their getting healthy.
[7] The actual numbers are -$219.64/DALY for Abasi and $3.57/QALY for Sakina. The interpretation of the larger magnitude Abasi number is confusing so wasn’t displayed in the text; this sort of analysis isn’t usually used to evaluate methods of saving money. The most important feature is that it is negative.
[8] When I say ‘we’, I mean the developed world. We’re usually in the perspective of the NGO provider.
[9] I have looked for data like I present here many but to no avail. I am very happy about finding it.
[10] Why did I not calculate the 25 year societal perspective? Because I’m fairly sure I need to learn how to discount money (I’ve forgotten how to properly do this) to answer the question even close to correctly. Also I do not know how to compare negative ICERs. Maybe I could model it like an investment?
[11] And if you're really nerdy, you could snicker that there is never more than some combination of the four basic operations. After all, what is integration but an infinite number of additions?

Appropriate Health Plans

  • Health plans designed for the poor (“Appropriate Healthcare”) should be cheap, accessible and should address the major causes of morbidity and mortality.
  • The top seven health problems in Kenya, making up more than 65% of the mortality, are malaria, lower respiratory infections (e.g. pneumonia), HIV, prenatal problems, nutrition, TB, diarrheal disease.
  • Cost effectiveness is a helpful way to think about allocating healthcare when resources are limited, particularly in the developing world.
  • Health fairs and local health workers could be two ways to address these major health issues in a cost-effective manner.
  • An appropriate Kenyan health plan should focus on the most cost-effective ways to address the seven major Kenyan health problems.
Note: this is far too long (and probably too technical) for a blog. I apologize in advance to my normal reader.

“Health Insurance” as it is modernly conceived serves two major functions. Firstly, as the name implies, to insure that you’re taken care of if something really bad happens. The more recent (and perhaps important) part is health maintenance. Health insurance pays for annual checkups, screening exams, and (increasingly) over the counter meds like allergy meds. So it’s not really health insurance. And this is what the public health people love: prevention. In the developed world, these two things are bundled together because we’re really rich and don’t really care. We need ‘em both, so why bother paying for health maintenance and health insurance separately? This is likely why no market for stand-alone health maintenance programs has emerged. Also, the kinds of death we want to afford when we buy health insurance require expensive hospitalizations, chemotherapy, and bypass surgeries. So, because these things are ridiculously expensive, so is the whole package of American “Health Insurance.”

But when we think about appropriate goods and services, which I’ll define as, “goods and services useful and affordable to poor people,” we need to think about economy. While we cannot forget that people in the developing world are dying of cancer and heart disease, traditional Coronary Artery Bypass Grafts aren’t even close to appropriate for those earning a dollar a day. If we were picking apples from a tree, we shouldn’t have a “Top branch or bust” strategy. There is plenty of fruit that we can reach while we’re still on the ground.

There are things people are dying and suffering from (we cannot forget what is called ‘morbidity’ in our consideration; that is, suffering short of death) which are easily prevented and cured. We want to take care of the easy stuff first.

If a healthcare plan were to be designed for the poor, it would have to meet these criteria
· It must be cheap, cheap, cheap
· It must be accessible
· It must addresses major causes of mortality and morbidity

We want to avoid the hospital. That’s where things get really expensive. In fact, we want to avoid the clinic if it’s at all possible. And transportation. And waiting. And we need to make sure we pay for the important stuff. We need to beware good intentions: we do not want a comprehensive plan covering everything but nobody.

Kenyan Problems
In considering this question, I’m going to look at some data from Kenya (believe it or not, “Africa” isn’t a country). Here’s some data from the World Health Organization from Kenya on the top five causes of overall mortality (compiled in 2002).[6]

ConditionMortality (thousands) %
#1 HIV/AIDS14438
#2 Lower respiratory infections3710
#3 Diarrheal diseases 247
#4 Tuberculosis 195
#5 Malaria185
Cost Effectiveness Analysis
The cost effectiveness analysis perspective will be very useful here. It contradicts the (probably true) belief that human life is invaluable and says essentially, “The reality is that we have limited resources; how can we do the greatest good with them?” Here’s a super-simplified example.
You go to the doctor and the doctor, after running some tests, comes in and tells you, “I have some good news and some bad news. The bad news is you have Really Deadly Disease (RDD) which, if untreated, will kill you tomorrow.”

You, having nerves of steel, are cool and collected. You ask flatly, “What’s the good news?”

“The good news is that there’s a cure! Well, it’s not really a cure. It’s a drug you have to take for the rest of your life. As long as you take it, you’ll be healthy. The day you stop taking it, you’ll die. And the drug costs $45,000 per year.”
In this example, someone (your insurance, hopefully) has to pay $45,000 for every year of life you enjoy. This is usually adjusted for quality and so we usually say Quality Adjusted Life Years or QALYs (you would discount life lived in a sub-optimal state; you might count 1 year as a paraplegic as 0.5 QALYs). Compared to the alternative (instant death, which costs nothing), you have an incremental cost of effectiveness of $45,000/QALY. That is something we can pay in the developed world, and because of such expensive treatments, is why our health insurance costs what it does.

QALYs and Development
In thinking about the developing world, we have extremely limited resources. We’re not talking about whether the line should be at $45,000 or $46,000/QALY. This kind of analysis has a much more powerful impact on developing countries. If a health-minded NGO wanted to do an intervention, are anti-malarial bed nets, antibiotics, or AIDS treatments more cost effective? Can more life be saved with one over the other?

In Kenya, healthcare spending is $105 per capita in 2006 (by PPP, not by exchange rate). Only a fraction of that has been by the government: $586 million (2% of $29.3 billion GDP) [1]. So even assuming we have $105 to work with (it’s very likely that most of that is a lot of spending by the richest in Kenya), what is more cost effective? Treating Malaria or Malaria bed nets? And whatever of those is better, is that more cost effective than treating HIV? And is HIV treatment better than antibiotics for pneumonia?

If I was an NGO who had $1 million and I wanted to do handouts, what should I spend money on? Should I fight AIDS and invest in HAART (Highly Active Anti Retroviral Therapy)? Or should I buy ITNs (Incecticide Treated Nets)? For HAART, it’s $1000 to save a life year[3]; for ITN, it’s $86. In other words, I could save over 11,000 people from Malaria for a year (assuming $4/net I’d have to buy 250,000 nets to do this), or I could save 1,000 people from HIV for a year. Of course there’s more people suffering from HIV, but with limited resources (as all NGOs have), the focus should probably be on addressing Malaria first. But then again, vaccinations against Pneumonia (Hib) are even more cost-effective ($62/year saved). And what about treatment for Pneumonia?

This is the sort of analysis which must be done as this work progresses. Any fool can shout about how big a problem is. It takes a wise man to find a solution. This is the mindset with which the remainder of this paper was written. Though there is not the data to do a numerical analysis, the things which have been chosen are gross approximations of what may be actually cost-effective.

An Overlooked Problem (A Ripe and Low-Hanging Fruit)
Why haven’t we ever heard about the #2 killer in Kenya (and from what I’ve heard, much of Africa)? We hear about AIDS all the time. And diarrheal disease all the time. And TB and Malaria. But why don’t people talk about “Lower respiratory infections”? And yet according to Kenya’s Ministry of Health, 1 in 37 Kenyans goes to a clinic for Pneumonia each year [9].

Here’s the ironic thing: they’re the easiest one on that list to treat. Everything else (with the possible exception of diarrheal disease) requires rather extensive measures. But Lower Respiratory Infections (aka “pneumonias”[8]) are usually easy to diagnose and easy to treat (certainly by comparison). X-rays are nice, but they’re usually just to confirm what the doctor can find out from getting a good history and physical. Stethoscopes aren’t that expensive[7]. And neither is first-line pneumonia treatment: Amoxicillin w/ clavulanate (“Augmentin”) [5] which can be gotten for $1.34 in Kenya[4].

That’s what you call affordable. For someone living on $1 a day, a $4 ITN with long-term (but no short term) benefits is a hard sale. A $1.34 drug which lets a person get back to work/play/school/home in a few days is a much easier sell. But there is presently no cheap way to get at it without spending a day to go to the clinic, paying for transport, waiting for a doctor, paying for the visit, get diagnosed and then hope they have the medication you need. The out of pocket cost is too high, not to mention the opportunity cost (instead of earning money, time was spent going to the doctor).

Idea One – Local Health Workers
How do we make it easier to treat pneumonia? Train local health care workers. Buy them stethoscopes (or loan them the money for stethoscopes and let them pay them off by working) and let them sell their services to their neighbors. It would be their job to purchase a small amount of pharmaceuticals and sell them to those who need them. If disease tracking was a concern of the local dispensary, they could require the worker document each case and only sell a new batch of drugs with the delivery of patient records. The patient form could require a signature and include the price of the drug (to limit health worker corruption), and describe the level of training of the worker. Or if we really want to be fancy, we could use SMS to communicate in real time to the dispensary.

The bottom line is that a person with pneumonia for, say, $0.25 can get a diagnosis and accordingly be offered treatment: “Yes, this is Pneumonia; I’ll sell you the drug for $1.32” or “No, this is not Pneumonia; I won’t sell you the drug.” This would provide broad and easy access to pneumonia treatment, and reduce mortality and morbidity of the #2 killer in Kenya, in addition to providing supplemental income for the health care workers.

Idea Two – Health Fairs
As transportation seems to be a major issue, bring the clinic to the people. This is what well-intentioned white doctors do all the time, and are able to help hundreds or thousands of people on a single day.

The organizers would stock up on common meds (“common” will quickly be defined after the first of these; likely antibiotics, de-worming meds and vitamins; it may be a good thing to do community surveys about before the first one). Ideally, doctors and nurses would volunteer or already be paid (by the national government); if not, their daily wage would be a part of the cost. Para-medical personnel (health representatives) would act as medical students under the doctors present, learning what they could (so as to better help people between fairs) and aiding in the streamlining of patients. Other volunteers would be needed for paperwork, administration and set up. Also, this should be done on a weekend or holiday where the opportunity cost would be lower (people don’t have to miss work/farming).

It could be discounted or (more likely) free for those on the healthcare plan; a fee would be charged for those who aren’t (reasonable, of course). All health related business could take place on a single day. Nets could be retreated. Sick people could get their meds (or at least people sick from diarrheal disease and pneumonia). Children could learn hygiene. In addition, with good record-keeping, this could be an excellent venue for tracking health statistics (a pre-interview could record recent births, deaths and illnesses in their family, relatives, friends, neighbors). These fairs could be rotating and occur as often as there was demand and funding.

Imagine we had a health plan which addressed the seven strategic Kenyan areas (HIV, Lower Respiratory Infection, Malaria, TB, Diarrheal disease, Neonatal/Maternal health, and Nutrition). For the expensive and well-funded diseases, it would act as a referral network, perhaps providing transportation to well-funded HIV centers. It would cover treatment by local health workers or health fairs for simple pneumonia and diarrheal disease, in addition to some simple nutritional supplementation if anemia is suspected. It would provide annual insecticide for bed nets. It would pay for a trained birth attendant. And it would pay a certain amount for emergency transport for serious illness.

By focusing on the extremely cost-effective interventions and omitting the more drastic ones (direct treatment of HIV, paying for hospitalization), healthcare may become affordable to even the poorest[13]. Much change would be necessary before this could be realized. It is certainly not possible with the present system. But it may become possible with a few intelligent changes and a community to support it.

The Challenge: To design a healthcare plan that would prevent and treat the most deadly and painful diseases accessibly and affordably; to drastically reduce the morbidity and mortality of the rural poor with $1.00 per month per person[10].

[1]Stats taken from GapMinder (which draws from reliable sources like the World Bank)


[3] Technically this particular study used Disability Adjusted Life Years (DALY); it’s similar to a QALY but figured out with a slightly different method. Fundamentally it’s saying the same thing.

[4] Item - PHA0545. 105.25 Kenyan Shillings which, according to Google, becomes $1.34 as of 5/2/09.

[5] 96% of pneumonia should be sensitive to this treatment in the US; it may even be higher in Africa because of less antibiotic usage. Taken from “Diagnosis and Treatment of Community-Acquired Pneumonia” by the American Academy of Family Physicians. M. NAWAL LUTFIYYA, PH.D., ERIC HENLEY, M.D., M.P.H., and LINDA F. CHANG, PHARM.D., M.P.H., B.C.P.S.

[6] . It is very interesting to note that in Kenya’s Ministry of Health annual report, they came to different conclusions. They talked about morbidity in the executive summary and said #1 was Malaria and #2 was respiratory infection. It seems they’re making their conclusions based on who shows up to the hospitals. If I’m right about the data source, this discrepancy probably means that HIV patients aren’t showing up to governmental healthcare facilities. Perhaps they don’t have the money for treatment. Perhaps there stigma. Perhaps they’re going to NGO sites who don’t communicate with the government. In any case, it’s a problem. Beware: it’s terribly written and goes on for a page of the Executive Summary complaining about how bad the data is and why it was that bad. For that report, check out:

[7] I remember buying decent quality stethoscopes for my group at $30 each; they get down to $7 on the internet… not that I’d trust a $7 stethoscope.

[8] Looking at the MOH report, they seem to think “Pneumonia” and “Respiratory Disease” are two separate things (some of the charts inconsistently call it “Other Disease of the Reparatory System”… I’m assuming ‘other’ than Pneumonia). Maybe in Kenya, they call typical pneumonia “pneumonia” and atypical pneumonia “other disease of the respiratory system.” Without ever defining their terms, it is impossible for me to know what “Respiratory Disease” means, or what possibly could be hospitalizing hundreds of thousands of Kenyans that is not COPD or pneumonia. But that’s just one chart. Further down there’s another that disagrees with it, saying that Pnemonia is the most significant disease and “Other Respiratory Disease” is nowhere to be found. Being unlabeled, I can’t quite tell what each of the charts is measuring and why they’re different. Bottom line is that Pneumonia is a big problem.

[9] p143. This seems way too high. I would guess two things are working together: nutritional vulnerability (immunosuppression) and misreporting. I doubt many clinics actually culture their patients. It’s probably easier to give an antibiotic than X-ray or culture sputum. So any productive cough becomes “pneumonia.” Not that I’d recommend any changes to the protocol; a good H&P should have decent enough specificity and sensitivity.

[10] Assuming $1/day x 2 adults = 2/day*30 days/month = $60/month/family. Assuming 4 children/woman, the average family has 6 members and $60. If the health plan cost $1/person/month * 6 people = $6/month, then that would come out to 10% of a family’s income, which is roughly what the rich and middle-class pay in developed countries (the poor pay a much larger percentage in developed countries). Perhaps this is still too high to be feasible, but it puts it in the right ballpark. Maybe it could be even cheaper. The right thing to do is find out (as with any product) how much people are willing to pay, and then design a plan at that price point.

[11] Though the data they present does not support them, Anemia was complained of by the MOH; this is likely prevalent and under diagnosed. I read elsewhere that protein insufficiency is a problem, especially for children. It may be (though this theory is a total stab in the dark) that this is part of why everyone gets pneumonia.

[12] There is a lot of potential synergy with these seven and other areas of development. Improving water and sanitation would prevent a large amount of diarrheal disease; improving agriculture outputs (esp. protein, vitamin A; raising chickens and eating their eggs and livers would do wonders) would improve nutrition. Of course, business development improves all areas with more money to spend on needed things.

[13] Another consideration is that without the limited ‘insurance’ side, it’s not necessary to make this a monthly ‘plan’. In essence, a health plan without insurance is simply pre-paying for health services from the buyer perspective. The primary advantage to doing so for the buyers is to help them set aside money aside regularly for services we (the provider) think they should buy. The primary advantage to the provider is that health money can be pooled and invested in the community’s health; for example, no one person could make a health fair where doctors are within walking distance and services, by virtue of massive volumes, are inexpensive. But there is a small insurance component to it: not everyone is going to need emergency transport, not everyone is going to get pneumonia, not everyone is going to come to the health fair.

Also, with a limited plan, it limits moral hazard (doing dangerous stuff because you're covered) by only providing limited treatment to diseases which aren’t preventable, and prevention to diseases which are expensive to treat (HIV, Malaria). Because services are limited, it prevents providers from feeling the incentive to do more things. They’re not paid commission on the drugs they sell, and they only have a limited number of services. This would be taking Britain’s approach to limiting healthcare spending: limit the supply of medical services (you can’t get an expensive MRI if there aren’t any near you).