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.

Introduction
“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]

Condition	Mortality (thousands)	%
#1 HIV/AIDS	144	38
#2 Lower respiratory infections	37	10
#3 Diarrheal diseases	24	7
#4 Tuberculosis	19	5
#5 Malaria	18	5

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.

Conclusion
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].

Notes
[1]Stats taken from GapMinder (which draws from reliable sources like the World Bank) http://spreadsheets.google.com/pub?key=pk7kRzzfckbzz4AmH_e3DNA&gid=3
http://spreadsheets.google.com/pub?key=phAwcNAVuyj0XOoBL_n5tAQ

[2] http://www.google.com/url?sa=t&source=web&ct=res&cd=4&url=http%3A%2F%2Fwww.netspear.org%2Fdownloads%2F3rd%2520network%2520conference%2520presentations%2FDay%2520one%2FThe%2520cost%2520of%2520care%2520for%2520pneumonia%2520and%2520cost-effectiveness%2520of%2520Hib.ppt&ei=u_f7SdqBMZOytAOZ_-XjAQ&usg=AFQjCNHhb-Lj9TTLYtS0CIhbbpgxbDy1Jg&sig2=KJRGvmFXAtkm9Iake4dbxw

[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] http://www.kemsa.co.ke/datagrids/kemsa_commodity_catalogue.php 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. http://www.aafp.org/afp/20060201/442.html

[6] http://www.who.int/whosis/mort/profiles/mort_afro_ken_kenya.pdf . 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: http://www.health.go.ke/Healthfacilities/Annual%20Report%20_%20HMIS.pdf

[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] http://www.health.go.ke/Healthfacilities/Annual%20Report%20_%20HMIS.pdf 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).