Today in class we learned about organ donation. We found out that there is a huge need for organs, and that 5,000 people are dying annually waiting for kidneys. Then we talked about how people can get kidneys and organ markets were mentioned. The message on them was, more or less, that they’re bad, but some people think they’re a good idea. The ethics professor and doctor who presented were both very strongly and ethically against the black organ market and a legalized true market (i.e. “Buyers’ Market”), and moderately opposed to legalizing government organ purchases (“Sellers’ Market”) in the US (6).
I’ve generally believed that markets can solve most resource problems when allowed to do so. This shortage of organs is artificial. We have hundreds of millions of spare kidneys in the US. It’s like the government making farming illegal and creating a food shortage. There are plenty of healthy people who would donate a kidney, but they just have no reason to do so. If markets existed, we’d have more than enough supply to meet the present (and growing) demand. I was surprised to see so great a need contrasted to so little support for the idea. In my mind, society should try to ethically maximize the number of years its citizens are alive and well; it seems that organ markets would do that. I figured that there must be compelling ethical reasons to prohibit organ markets.
My professors brought many objections to the idea. Some of the reasons seemed minor or question-begging (e.g. “Commoditization of organs is objectionable”)(9). The two real objections to organ markets that I want to focus on are on issues of equity and undue inducement. First, would rich people benefit more than poor people? Second, would more poor people sell their organs and thus get coerced into taking bad risks?
Superficially, this seemed not utterly different from a normal trade. It’s a voluntary transaction. In general, people should be allowed to trade something they value less for something they value more. That is the essence of every Starbucks purchase, every home sale, and the foundation of our economy: trading your labor for money, and that money for stuff. And indeed, it does seem likely that if people were allowed to sell their organs, poor people would do so more than rich people. But is there a problem with that? Let’s imagine an analogous situation.
Imagine that I am the CEO of a drug company. My company invents a drug that cures breast cancer. The production cost is high and I decide to set the price near the cost of production. Nevertheless, only a tenth of those with breast cancer can afford it. As an act of corporate responsibility, I also donate free treatment to 1% of the poor with breast cancer. Also imagine part of the high cost of the drug is because it’s made out of a rare mineral found in the oceans and I have to hire a crew of 35 fishermen for a year to find enough for one cure (3). The work is non-technical, dangerous, and well-paying; thus I attract mostly poor people to do it. Is this situation unethical? Is the disparity in rich and poor so bad as to prohibit this from happening? Are the fishermen being unduly induced to do the dangerous work?
How does this connect to kidneys? If we are trying to save life, how could we do the best job at it? A kidney transplant recipient will live, on average, about 15 years longer than on dialysis. A healthy kidney donor will have minimal adverse health effects, certainly no more than 1 year of lost life on average (that is, some may die in surgery, others from later complications but almost all of them will live without complication; as far as I know, it has not been accurately measured but is presumed small). There are ~5,000 people dying on the transplant list every year. This list is thought to be biased toward the rich who can push and connive their way onto lists(7). So, every year, we’d roughly save 70,000 life-years annually if we had enough kidneys. Even assuming only 1 in 10 on the transplant list was poor, and everyone donating a kidney was poor, that would still be net 2,500 life-years saved for the poor.
This breast cancer cure story above is ethically equivalent to organ markets in terms of life-years lost by the poor and gained by the rich. 70,000 life years are saved amongst the diseased (breast cancer victims; people on the waiting list), 7,000 of which are for the poor (charity recipients; poor on the waiting list). To deliver this treatment, the poor are voluntarily exchanging risk for money and collectively losing 2,500 life years (fishermen; poor donors). The sick rich are living longer; the sick poor also are living longer. The only people who lose life years are the fishermen/donors who voluntarily take a risk for high pay.
It seems that this situation is equivalent to those which we now permit. Even without my imaginary company’s charity (that is, assuming the poor didn’t benefit in life years at all), it’s hard to argue that we should prohibit the saving of some lives by the voluntary action of others. Shall we pass laws like, “No one shall run into burning buildings to save people, especially not if one is being paid by rich people to do it?” On the contrary; we have government-run public safety systems that pay poorer people to take risks for richer people. It’s not movie stars who come to the rescue when Malibu catches fire. We permit dangerous jobs, and we permit poor people to do them. We consent to this system of risky jobs every every time we order a pizza or use a piece of paper; delivery servers and lumber workers have among the highest mortality rates (4). If allowing the poor to take risks for pay is absolutely unethical, then I ask you: how many drops of the blood of the poor are you comfortable having mixed into your pizza sauce, and how bloodstained is too bloodstained for your white paper?
What does losing 70,000 life-years mean? That means that this question is a big deal. To give you a sense of scale, in 2004, there were 42,000 life-years lost in Iraq and Afghanistan, 79,000 to fires and 86,000 to drowning (5). In other words, far more life is lost because of the government-created kidney shortage than to terrorist bullets and IEDs; the benefit of a kidney supply is about as good as preventing every lethal fire, or throwing a life preserver to every would-be drowning victim.
This is a big ethical fork in the road, and we should not change course without a compelling reason. 70,000 life-years annually is a compelling reason. It’s like someone invented a $1 cure for uterine cancer and we’ve outlawed its use for ‘ethical’ reasons (5). We’d better have a good ‘ethical’ reason to let people die. And they are dying, about 12 a day, because we’re worried about the equity of some rich people living a bit longer than they should, or poor people taking risks that they shouldn’t. If we legalize organ markets two things would happen: 1. Rich people and poor people would live longer 2. A lot of rich people’s money would end up in poor people’s pockets. Why is this bad?(8)
(3) Fisherman mortality: 71 deaths per 100,000 http://www.menatrisk.org/health/dangerousjobs.html Assuming an average US age of 36.7, and an average life expectancy of 78.2 years, and a mortality rate of fishing of 71.1 per 100,000 per year. That works out to A x (78.2-36.7)x71.1/100,000= 1 life-year (where A is the number of people exposed to this risk to equal 1 life-year). A = 33.9 fishermen working for a year together lose 1 life-year. Round to 35.
(4) Timber workers have a mortality of 117.8 per 100,000 and delivery servers have a mortality of 37.9 per 100,000.
(5) WHO BOD – 2009; US data from 2004. Breast Cancer: 612,000 DALYs. Uterine Corpus Cancer: 75,000 DALYs.
(6) The only difference, it seems to me, is not an ethical but practical. Organ donors would only get a fair price or have adequate supply in one of those two systems. Governments don't have a very good track record at setting prices.
(7) Another essay could be written on the economics of a market. With the amount that Medicare already spends on the poor for dialysis, it could probably buy the kidneys, transplant them, and have lots of money left over. There very well might not be any gap in rich and poor, at least when it comes to kidneys. In this case, the money flow would still be from rich (through taxes) to poor (after a stop in a Medicare account).
(8) This analysis is from a policy perspective, making assumptions about people acting out of self interest. Much more could be said about the virtue of self-sacrifice. I hope to write more on sacrifice, its virtue, and how medicine tends to prevent it. More on that later.
(9) The argument seemed to be of the form: 1. Commoditization is unethical 2. Selling organs is commoditization 3. Selling organs is unethical. This argument gives no actual insight into the problem, but simply confuses it with an econom-ethic word to obscure meaning. Why is premise 1 true?
“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:
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].
Perspective
Abasi
Sakina
Payer
Cost saving
$0.10
Provider
$0.14
$0.08
5-year Societal[10]
Cost saving
$3.57
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.
Discussion
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.
Conclusion
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.
Notes
[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.
[2] http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_part3.pdf
[3] I have found this table at long last! WHO did not make it easy. http://www.who.int/healthinfo/global_burden_disease/GBD2004_DisabilityWeights.pdf
[4] Life Tables, Kenya. http://www.who.int/whosis/database/life_tables/life_tables.cfm
[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?
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 EffectivenessAnalysis
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
[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).
So for those of you who don't know, there is this thing called the Human Development Index. It's a mathematical way to calculate who's "Developed," who's "Developing," and who is, well, "Underdeveloped." For those of you who are over 22, you are probably more familiar with descriptions of the "First world." These have been done away and have been, more or less, relabeled in terms of development. Lots of math and thinking has gone into this index. For the mathematically inclined, just take an average of the following indicies to get overall HDI:
And just like that, you know if your country sucks or not. (For those actually interested in the math, check out the Wikipedia article, from whence these formulas were jacked).
Now, that's the background. I was reading the prophets this morning. God was describing the future peace of Jerusalem and one of the attributes of it was this:
Zec 8:5 And the streets of the city shall be full of boys and girls playing in the streets thereof.
Isn't that a lot easier? Instead of massive economic and social indicators which take thousands of man-hours to assemble, go to a place and see if there are children playing in the street. This will tell you many things: the kids are not forced to work for their food. The streets are safe. The children not sick.
This is consistent with my experience as well. My own home street is a great example of this. It is a suburban dreamland, and when I drive home I have to go 5MPH because children consider the street a placeplace and cars intruders. In various communities in Mexico, the difference between a 'good' neighborhood and a 'bad' one really is kids playing in the street. So next time you're in a foreign country and want to know if it's a good place or bad place, look for kids playing.
