Recent Articles
Thank you all for your interest in the HSAN Student Section. I want to apologize for the delay in greeting everyone; things have been a bit hectic with all of the new developments.
This issue of the newsletter will remain short, but I do want to give you an overview of what we have been able to accomplish so far and where we plan to take the HSAN Student Section in the future.
Please peruse the website if you have not already done so. In particular, I want to draw your attention to the Collaboration Center. The Collaboration Center is a platform for us to gain experience in Health System Strengthening. Admittedly, the Collaboration Center is sparsely populated with opportunities for now. But, with increasing involvement by the experts in the Health Systems Strengthening (HSS) community, we will continue to increase the number of opportunities available for involvement. Please tell you friends, colleagues, and Professors about this resource to generate momentum.
The HSAN Student Section is teaming up with some really great groups, publications, and institutions to expand the reach of HSS education and participation. Notably, we have been in communication with the Lancet Student, Medsin, the International Federation of Medical Students’ Associations (IFMSA), and Tata Institute of Health Science (TISS).
Also, we have posted a blog entry on the Lancet Student website which outlines some reasons for students to get involved with HSS.
Moving Forward
We are developing a work plan that will outline the formal mission of the HSAN Student Section. The work plan will likely focus on 5 key areas:
1) Quantify the deficit in knowledge about health system principles among health students.
2) Develop an online resource for learning about and participating in HSS.
3) Organize existing and develop new didactic educational materials for HSS through an online platform.
4) Organize existing and develop new experiential learning opportunities in HSS through an online platform.
5) Promote mentorship in HSS.
I look forward to collaborating with HSAN Student Section’s partners to accomplish these goals. Based on the work plan, we will soon be sourcing funding to bolster our efforts.
The more of us get involved in the HSAN Student Section, the more rich will be our experience. Here are some great ways to get involved:
1) Follow HSAN Student Section on Twitter.
2) Contribute blog entries about any cool thoughts pertaining to global health or HSS.
3) Submit original articles for peer-review.
4) Become a reviewer for articles. (email students@hsanet.org if you’re interested)
5) And of course, check out the Collaboration Center!!!
Please let me know if you have any questions or comments. This site is meant to be for us and by us, so don’t be shy.
And please tell others about the site so we can more input and participation!
Thanks for reading,
International Health has gained significant momentum in the past few years, making it one of the trendiest avenues of medical practice. (1) As the machine of global medicine quickly accelerates toward improving health conditions abroad, domestic healthcare issues must not be allowed to fade from view. Overcoming international and domestic healthcare obstacles may pose different challenges. But, the approaches to overcoming these challenges are not mutually exclusive. Several lessons from attempts to administer health systems in developing countries are applicable to all health systems. It is time to apply the lessons learned abroad to problems faced at home. The following overview of lessons from developing countries is meant to serve two functions: 1) to remind doctors practicing abroad that they have unique expertise which is much needed at home, and 2) to encourage health system administrators to think outside the box – and the borders – when addressing local healthcare issues.
Donor Fund Allocation
The first lesson pertains to one of the most salient issues in health system strengthening, which is the proper allocation of funding. This issue is not a matter of how much money is being pledged to aid developing countries, but rather where the money is going. Earmarked funding for AIDS alone or TB alone or Malaria alone creates several parallel programs that stifle health system integration. For example, in Uganda, international agencies’ funding of HIV and AIDS programs exceeds the entire Ugandan government’s health budget. (2) Consequently, these programs paralyze the local governments by congesting too few avenues with too much money. Instead, funds should traverse through an integrated network of thoroughfares which would lead to general health system strengthening. The lesson here is to efficiently address the major diseases simultaneously by bolstering the ministry of health as a whole and using it as a common foundation upon which individual disease interventions can be constructed.
This lesson is sadly ignored in developed countries like the United States. While several states have made valiant efforts to create universal access to healthcare, the majority are lagging. Much of the contention, as usual, comes down to funding. Politicians argue that it is too expensive to fund programs that provide universal access, so they concede to fund piecemeal interventions that only address solitary problems even though universal access can actually be less expensive. For example, in the state of Maryland, a beautifully crafted proposal for universal healthcare access is projected to cost $3.1 billion per year, whereas the current annual budget for healthcare exceeds $22 billion. (3,4) Unfortunately, political and financial pressures will likely defeat the fiscally sound Maryland proposal and perpetuate a disjointed health system.
Role of Economics in Health Outcomes
Whether seeking to reform the health system of a small state or an entire country, the issue of money inevitably accompanies the issue of medicine. Another key lesson from developing countries is that socioeconomic determinants are linked to health outcomes. (5) To elucidate that link, the World Health Organization (WHO) used data from developing countries to create a conceptual framework for understanding the complex relationship between health and its various determinants. The framework encompasses the direct and indirect effects of the national economy, household economies and health-related sectors on population-level and individual health. (6) The WHO builds on this framework and codifies a key lesson by highlighting that the health of poor populations can be improved through economic interventions.
Some developed countries lose sight of the reciprocal relationship between the economy and health outcomes. In a time when financial stability of even the wealthiest nations is in jeopardy, policy makers are reluctant to commit significant funds toward healthcare.What must be realized from lessons from abroad is that stabilization of the economy is contingent upon a stable healthcare system. For example, if the current fiscal constraints cause a flood of people to lose their jobs, they would ultimately be unable to pay for their medical care. Subsequently, large medical bills would go unpaid, hospitals would accrue debt, and providers would not be paid for their services. This scenario could quickly snowball into the healthcare system equivalent of the U.S. banking crisis. By saving old jobs and/or creating new jobs that provide a means to pay for healthcare, the economy can be used to bolster population health. Healthier people would make more productive workers and in turn boast the economy. Fortunately, the Obama administration quickly realized this association by making healthcare a top priority in times of extreme financial turmoil. This and other developed nations should not think of investment in healthcare and the economy as two separate, high-priced bank notes, but rather as different sides of the same frugal coin.
Vertical and Horizontal Health System Integration
Experiences in developing countries teach that providing adequate care in resource poor settings requires more than just economic stimulation; it also requires vertical and horizontal integration of the health system.
In a poorly integrated system, top-down administration, such as country-wide ministry of health mandates, has limitations because the needs and resources of each locality may be different. To address this problem, a 2005 WHO consortium of government officials and NGOs from developing countries recommended that local actors need a place at the national policy table to give appropriate perspective, offer education, and provide access to care. (7) This recommendation affirms that health system information and interventions must be vertically integrated from the bottom-up as well as from the top-down to properly address all parties’ healthcare needs. Additionally, experts in health system administration in low-income countries suggest that collaboration between parties at the same health system level would promote better provision of services. (8) Thus, horizontal integration through side-to-side communication between various health sectors can augment vertical integration by avoiding unnecessary bureaucratic obstacles or duplication of services.
The tenets of vertical and horizontal integration can similarly be applied to developed countries to improve access to care. In the state of Maryland, a single county did just that. Healthy Howard is an effort spear-headed by the former Baltimore City health commissioner, Peter Bielenson, that created universal access to healthcare for all residents in Howard County. (9) The initiative utilizes vertical integration by having county officials advocate for local healthcare needs by soliciting state funding. Additionally, various parallel services offered through the health commission, private industry, tertiary hospitals, and health interest groups are horizontally integrated into a net that covers almost every constituent’s health needs. Although Healthy Howard is an example of successful health system integration leading to universal access to care in a developed nation, it is the exception rather than the rule.
Messaging
The success of Healthy Howard would not have been possible without the right messaging. Messaging comes in two flavors. Positive messaging, also known as framing, is taking true messages and making them known to the public through accurate education. Negative messaging, or spin, is conveying messages in a misleading way that obscures the true content of the message. In developing countries, where there is so much misunderstanding about health issues, health interventions are futile without the right messaging.
The importance of messaging in developing countries is highlighted in an HIV prevention study of over 600 men in Ghana. The data show that perception of condom efficacy strongly influences actual condom use. (10) In other words, health information must be properly framed in order to influence behavior. Fortunately, positive messaging has been quite effective. In Brazil, an advertisement campaign focusing on safe sex was developed in response to statements by some religious leaders questioning the efficacy of condoms in preventing HIV infection. The campaign effectively educated the public and influenced condom use in the country. (11) Unfortunately, messaging is effective even if it is negative. For example, the Bush administration’s President’s Emergency Plan for AIDS Relief (PEPFAR) mandate overemphasized abstinence and faithfulness to the exclusion of condom prevention strategies. The mandate’s misguided focus resulted in “major funds going to religious groups with little or no experience in either AIDS programs or Africa more broadly.” (12) Consequently, the spin from these groups regarding HIV prevention is largely skewed. Studies show that abstinence-only programs run by such groups have “high rates of failure in terms of both infection and other adverse outcomes such as unintended pregnancy." (13) Messaging campaigns in developing countries provide the lesson that public perception is a determinant of public health.
Messaging falls under the purview of Public Relations (PR), and in developed countries this is a booming industry. However, PR has not been fully utilized by the medical establishment to appropriately frame the major healthcare issues. Medicine has spread beyond the walls of hospitals into the arenas of law, business, and even entertainment; it’s time for medicine to start doing PR. In a society saturated with spin on healthcare, medicine must recruit PR experts to influence policy makers and the public to embrace productive changes to the current health system.
Conclusion
Using these lessons, health systems in developed countries can be bolstered by refining fund allocation, incorporating healthcare with the economy, integrating health sectors, and employing effective messaging. In an era where communication with the opposite end of the world is no longer limited by mileage but rather by band-width, sharing ideas between developing and developed countries is easier than ever. With globalization at a peak, physicians with global health experience are perfectly suited to make significant contributions both at home and abroad. The medical establishment should encourage more physicians to engage in international health in order to continue generating transposable lessons in health system strengthening.
References
(1) Ostrovsky A. Global health is “the new pink”. Lancet Student 2008. Available at http://www.thelancetstudent.com/2008/11/19/global-health-is-%e2%80%9cthe-new-pink%e2%80%9d/
(2) England R. The dangers of disease specific programmes in developing countries. 2007. BMJ, 335 (7619):565.
(3) Maryland Citizens’ Health Initiative. “Health care for All” Plan Proposal. 2008. Page 1. Available at <http://www.healthcareforall.com/parameters/healthcareforall/uploads/dl/2008_HCFA_Plan/MD_HCFA_Plan_2008-11-12.pdf >
(4) Wilson DE. State Health Care Expenditures. MarylandHealth Care Commission. 2004. Page 9. Available at http://mhcc.maryland.gov/health_care_expenditures/shea02/shea2002.pdf
(5) Mosely WH & Chen LC. An analytical framework for the study of child survival in developing countries. Population and Developmental Review. 1984, 10: supp25-45.
(6) Woodward D; Drager N; Beaglehole R; & Lipson D. Globalization and health: a framework for analysis and action. 2001. Bull World Health Organ, 79(9).
(7) Travis P & Bennett S. The “Montreaux Challenge”: Making health systems work: Background paper. WHO. 2005. Available at http://www.who.int/management/background_1.pdf
(8) Bennett S, Hanson K, Kadama P, & Montagu D. Working with the non-state sector to achieve public health goals: Background Paper. WHO. 2006. Available at http://www.who.int/management/background.pdf
(9) Howard County, MD Government. Healthy Howard Access Plan. Healthy Howard. Available at http://www.howardcountymd.gov/Health/HealthMain/Health_HHAccessPlan.htm.
(10) Adhi WK & Alexander CS. Determinants of condom use to prevent HIV infection among youth in Ghana. J Adol Health. 1999;24:63-72.
(11) Okie S. Fighting HIV — Lessons from Brazil. NEJM. 2006:354(19);1977-1981
(12) Dietrich J. The Politics of PEPFAR: The President's Emergency Plan for AIDS Relief. Ethics and Int Affairs. 2007;21(3):277-292.