Healthcare in the Developing World

Stephen DeAngelis

July 01, 2010

You might not have heard that Bill Gates is no longer the world’s richest man. He lost his unofficial title earlier this year to Carlos Slim, a Mexican telecom magnate. I bring up this bit of trivia because the two men recently partnered together to donate money targeted at fighting “malnutrition, dengue, malaria and other health problems in Mexico and Central America” [“Bill Gates, Carlos Slim announce $150M for health,” Associated Press, 14 June 2010]. According to the article, “foundations run by Microsoft co-founder Bill Gates and Mexican telecom magnate Carlos Slim will each donate $50 million to the 2015 Meso-American Health Initiative” and the Spanish government will contribute an additional $50 million. “The program also aims to reduce childbirth deaths and to help vaccination campaigns in the eight countries in the region.”

As I have noted in previous posts, the Bill and Melinda Gates Foundation has been active in promoting healthcare initiatives in the developing world for some time. The $50 million the foundation is donating to the Meso-American Health Initiative is small change compared to the $1.5 billion it has pledged over the next five years to support “maternal and child health, family planning and nutrition in developing countries” [“Gates Foundation Signals New Focus on Maternal, Child Health,” by Miriam Jordan, Wall Street Journal, 7 June 2010]. Jordan reports:

“Melinda Gates said the foundation was taking the lead to jumpstart a global effort. She urged world leaders in the developing and industrialized world to also do their part to prevent mothers and babies from dying. ‘It is going to take government effort and investment,’ she said at a women’s health conference where she made the announcement. ‘Every year, millions of newborns die within a matter of days or weeks, and hundreds of thousands of women die in childbirth,’ Mrs. Gates said. ‘The truth is, we can prevent most of these deaths – and at a stunningly low cost – if we take action.’ Mrs. Gates said she was inspired to take up the cause by the success in poverty-stricken countries like Malawi, in Africa, where the government has trained 30,000 health workers who have been crucial to lowering childhood and maternal mortality. Sri Lanka, in South Asia, has instituted policy changes that cut maternal mortality dramatically, she said.”

The funds, according to Gates, will be targeted at countries like India and Ethiopia, “where death rates among mothers and children remain stubbornly high.” Lessons learned from programs like those in Malawi will be implemented as funding “will be spent on training health workers” as well as spent on “developing antibiotics for infections in newborns and treating post-partum hemorrhage in mothers.” Drugs developed as a result of the program will obviously benefit women and children around the world. Jordan continues:

“Mrs. Gates cited recent studies by the University of Washington’s Institute for Health Metrics and Evaluation and researchers in Australia that found the number of women dying from pregnancy-related causes has dropped by more than 35 percent in the past 30 years — from more than 500,000 annually in 1980 to about 343,000 in 2008. She said the next several months represented ‘a critical window of opportunity to secure new global action.’ Canada, which is hosting the G8 summit in Ontario [in June 2010], will call on donor countries to endorse a major maternal and child health initiative. Also at the ‘Women Deliver’ conference, Ban Ki-moon, secretary general of the United Nations, announced a so-called ‘joint action plan’ to improve the health of women and children. The plan urges governments, civil society, the private sector and U.N. agencies, from the World Health Organization to Unicef, to provide funds and devise policies to help developing countries. ‘We have had success on HIV AIDS, malaria and tuberculosis,’ he said in an interview. ‘A global partnership is required’ to combat child and maternal mortality, which has been the ‘slowest moving’ health area requiring international attention.”

Although healthcare is expensive in the developing world, basic medical care can be provided at a much more reasonable cost in the developing world. Rwanda, for example, provides national healthcare and charges only $2/year as a premium [“A Dirt-Poor Nation, With a Health Plan,” by Donald G. McNeil, Jr., New York Times, 15 June 2010]. As you might imagine, the services provided are very basic and the equipment available for treating patients is modest. McNeil reports:

“The maternity ward in the Mayange district health center is nothing fancy. It has no running water, and the delivery room is little more than a pair of padded benches with stirrups. But the blue paint on the walls is fairly fresh, and the labor room beds have mosquito nets. Inside, three generations of the Yankulije family are relaxing on one bed: Rachel, 53, her daughter Chantal Mujawimana, 22, and Chantal’s baby boy, too recently arrived in this world to have a name yet. The little prince is the first in his line to be delivered in a clinic rather than on the floor of a mud hut. But he is not the first with health insurance. Both his mother and grandmother have it, which is why he was born here. Rwanda has had national health insurance for 11 years now; 92 percent of the nation is covered, and the premiums are $2 a year. … For $2 a year, of course, Rwanda’s coverage is no fancier than the Mayange maternity ward. But it covers the basics. The most common causes of death — diarrhea, pneumonia, malaria, malnutrition, infected cuts — are treated. Local health centers usually have all the medicines on the World Health Organization’s list of essential drugs (nearly all are generic copies of name-brand drugs) and have laboratories that can do routine blood and urine analyses, along with tuberculosis and malaria tests. Ms. Mujawimana gave birth with a nurse present, vastly increasing the chances that she and her baby would survive. Had there been complications, they could have gone by ambulance to a district hospital with a doctor.”

Rwanda’s basic health insurance underscores Melinda Gates assertion that “we can prevent most … deaths – and at a stunningly low cost – if we take action.” McNeil continues:

“Since the insurance, known as health mutuals, rolled out, average life expectancy has risen to 52 from 48, despite a continuing AIDS epidemic, according to Dr. Agnes Binagwaho, permanent secretary of Rwanda’s Ministry of Health. Deaths in childbirth and from malaria are down sharply, she added. Of course, many things that are routine in the United States, like M.R.I. scans and dialysis, are generally unavailable. Cancer, strokes and heart attacks are often death sentences. The whole country, with a population of 9.7 million, has one neurosurgeon and three cardiologists. (By contrast, New York City has 8 million people; at a national softball tournament for neurosurgeons in Central Park 10 days ago, local hospitals fielded five teams.)”

McNeil points out, however, that Rwandans don’t suffer (yet) from one health concern that plagues the U.S. — obesity. “Visitors to Rwanda,” he writes, “are quickly struck by how thin everyone on the street is. And it is not necessarily from malnutrition; even the president, Paul Kagame, a teetotaling ascetic, is spectral.” McNeil goes on to explain that if $2/year insurance sounds too good to be true, it is:

“General surgery is done, but waits can be weeks long. A few lucky patients needing advanced surgery may be treated free by teams of visiting doctors from the United States, Cuba, Australia and elsewhere, but those doctors are not always around. Occasionally, the Health Ministry will pay for a patient to go to Kenya, South Africa or even India for treatment. Still, even with rationing this strict, how can any nation offer so much for $2 a year? The answer is: It can’t. Not without outside help. Partners in Health, the Boston-based health charity, which runs two rural hospitals and a network of smaller clinics in Rwanda, said its own costs ran $28 per person per year in areas it serves. It estimated that the government’s no-frills care costs $10 to $20.”

Still, basic healthcare for less than $35/year is great and still qualifies as a stunningly low cost.

“According to a study recently published in Tropical Medicine & International Health, total health expenditures in Rwanda come to about $307 million a year, and about 53 percent of that comes from foreign donors, the largest of which is the United States. One big donor is the Global Fund to Fight AIDS, Tuberculosis, and Malaria, which is experimenting with ways to support whole health systems instead of just treating the three diseases in its name. It pays the premiums for 800,000 Rwandans officially rated as ‘poorest of the poor.'”

One of the things I like about the Rwandan system is that important decisions are made at the local level. McNeil explains:

“In a nation of poor farmers, who is officially poorest is decided by village councils. They weigh assets like land, goats, bicycles and radios and determine whether a hut has a costly tin roof or just straw. ‘People know their neighbors here,’ said Felicien Rwagasore, a patient coordinator at the Mayange clinic. ‘They do not make mistakes.'”

Another characteristic of the Rwandan program is that it stresses personal responsibility.

“Making every Rwandan pay something is part of President Kagame’s ambitious plan to push his people toward more self-reliance and, with luck, eventually into prosperity. The country has been called ‘Africa’s Singapore.’ It has clean streets and little crime, and each month everyone does one day of community service, like planting trees. Private enterprise is championed, and Mr. Kagame has been relentless about punishing corrupt officials.”

As I’ve noted in other posts concerning Rwanda, President Kagame is not without his critics. Those “critics say, he suppresses normal political dissent, too.” For the latest on what critics are saying, read “Rwanda pays heavily for Pax Kagame,” by Eleneus Akanga, BusinessDay, 30 June 2010]. McNeil reports that using the Rwandan system as a model for other developing countries faces a “practical obstacle,” namely, “most of the world’s poor, including Rwanda’s, resist what they see as the unthinkable idea of paying in advance for something they may never get.” They simply don’t understand the logic behind insurance. Like many other health insurance plans, the Rwandan system also requires co-pays that often exceed the cost of annual premiums. That, too, can be a problem. McNeil continues:

“‘If people pay the $2 and then don’t get sick all year, they sometimes want their money back,’ said Anja Fischer, an adviser to the Health Ministry from GTZ, the German government’s semi-independent aid agency. Also, the co-pays can be overwhelming. Even $5 for a Caesarean section can be too much for people as close to the edge as the Yankulijes, who live by growing beans and sweet potatoes and wear American castoffs (Mrs. Yankulije’s T-shirt read ‘Wolverines Football’). Many live by barter and cannot scrape together even $2 in coins, said Dr. Damas Dukundane, who works in a poor rural area. Since the government accepts only cash, he said, his patients sometimes go to traditional healers, who could be dangerous quacks but will take goats or chickens. As a result of all these factors, Rwanda is a patchwork of small clinics, some richer or better-run than others. Mayange’s, for example, gets donations and guidance from the Access Project founded by Josh N. Ruxin, a Columbia professor of public health who now lives in Kigali.”

In previous posts, I have noted that President Kagame wants Rwanda to enjoy the benefits of a connected society, including the benefits that can accrue in the medical sector. “For example, the computer that prints the insurance cards has a Webcam on it. Previously, Professor Ruxin said, for insurance costing $2, villagers had to bring in photographs that had cost them $1 or more.” McNeil concludes that the system is not perfect, but it has made a significant difference in an impoverished country. One of the things that may be changing is the fact that the poorest and richest people in the country pay the same $2/year premium. Legislators are considering implementing a graduated system of premiums. Affordability, however, remains a top priority.

Before leaving this topic, there’s one other article I’d like to mention that reports on a promising device that could help reduce infant deaths. It’s called the Baby Bubbler [“Infants in developing nations could be saved by the Baby Bubbler,” by Ben Coxworth, Gizmag, 8 June 2010]. Coxworth reports:

“You can’t not like an invention called the Baby Bubbler … as it’s doubtless going to save many young lives. A team of five seniors from Houston’s Rice University developed the Bubbler, officially known as the Continuous Positive Airway Pressure (CPAP) device, for use on infants with respiratory infections in developing nations. Given that around 20 percent of deaths in children under five are caused by lower respiratory infections, that could make for a whole lot of saved babies. The Bubbler is not meant to be used as a replacement for a ventilator, but as a respiratory support device.”

Like many other devices targeted for use in the developing world, the Baby Bubbler comes from a university program that encourages students to tackle challenges in the developing world. You have to be impressed with the work of these young people and with their sincere efforts to make devices that are both useful and affordable. The Rice program that produced the Baby Bubbler, the university’s Beyond Traditional Borders global health initiative, also produced a blood centrifuge based on a hand-cranked salad spinner. Coxworth explains how the Baby Bubbler device works:

“It consists of two main components, a flow generator and a regulator. The generator pumps air through a tube and up the baby’s nose, through nasal prongs. That tube then continues on to the regulator, which is actually just a bottle of water. The air pressure being delivered to the baby can be changed by simply adjusting the amount of water in the bottle. Given that hospitals in developing nations can be woefully understaffed, an alarm will warn nurses if the system loses power and water starts to back up the tube.”

Interestingly, the device was first used in Rwanda this spring and will be introduced later this year into another country mentioned earlier in this post, Malawi, as well as into Lesotho. Cox concludes:

“Given that each Bubbler only costs US$140 to make, they will hopefully be widely accepted. ‘The United Nations has designated reducing under-five mortality by two-thirds by 2015 as one of its Millennium Development Goals,’ said project adviser Heather Machen. ‘We hope that this bubble CPAP will contribute toward achieving that goal.'”

It wouldn’t surprise me at all if some of the money from the Gates Foundation is used to purchase Baby Bubblers. Since having a healthy workforce is one essential characteristic needed by developing countries in order to attract foreign direct investment, continued efforts in this area are essential for the future.