Tertiary Care for Long-Term Health Care Development
01/25/2010
Gerardine Luongo on the need to strengthen tertiary care in developing countries
Just less than two years ago WHO issued the Report from the Commission on Social Determinants of Health. The report cites the growing inequities of well-being between rich and poor countries despite billions of dollars in aid. The report harkens back to much older advocacy strategies designed to build more comprehensive approaches to health development assistance. Unfortunately, the global health community (governments, NGOs and individual advocates) continues to fail, and fail dramatically, to frame and pursue strategies for long-term health systems development. We continue to implement often short-sighted, disease specific approach to health care-aid that will save some lives, but its greatest achievement will be to ease our collective conscience.
We have been granted an opportunity now in Haiti to respond to the immediate needs but also build a strong and comprehensive health-care infrastructure with tertiary care as a core component.
The U.S. is engaged in heated, even vitriolic debate about its health care future. Yet despite the diverging views, no one would argue that tertiary care be left out of the available complement of services. And yet global health advocates all but ignore the value of tertiary care, training physicians and surgeons and well-educated nurses in pursuit of less expensive approaches to capacity building in emerging nations. Ignorance is far from bliss in this case.
Primary care is one component of a comprehensive system of care. But it is just that, one component. It is arguably less expensive than secondary or tertiary care. If done well, it should have tremendous, positive impact on a large percent of the population; and, if developed in isolation from or in lieu of a comprehensive health-care system will not be able to sustain itself. Primary, secondary and tertiary care must be developed simultaneously within emerging nations if such nations are to stabilize overtime and come into there own.
Health is complex; it is far from the absence of disease. Thus, the architecture of a system responding to the complex nature of health must also be multi-faceted if it is to address the needs of any population. The architecture requires hospitals and regional centers of excellence comprised of physicians, surgeons, nurses with college degrees, researchers; highly skilled, highly educated professionals who serve as faculty and medical advocates. Hospitals are central to comprehensive health-care systems. Teaching hospitals provide countries with the life-saving pipeline of well-trained health-care professionals at all levels and yet hospital care is grossly neglected among global health advocates.
Developing nations are sorely lacking in their ability to produced higher level medical professionals.
All the countries of Africa collectively graduate about 5,100 physicians each year, half of whom emigrate. Pediatric surgery is often considered an expense that most African governments can not or will not include in its child health programs. It is estimated that less than 75 of the 600 physicians who have graduated from Zambia's only medical school during the past 40 years are actually practicing in Zambia. In countries such as Ghana, 60 percent of nursing positions go unfilled. Ethiopia has two hospital beds to serve every 10,000 people; in Senegal the ratio is one to 10,000.
One study reported that only 400 surgeons were available to serve more than 200 million people in East Africa. Ethiopia has only two doctors for every 100,000 people. Uganda has about 20 orthopedic, three neurosurgeons and about three plastic-reconstructive surgeons.
The lack of surgeons, physicians and nurses is the result of decisions made by world health advocates who have chosen very short sighted view of health-care development.
One example of the failure to build hospital based capacity in the emerging world is the dramatic and steadily growing rate of death by trauma and injury. While some injuries are indeed preventable, many are simply unavoidable. What is absolutely preventable is a life long disability due to lack of access to surgical care needed to appropriately respond to the injury.
The likelihood of dying from an injury is twice as high as the risk maternal death in developing nations. WHO estimates that injuries reflect 12 percent of the burden of disease: twice that of HIV and greater than TB, diarrhea and malaria combined. The leading cause of death for people ages 5-45 is injury, or more precisely, the injury leads to death from a lack of even the most basic hospital and surgical care.
Poor surgical care is a major public health threat in the developing world that has failed to gain the attention of the global health community. The lack of qualified surgeons and hospital care contributes to the burden of disease and death at a rate greater than that of communicable diseases.
Unfortunately, the champions of tertiary care are viewed are viewed as self-serving. The global health community has myopically embraced the philosophy that all resources must be directed toward the most people for the least amount of money. While on its face, the statement appears logical; unfortunately it denies the actual myriad needs of people and nations. Reducing morbidity and mortality requires much more than implementing a series of simple tasks.
Shortage of health-care workers has been identified as the leading obstacle to achieving MDGs. We have opted to respond to this lack largely by identifying the most basic of skills needed for primary care and training to those skills. We are not developing critical thinkers who can lead their countries in healthcare development for years to come. Malawi as an example has one medical school whose senior staff is mostly expatriates. Task-shifting has merit but only if pursued within comprehensive approach to systems development.
We know we increase retention of professionals when there is opportunity for ongoing training, complex problem solving and advancement. But we are actively designing flat systems without such opportunities.
It is certainly not my intent to deny the value of community based health-workers, traditional birth attendants or other first-line workers. They are vital. Nor it is my intent to imply that immunizations and/or other preventive care are unimportant. These initiatives are critical to survival of all nations. In the limited space of a blog, I have attempted to call attention to the need for the development of high quality tertiary care as a fundamental component to all systems of health care. Prevention is important but all morbidity is not preventable.
CURE International Responds to Haiti
CURE International had a surgical team on the ground 48 hours after the quake. The team is from CURE's pediatric hospital in Santo Domingo. Within 72 hours CURE deployed a second team of U.S. surgical and medical professionals and a cargo load of medical supplies and water. Within the first few days, more than 300 surgeries were performed, and teams are scheduled through the end of February. CURE has helped to establish six field operating theaters, surgical ICUs and a triage center. CURE's teams are currently working out of three area hospitals including Comuntae or Hospital de la Comuntae and "CDTI" hospital. CURE worked with the Comuntae hospital administrator to "re-open" the facility by staffing it with more than 100 Haitian and foreign medical professionals. An estimated 250,000 Haitians have been injured and will require orthopedic and reconstructive surgery in the months and years to come.
Gerardine Luongo, MSW is director of government and foundation relations at CURE International.
What happened in haiti was/is an eye opener to the whole world.
— bertrand on 2010-01-26
Ms. Luongo very astutely brings up an important issue which was also addressed in the World Health Report of 2008. If the very conservative estimate that 11 percent of DALYs are due to surgical conditions, then over 600 million DALYs per year (more than HIV/AIDS) are ignored by a focus only on primary care issues. Further, for many people, a single surgical intervention averts a lifetime of disability.
— Dr. Scott Corlew, Interplast Chief Medical Officer on 2010-02-02
While I would not go against the massive benefits of primary care, and whole-heartedly support efforts to build capacity in health systems overseas, I would counter that primary care is less expensive up front, when compared to secondary or tertiary care, but has the potential to greatly increase costs elsewhere in a health system. Not to be pessimistic, but for each child who dies before five, that’s one more child who will not need routine care or treatment for non-communicable diseases later in life, further burdening an already over-taxed system. A well-articulated post, though, about an issue of great importance to the future of the global health agenda.
— Amanda Makulec, MPH on 2010-02-22