Find a message here by Innocent Musore, Executive Director Global Initiative for Environment and Reconciliation-GER Kigali City, Rwanda, as a reminder of GER-Rwanda 2022 field engagement and practices. We are pleased to post and circulate it as a follow-up to Improving Communities’ Livelihood, Healing and Reconciliation in Rwanda PEAH published by the same author on February this year

By Innocent Musore

Executive Director

Global Initiative for Environment and Reconciliation-GER

Kigali City, Rwanda

A Message From Global Initiative for Environment and Reconciliation – GER Rwanda

 

Welcome to GER!

Since 2015, Global Initiative for Environment and Reconciliation (GER) –a Non-Governmental Organization ,  whose Vision is to see people living in harmony with themselves and the environment , with a Mission to support the process of peace building and community development in Rwanda, and the Great Lakes region has  actively been a peacebuilding and development organization.

We work with communities and stake holders, community based organizations to facilitate conflicts transformation and ecosystem conservation with a keen focus to empower women and youth to become agents of change.  We facilitate interactions with people of all walks of life, including; survivors of the 1994 Genocide against the Tutsi, and perpetrators to reconcile and recover from collective trauma and historical wounds.

We facilitate community knowledge exchange and intergenerational learning dialogues that help environmental reconciliation and conservation initiatives to secure food system by Agroecoly farming. This includes and is not limited to testimonies and story-telling.

The beneficiaries should know how to cultivate their land so that it becomes and remains fertile to the future generations, even in times of climate change. Our aim is to raise community awareness so that people are sensitized to become better informed and enlightened about how our actions impact the environment and the associated ecosystems.

We are thus able to understand not only the impact of our decisions and actions, but also learn how to anticipate these changes before they occur and act in such a way as to protect our natural environment which allow us to live in harmony with nature. We work with communities to improve ecosystem conservation and climate resilience.

Our interventions are in Rwanda and the Democratic Republic of Congo (DRC) particularly in the Eastern part of North Kivu, where communities have been affected by ethnic conflicts and violence, famine, disease as well as extreme poverty. Principally, working with communities has enabled us to learn much from their experiences and program interventions, hence meeting their needs already identified in the communities.  We believe that change is possible when communities are empowered and supported to take full ownership and engage in their own home-grown community development initiatives. Noteworthy, community-based approach permits changes from individuals to families, community members and societal levels.

To that end, we therefore invite individuals with tangible ideas and good will from various organizations, foundations and development partner to support this noble cause of restoring trust and regional integration.

For more information www.globalr.org, our social media: https://twitter.com/GER_Global, https://web.facebook.com/GERRwanda, https://www.instagram.com/ger_global250.

Thank you!

 

 

 

Technical innovation in globalized health systems seems to become the future pandemic in our current time frame. Disruptive technologies can be used for the good and the bad. This research letter wants to pinpoint the landscape of choices in which medical doctors and other medical professions need to balance the trade in health services with their ethical stance and commitment to nurture and treat patients

By Dr. Tomas Mainil

Phd, Ma, Msc, PD, Senior Lecturer/Researcher and strategic policy analyst, Breda University of Applied Sciences, the Netherlands. Mainil.t@buas.nl

 

 The Reality of Ethics and the Role of Disruptive Technologies in the Medical Data Industry: How Do They Align?

 

Innovative technologies such as Digital Twins, AI and Blockchain are currently changing the way of working in the medical industries, which probably will lead to early adaptors versus businesses which will react to late in this technological battle for the patient. (Nam et al., 2021) point out that smart destinations are beginning to embrace blockchain solutions, which could result in different business practices. According to (Gossling, 2021) we have arrived in the stage of usurpation with regards to ICT adoption in the tourism industry. This is certainly also true for the structure present in the health space worldwide. It will generate new room for imagination to envision the future (Xiang, 2018). So, we need to assess if the application of these technologies are influencing: mutual understanding between health management levels and professionals, Individual fulfillment, Sustainable development, Stakeholder obligations, Right to health care, Liberty for medical movements and finally the rights for health workers in the medical industry.

Each of these ethical perspectives will be touched by the usage and implementation of these technologies. We want to analyze for each of these principles what the positive and negative relationships are with the continuous development of these technologies. This technological shift will be in need of anti-disciplinary thinking, embarking on new paradigms and mindsets (Sigala, 2018).

In the near future disruptive technologies will change the medical industry rapidly and without taken into account workforce, sustainable communities and hosting places and geographic sensitive environments. In the distant future AI and the development of synergetic systems of supervised machine learning will replace human activities and ways of acting in general societies and how these societies will be organized: technology at the front of destructive innovation or technology and AI for the good of society, the citizens in those societies, and last but not least technology which will create a shift in the trade-off between the elite and endangered communities all over this planet.

So, to humbly conclude: do we want as a globalized civil system to sustain our medical apparatus and the planet; or do we want to perish, and is this current time frame the advent of not being able to provide future generations what our ancestors understood better: to simply live in a harmonic system, rather than to enslave our own past and future. Urgently, but at the same time without any political and policy speeding up processes, we have – without debate – arrived at the bones of our current society.

Without solutions and actions from inside our outside the medical profession, no globalized sustainable health system will arise. But in the end, these disruptive technologies can enhance the sustainable character and the ratio of the healthcare sector: to make the right choices and finding the right equilibrium between human striving and technological innovation. (Putera et al., 2022) show evidence in Indonesia, where technology, policies and health care delivery are coinciding.  Possibly and hopefully this will deliver stuctural results or solutions.

 

The author has no conflicting interests

 

References 

Nam, K., Dutt, C.S., Chathoth, P. & Khan M.S. (2021). Blockchain technology for smart city and smart tourism: latest trends and challenges, Asia Pacific Journal of Tourism Research, 26(4), 454-468.

Gössling, S. (2021). Tourism, technology and ICT: a critical review of affordances and concessions, Journal of Sustainable Tourism, 29(5), 733-750.

Putera B.P., Widianingsih, I., Ningrum, S., Suryanto, S., Rianto, Y.(2022). Overcoming the COVID-19 Pandemic in Indonesia: A Science, technology, and innovation (STI) policy perspective, Health Policy and Technology,11(3) https://doi.org/10.1016/j.hlpt.2022.100650.

Xiang, Z. (2018). From digitization to the age of acceleration: On information technology and tourism, Tourism Management Perspectives, 25, 147-150.

Sigala, M. (2018). New technologies in tourism: From multi-disciplinary to anti-disciplinary advances and trajectories, Tourism Management Perspectives, 25, 151-155.

Some smart reflections here on the overarching importance of not to be postponed ONE HEALTH ONE WORLD mindset in today’s planetary arena at the intersection of human, animal and environmental contexts

By Kirubel Workiye Gebretsadik

Medical Doctor and Master of Public Health student 

Addis Ababa, Ethiopia

ONE HEALTH ONE WORLD

 

There is a health day on November 3. This day is meant to honor and draw attention to the idea of “one health, one globe.”

Animal health, and shared environmental health are all directly related to human health.

One health is a transdisciplinary, multisectoral, and collaborative strategy. In addition to addressing health issues, including the rise of infectious illnesses, antibiotic resistance, and food safety, collaboration across sectors and disciplines also helps to promote the health and integrity of our ecosystems. One Health, according to WHO, may cover the complete spectrum of disease control, from prevention to detection, readiness, response, and management, and contribute to global health security by tying humans, animals, and the environment together.

Tedros Adhanom Ghebreyesus, director-general of WHO, commented on one health, saying: “We need to develop a more thorough and integrated one health governance framework at the global level. We require a capable labor force, a political commitment, and ongoing financial support. To bring about the change we need, we must adopt a more proactive communication and engagement strategy across sectors, disciplines, and communities.

Since agriculture and farming technologies permitted humans to dwell in sedentary communities, near their livestock and crops, diseases have been emerging at the human-animal interface. Over 85% of Africans still rely on agriculture and livestock breeding. As a result, the conversation is still ongoing. Deforestation is becoming more widespread in emerging nations due to a growing population and a lack of agricultural land. As a result, people and wild creatures come into proximity.

According to information from the World Health Organization, 75% of newly discovered or developing infectious diseases are zoonotic, and 60% of all infectious diseases reported in humans have an animal origin. The COVID-19 pandemic, avian influenza, swine influenza, monkeypox, and antibiotic resistance are all excellent teaching tools for our society about the importance of collaborating across human, animal, and environmental health.

According to the Johns Hopkins School of Public Health, COVID-19 would cost the US $16 trillion. What about in developing countries? Therefore we have to speak loud ONE HEALTH ONE WORLD.

 

By the same Author on PEAH

Social Innovation in Healthcare

 

…many people now go about their lives as if COVID was no longer with us and has been relegated to history. This “out of sight is out of mind” mentality is reflected in their day-to-day behaviour and when translated to a population level poses a real threat to any attempts to control the spread of the virus, reduce its transmission or prevent individuals from being needlessly infected…

By Dr. Brian Johnston

Senior Public Health Intelligence Manager

London, United Kingdom

The New Abnormal

 

In promoting a plan of Living with COVID, the UK government has made sweeping relaxations of COVID-19 restrictions. While this plan recognises that the COVID pandemic is not over and proposes a flexible approach to cope with an unpredictable future, the general population have largely resumed their lives in a way that is reminiscent of pre-pandemic times.

Although COVID has been responsible for over 200,000 deaths in the United Kingdom and currently kills several hundred people each week, according to official government statistics, there is currently very little media coverage of the pandemic. Other topics have attracted media attention away from the pandemic and COVID-19 no longer retains the exclusive and dominant place in the public’s imagination, that it once held. Consequently, many people now go about their lives as if COVID was no longer with us and has been relegated to history. This “out of sight is out of mind” mentality is reflected in their day-to-day behaviour and when translated to a population level poses a real threat to any attempts to control the spread of the virus, reduce its transmission or prevent individuals from being needlessly infected.

If you travel across London today, you could be forgiven for thinking that the COVID pandemic had not happened, or it is a figment of your imagination. People crowd into busy trains and buses, few wear face masks or attempt to socially distance and hand gel dispensers at stations are often empty. In many restaurants and pubs, customers squeeze into confined spaces, where adequate ventilation is often by chance, rather than design. Human beings often remember petty insults and insignificant nonsense for generations but can “forget” truly important things in days when it suits them, there are no consequences, or it is expedient.

From an alternative perspective, some COVID restrictions, such as lockdowns, social distancing and regulation of visiting to care homes, did place a considerable burden on the mental health of many people during the pandemic. Reports of excessive alcohol consumption, loneliness and social isolation were rife, and it is likely that the scars left by this period of our recent history, will remain for years to come. It is therefore understandable (to an extent) why survivors of this global tragedy should embrace life with a renewed fervour, when these restrictions have been relaxed.

However, the damage done by this virus continues to show itself in many other ways and its corrosive effect on the fabric of society keeps on evolving. The financial effects of the pandemic, whether through closure of businesses, redundancies or unemployment, will now be worsened by a cost-of-living crisis and impending recession, which will have major health and wellbeing implications across the world. As deprivation spreads, the development of health inequalities will be felt more strongly, whether they are expressed through reduced access to healthcare services, poor nutrition or the worsening of long-term conditions, exacerbated by patchy or inadequate monitoring.

For example, lockdowns and restrictions on social contact, during the pandemic, led to considerable growth in the number of fast-food outlets and food delivery services, in many areas of the UK. This increased access to fast foods, which are often high in refined sugars, preservatives and saturated fats, will have had a detrimental impact on the nation’s health in terms of obesity, diabetes, hypertension, heart disease, cancers and a range of other conditions. In a similar way, the current economic crisis could easily have serious health implications, as people seek cheaper options (including fast food) to feed their families. In this way, COVID will continue to impact both mortality and morbidity, indirectly, and for years to come.

To quote Shakespeare; “When sorrows come, they come not single spies, but in battalions,” so we should expect a tragedy on the scale of COVID to cause damage in many ways, at multiple levels and across time. For this reason, it is important for us to remain vigilant, monitor the emergence and spread of new viruses closely and act quickly and effectively, when a pandemic threatens to gain momentum. In this modern world, where a staggering variety of things compete for our attention, it would be easy to lose sight of the ongoing threat posed by COVID-19 and other pathogens. This would be dangerous and negligent, and likely to both worsen and prolong the damage caused by any resurgence of the current pandemic, or the blossoming of a new one.

A recent report by the British Medical Association (BMA) on The impact of the pandemic on population health and heath inequalities, recognises that the UK entered the COVID pandemic from a position of weakness due to many factors including cuts in public services, underfunding of public health and a lack of cross-governmental accountability for health.

Reducing health inequalities and improving population health would have lessened the impact of the pandemic. However, an “inverse care law” underlies many health inequalities, in which those people most in need of care are the least likely to receive it. Unfortunately, health inequalities were exacerbated by COVID, when reduced access to care was disproportionately felt by the most vulnerable people and groups most at risk.

This BMA report recommends that the UK ensures that it is better prepared to manage any future pandemic, by considering the impact on health inequalities through:

• explicitly supporting and protecting those vulnerable and at-risk groups disproportionately affected by reduced access to care
• promoting accessible and up-to-date public health communications and
• investing in high quality, linked health data.

In the UK, whilst there has been a concerted effort to get life back to normal by reducing backlogs of delayed operations and continuing to administer the COVID vaccination and booster programmes, the emerging cost of living crisis seems very likely to exacerbate existing health inequalities.

Action must now be taken, if we are to avoid placing unnecessary stress on our health sector later this year, when a range of factors (such as cost of living, climate change and fuel poverty) could create a perfect breeding ground for COVID infections. Governments are best placed to introduce measures to address the cost-of-living crisis by mitigating the worse effects of rising food and fuel prices and the resultant health inequalities. However, the general public also bears some responsibility and can exert a major effect, through changes in behaviour. For example, people can resume the wearing of face masks on public transport and in crowded venues where possible. They can wash their hands properly, social distance appropriately and ventilate effectively, without the need for new guidance, laws or rules to coerce them into doing it. To avoid another catastrophe this winter, we will all need to invest time, effort and expense in helping to protect ourselves against the development of a potential tidal wave of new COVID infections.

Over half of the UK population has had COVID-19 and while figures from the Office for National Statistics (ONS) currently show downward trends for infections and hospitalisations, there has recently been a worrying increase in deaths. Against this background, if we are to prevent a tragedy, or at least ameliorate a possible resurgence of COVID cases, we must work harder as individuals and collectively, to create a “new normal” that is both safe and secure.

A recent article in Scientific American states that the main question when creating a new COVID narrative is whether or not the virus still poses a major threat to public health. This is a difficult question to answer, but it is certain that our collective behaviours and decisions will shape our relationship with COVID-19 and determine whether we have a palatable “new normal” or a catastrophic “new abnormal.”

 

By the same Author on PEAH


Death in the Time of COVID

Unleashing the True Potential of Data – COVID-19 and Beyond

Living with COVID in a Transformed World

 

Despite designing some targeted programs for financial support for the poor in Iran, many poor people are left out of coverage due to the fragmentation of the programs. But what makes such challenges for a health system to reach the poor? It will be hard to make substantial progress towards pro-poor UHC without promoting simultaneously universal social protection that will contribute to realize SDG 1 targets of alleviating poverty. This requires system-wide social and health policies breaking the boundaries of traditionally fragmented welfare systems and health programs, where there is a "Berlin Wall’ that separated health and social care services. There is a Ministry of Cooperatives, Labor and Welfare (MCLW) in charge of universal health protection and Ministry of Health and Medical Education (MOHME), who is the steward of the universal health coverage and health insurance system, without a clear cooperation line which makes a thick berlin wall among these two files

By Dr. Manal Etemadi

Health financing researcher, Iran Health Insurance Organization (IHIO), Tehran, Iran

The Berlin Wall Between Welfare and Health in Iran: Who Gains the Health Subsidies?

 

Health financing policies must face the question of how to increase equitable financing, this implies progressive financing which means that the rich pay a greater share of their income than the poor. In many countries, the lowest income deciles experience less catastrophic health expenditure than the highest income deciles which reflects the nature of the patient cost sharing. When people are very poor, they don’t use services so they don’t have to pay and therefore don’t expose to catastrophic expenditure. If their income situation improves, they will begin to use services but will suffer the adverse financial consequences associated with paying for care.

Two main challenges must be considered for improving the equity in health financing: firstly, that families do not become poor or do not pay a large share of their income to receive the necessary health care, and secondly, that poor families pay less than rich families. Poor families not only have less income, but a larger share of their income is spent on basic needs such as food and shelter. Every family should pay a fair share of the health system costs, and when it comes to the poor, a fair share may mean not paying.

Due to the increase in demand towards the private sector for interventions that are not included in the basic benefit package, the impact of out-of-pocket payments on the poor must be considered. One of the four main determinants of the financing performance of a health system is the flow of subsidies to the poor. Cost sharing mechanisms reduce the demand for services totally and harms the poor. Even when services are free, they are not necessarily affordable for the poor because other costs associated with seeking health care, such as the cost of medicines, informal cost to providers, transportation, and time lost to work, are also important. Even when there are exemptions or subsidies to cover the costs of the poor, other factors prevent the poor from using health services that are difficult to assess: the reluctance of the poor to seek services due to stigma or the way health workers treat them.

The financing strategy should ensure that the poor receive the service they want in time of illness without financial barriers. Therefore, out-of-pocket payments for care, especially for the poor, should not be considered a long-term source of health system financing.

Public spending on basic services, i.e., primary health care, benefits the poor, while the main beneficiaries of subsidies for tertiary hospital are the non-poor. The poor rely more on public health care facilities, while wealthier families use private hospitals and private care services. The lower costs of public health compared to hospitals tend to support the poor, while hospital costs and the provision of drugs are not well targeted. Hospitals and infrastructure costs are not pro-poor and progressive. Evidence also shows that spending on infrastructure disproportionately benefits the non-poor. The most effective way to improve the health system for the poor is to identify their most urgent health needs of the poor and design an effective way to meet those. Focusing on the specific needs of the poor may not save money, but it does ensure that what is spent is well targeted.

In order to realize the purpose of targeting, which includes minimizing the leakage of benefits to non-target groups in order to maximize the resources available for targeting the desired group, the inclusion error (or leakage error which means the proportion of non-target people who benefit from the benefits of the intervention) and the exclusion error(or coverage error which means the ratio of people from the target group who do not benefit from the benefits of the intervention) should be distinguished and balanced in policy formulation.

To direct more health benefits to the poor, since the poor are less likely to use services than the rich, public health programs may use targeted strategies. The application of targeted mechanism in insurance system which includes high subsidization, integration of subsidized people and participating people, balanced benefits package for all and reduced cost sharing, are considered as effective measures to expand insurance coverage for poor people. Targeting strategies may identify the poor as eligible for specific benefits, implement programs in specific areas where the poor live (as has been stipulated in general health policies in Iranian health system), or cover health problems that the poor often experience. Programs that use multiple targeting approaches will be more effective. In addition, where governments define a cost sharing for public health services, waiver strategies and Sliding – scale fees will be critical to successfully direct benefits to the poor.

As the very poor cannot afford to pay for health services, governments must guarantee the financing of health services for them, and especially for the use of hospital care, either through direct payments from tax revenues or through cross-subsidies in health insurance-based systems. Political pressures may prevent changes in the allocation of resources to the poor, and limited government capacity may prevent the effective implementation of exemption programs to protect the poor, what we can see in Iranian health system. In allocating public resources, policymakers should give priority to public health and disease prevention and subsidies for the poor.

Iran, as a populated lower-middle income country which suffered from severe financial constraints and limitation due to economic sanctions, already struggled with health financing. There is a Two-tier health system with private sector’ which served better-off and some of the poor obliged to refer only to public sector and also a tiered health insurance system with inequitable benefit packages for different segments of the population, including complementary and supplementary health insurance only for the better-off that the poor don’t have the access to it. There is separated delivery system for most of the poor through family physician and referral system. Despite the fact that the law requires the health system to design the cost-sharing based on the income levels, all the poor have to pay same rate of user fee at the point of service delivery, except the rich who enjoyed the complementary health insurance and in most cases they don’t have to pay considerable fee from the pocket at the point they receive their needed services.

What is considered in Iran in the form of specific and official programs for financial protection for the poor is divided into two main parts: Health insurance programs include subsidized insurance coverage for poor people and the non-insurance programs include providing low-cost services to all in public hospitals and unstructured cost-sharing reduction for poor people in public hospitals in the case that the poor claim they are not able to pay the cost of services, which has led to outpatient services and especially Medicine still has a high out-of-pocket payment burden. Supply-side subsidies in the form of low cost of all services for all patients in public hospitals, benefit the rich more than the poor, as the Inverse Care Law which claims that the poor bear the greatest burden of disease, but have a smaller share of health care, and thus the public subsidized services (from the simplest to the most complex and expensive services provided in public hospitals) are mostly benefit the rich than the poor, who are the main target group of these services. This is because due to the lower price of services in the public sector, any use of the services by people with higher incomes is a subsidy for this group.

Despite designing some targeted programs for financial support for the poor in Iran, many poor people are left out of coverage due to the fragmentation of the programs. But what makes such challenges for a health system to reach the poor? It will be hard to make substantial progress towards pro-poor UHC without promoting simultaneously universal social protection that will contribute to realize SDG 1 targets of alleviating poverty. This requires system-wide social and health policies breaking the boundaries of traditionally fragmented welfare systems and health programs, where there is a “Berlin Wall’ that separated health and social care services. There is a Ministry of Cooperatives, Labor and Welfare (MCLW) in charge of universal health protection and Ministry of Health and Medical Education (MOHME), who is the steward of the universal health coverage and health insurance system, without a clear cooperation line which makes a thick berlin wall among these two files.

In insurance programs in Iran, where the government takes the place of the employer and provides subsidized coverage, it is not able to protect people equally from catastrophic health expenditure, and previous plans in Iran Health Insurance Organization, as the main public health insurer in Iran, including urban hospitalization insurance and the Rural health insurance program have had regressive effects on the distribution of health care financing as ignored the progressive factor of financing. Urban Hospitalization Insurance, which was designed in 2002 with the aim of covering uninsured people in cities and became known as urban vulnerable people insurance, is an example of non-targeted subsidized insurance in the country, which was literally changed to the self-fund pool (Iranian Pool) and was continued with a discount in the payment of insurance premiums for the poor. In the Universal Health Insurance Pool and Rural Health Insurance Pool, without distinguishing the poor from the rich, this subsidy is allocated for insurance premiums, and this issue causes to waste earmarked resources toward the rich. Table 1 indicated some programs designed to protect the poor in health system of Iran.

Targeting mechanisms for social health assistance

In formulating financial support policies for the poor in Iran, type 1 error in policy making leakage error, is considered the main policy tool. Policy makers are not willing or believe (or both) to target the health subsidies and therefore the resources are earmarked for the poor which the rich people benefit more. Therefore, due to the imposition of a heavy cost burden and beyond the capacity of the determined resources with the entry of the rich into the plan, designed policy has failed, been redesigned, and usually become limited. The current policies to support the poor have design benefits to the poor that the majority of the poor population do not have correct and complete information about them, do not have the correct referrals to receive support, and sometimes espose to higher costs and pay higher out of their pocket.

The health system in Iran has not been able to make effective interventions in financial support for the health of the poor. Moving the supply side subsidies to the demand side in health insurance system in the form of exemption policies for the identified poor in the comprehensive social protection system is the first step to targeting the subsidies to the poor.

Generally, in countries with a similar socio-economic situation to Iran, there is a need for targeted policies for the poor in the economic and health sectors in parallel, and reducing poverty while ensuring the poor have financial access to health services should be followed up together. By designing targeted programs for the poor including focusing on their specific diseases and conditions, calculating and reducing the burden of out-of-pocket payments for all health services, especially the services that the poor use the most and exemption from paying for them, increasing the health literacy of the poor, improving the social determinants of health in the places where the poor live, to name but a few, can prevent the poor from falling into the poverty trap and becoming poorer because of treatment costs and should be on the agenda of the government. Focusing on targeted programs to financially support the poor is a necessary prescription for Iran because evidence has shown that untargeted programs leave the poor behind.

 

References 

1. WHO. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies: World Health Organization; 2010.
2. Murray CJ, Frenk J. A framework for assessing the performance of health systems. Bulletin of the world Health Organization. 2000;78(6):717-31.
3. WHO. The world health report 2000: health systems: improving performance: World Health Organization; 2000.
4. Etemadi M, Hajizadeh M. User fee removal for the poor: a qualitative study to explore policies for social health assistance in Iran. BMC Health Services Research. 2022;22(1):1-12.
5. Gafar J. Do the poor benefit from public spending? A look at the evidence. The Pakistan Development Review. 2005:81-104.
6. Fogel RW, Lee C. Who gets health care? National Bureau of Economic Research, 2003.
7. Jacobs B, Price A. A comparative study of the effectiveness of pre-identification and passive identification for hospital fee waivers at a rural Cambodian hospital. Health and social protection: experiences from Cambodia, China and Lao PDF. 2008.
8. Mathauer I, editor State budget subsidization of poor and vulnerable population groups in health insurance type schemes in low-and middle-income countries: A global overview and trends in institutional design. Bangkok: Prince Mahidol Award Conference; 2015.
9. Ashford LS, Gwatkin DR, Yazbeck AS. Designing health and population programs to reach the poor. 2006.
10. Bennett S, Gilson L. Health financing: Designing and implementing pro-poor policies. 2001.
11. Heller MPS. What Should Macroeconomists Know about Health Care Policy?: International Monetary Fund; 2007.
12. WHO. The world health report: health systems financing: the path to universal coverage2010.
13. Maher A. The relationship between poverty and health in Iran. Journal of Social Welfare. 2005;5(18):1-19.
14. Moradi-Lakeh M, Vosoogh-Moghaddam A. Health sector evolution plan in Iran; Equity and sustainability concerns. International Journal of Health Policy and Management. 2015;4(10):637-40.

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

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News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

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…With the pre-COVID projected evolution of the workforce of primary care practitioners and the ever-increasing demand for healthcare, it already will not be possible to provide the same services as today. In the future, the first contact with the health care system might not be with your family doctor or nurse practitioner, but with an artificial intelligence. Routine visits and screening will be automated and a personal interaction will only be reserved for “referred” cases.

Obviously, this situation does not provide the medical professionals the time to analyse and assess all the extra medical information from wearables and others, a big part as raw data, that an individual might possess…

By Tony De Groote

Health System Strengthening – Health Policy – International Development

Antwerp,  Flemish Region, Belgium

 Changes in the Provision of Primary Health Care

A More Empowered Role for the Individual

 

The Primary Health Care approach still rules

The advantages of Primary Health Care (PHC) are well established.  Promoted by the World Health Organisation at the Alma Ata conference in 1978 to achieve “health for all by the year 2000”, PHC has been confirmed as the best approach to organise health systems. Not all countries have adopted the concept completely but those that did can show much better health outcomes, equity, cost-efficiency and resilience than those that didn’t.

A key role for correct implementation of PHC is the primary care provider. They constitute the point of entry to the health system, or, in other words, the first contact of the user with the national health system. They provide the full spectrum of promotive, preventive, curative, rehabilitative and palliative care or refer to specialist care when needed. Key aspects are continuity of care and the synthesis function. Primary care providers can be family doctors, general doctors, nurse practitioners, nurses, etc. or a team of medical and para-medical professionals.

But the Alma Ata conference happened more than 40 years ago and the world has changed tremendously since then. The biggest changes with an effect on health care over the last years are probably the various effects of ageing of the population, increasing prevalence of chronic diseases, climate change, but also globalisation, the expansion of the internet, the emergence of artificial intelligence and other technological innovations.

The Astana declaration of 2018 reconfirmed the basic principles of Alma Ata but included, among others, empowerment of individuals and communities, and health literacy. The usefulness of  (digital) technology to improve the health of the population is recognised and promoted. “Through digital and other technologies, we will enable individuals and communities to identify their health needs, participate in the planning and delivery of services and play an active role in maintaining their own health and well-being.”

Wearables and telemedicine

Wearables and medical devices for home use offer a source of medical information to an individual without involvement of a medical professional. Holter monitoring, prescribed and provided by cardiologists, has been around for some time. Home blood pressure manometers, blood glucose meters, apnoea monitors, and others have been purchased mostly on advice from a health care provider and the result logs were presented to medical professionals for analysis.

But the explosive growth in recent years in the use of smartwatches, fitness trackers and other wearables has not happened under the impulse of the medical profession. The usefulness of these data collected at home is still under debate: some doctors argue that it provides insightful information about their patients (mobility and calorie usage, heart rate monitoring, quality of sleep, …), while others are weary to use the data because the devices are not approved by FDA or other regulatory agencies. Yet, the quality and reliability of the recorded data will rapidly improve and official endorsement will undoubtedly occur in the very near future.

Telemedicine (or the broader term telehealth) is not a new practice. The most cited starting point of telemedicine dates from the mid-1950s when the Nebraska Psychiatric Institute implemented closed-circuit television to remotely monitor patients and later expanded this to provide group therapy, long-term therapy and medical student training. But already in 1928, the Aerial Medical Service in Australia used the telegraph and radio communication to provide medical consultations to remote areas in the country.

Limited geographical accessibility used to be the main reason for the use of telemedicine and it remained an exceptional measure. In 2015, approximately 800,000 telemedicine consultations were performed in the United States. However, according to a CDC report, there were an estimated 883.7 million physician visits in the United States. Telemedicine made up less than 0.1% of all consultations.

During the COVID-19 pandemic, this changed completely. During the lockdown in France, the percentage of teleconsultations (phone or video) peaked at 27% of all consultations. It has dropped  again after the lockdown but its numbers are still hundreds of times higher than in the pre-COVID-19 age. Online consultations during the COVID-19 pandemic started as a need to limit potential exposure, both for the patient and the medical professional. The convenience for both parties is very much appreciated and the quality of care and outcome does not seem to diminish for routine contacts. It is thus worthwhile to maintain and even expand this practice in the future.

Once online medical contacts with medical practitioners become more commonplace,  there is no reason to believe that it will remain limited to your own family doctor and specialists.

A simple internet search for “online medical/doctor consultations” yields an impressive number of websites where international general practitioners and specialists are offering their services to the general public by chat, call or video call. The advertising slogans for these sites mention the advantage of getting a second opinion, the convenience of not having to leave your house and short waiting lists.

Online consultations can prove useful for users in a health system with a strict gatekeeper function, lack of specialists, or difficult geographical or even financial accessibility. But these online companies are private enterprises and by no means limit the use of their services to “legitimate reasons”, nor seem they to be strictly controlled by any national or international regulatory body. Their reach is truly global across international borders and the only restriction appears to be language barriers.

Registration to make an appointment is exclusively done by the individual and no referral by a medical professional is needed. It is also completely up to the individual to decide if he/she will share the outcome of this consult with their regular primary care provider.

Shortage of medical professionals

At the same time, there is a global shortage of medical professionals. This phenomenon can be observed worldwide, in low-, middle- and high-income countries, and is most precarious for those roles that can be labelled as primary care practitioners: family doctors, nurse practitioners, and others. The reasons for this shortage are multiple and relate to increased demand for health care by ageing of the population and the rise in prevalence of chronic diseases. This increased demand is exacerbated by a deterioration of all determinants of workforce numbers: entry, retention and exit. The COVID-19 pandemic has accelerated the projected shortage by a mass exodus of medical professionals through burnout, death and termination, or loss of employment due to the deteriorating economic situation. If fewer students will decide to pursue a medical career now that the pandemic has highlighted the dangers and heavy workload of the medical professions, this will only become evident in the coming years.

With the pre-COVID projected evolution of the workforce of primary care practitioners and the ever-increasing demand for healthcare, it already will not be possible to provide the same services as today. In the future, the first contact with the health care system might not be with your family doctor or nurse practitioner, but with an artificial intelligence. Routine visits and screening will be automated and a personal interaction will only be reserved for “referred” cases.

Obviously, this situation does not provide the medical professionals the time to analyse and assess all the extra medical information from wearables and others, a big part as raw data, that an individual might possess.

“Patient” empowerment

“Health” is a much wider concept than “health care”. Most “health actions” have always been outside of the formal healthcare system in the form of self-care (lifestyle choices, self-treatment, OTC medication, etc.) and lay care by others in their social circles. The difference is that these out-of-the-formal-health-system actions from wearables and telemedicine now generate medical information in need of more specialised attention and interpretation.

This represents a shift in power for decision-making on health issues from the healthcare system towards the individual. While the integration function of the primary health provider allowed them to have a global overview of the medical situation of their patient and take the lead in the decision-making process, this will not be the case anymore. It will be increasingly more the individual who will be the guardian of his information and will decide what to do with it. The role of the primary care provider will change from coordinator of the medical care for the individual to the role of a “trusted advisor”. This will mean a further evolution in the principle of provision of health care beyond “patient-centred care” to a more active role of the individual in the process or  “individual-led care” or “person-led care”.

The road ahead

How will the individual be able to make sense of all these health data that are now available exclusively to him or her? The asymmetry of information in the doctor-patient relationship due to the superior medical knowledge of the medical professional includes also access to information and, especially, the interpretation of the data. As the individual doesn’t have the necessary expertise and as the shortage of medical professionals limits the provision of personal assistance, support will have to be found in logarithms and artificial intelligence. But these tools will have to be “smart” or at least smarter than they are now. To offer a viable alternative to the synthesis function of the primary care physician, it is not sufficient to have a simple, isolated analysis of the variations of the blood pressure of an individual, or the evolution of the blood glucose levels over time. There should be a more comprehensive analysis of all the raw, home-based data (blood pressure, blood glucose, sleep quality, stress levels, etc) together with all other relevant information (online consults and second opinions, ongoing treatment at a distance, etc), and taking into account their mutual interactions. And the final evaluation should be linked with the personal social, cultural, and economic determinants of the individual. Only when this is available, will the individual be able to make the most of this shift in access to information and be able to make valuable informed decisions about his or her own health.

But who should we trust for developing these algorithms? How can we avoid that the analysis is not skewed towards increasing profit of the developer but maintains the best interest of the individual as the objective? Governments and national and international public institutions will have to assume this role and already now start taking responsibility for this important task of safeguarding the health of the population. In the long run, it will probably even be more cost-efficient than trying to remedy the shortage of medical professionals. And in a changing landscape of increased automatisation and globalisation, it might even be the most appropriate solution.