By Dr. Jonathan D. Quick
A study released last week found that insurance is saving lives in Massachusetts. Expanded coverage will mean 3,000 fewer deaths over the next 10 years. We have state-of-the-art health facilities and are among the healthiest of Americans. Despite the fiasco of our failed enrollment website, the state maintains near-universal health coverage, and inspired the Affordable Care Act.
Our example is heartening not just for America, but for the many low- and middle-income countries around the world working toward universal health coverage. These countries aren’t just taking a page from our book, though — they have valuable lessons for us, too.Here are four things Massachusetts could learn about health from developing countries:
1. Bring health care to the community level
Community health workers (CHWs) have been a staple of health systems in developing countries like Ethiopia for decades. Community members trained in basic prevention and treatment interventions, such as oral rehydration for childhood diarrhea and family planning education, are making a big difference. Although not as specialized as doctors or nurses, they work in places where those professionals either aren’t present or are overburdened. CHWs are not only cheaper to train and deploy, but they are also trusted neighbors, who don’t require the four-hour walk necessary to reach the nearest health facility.
CHWs are now catching on in Massachusetts and other places in the U.S. In NPR’s “A Doctor’s 9 Predictions About The ‘Obamacare Era,’” an American physician predicts “A new category of health worker will flourish: the community health worker.” Few Americans face long walks to health facilities, but many face other challenges, such as mental or physical disabilities, chronic pain, lack of transportation or difficulty navigating the health system. CHWs provide low-cost outreach that helps patients deal more effectively with these barriers.
2. Make it convenient
Another approach used in global health is accredited drug dispensing outlets. When people get sick in Tanzania, their first stop is a local drug shop. Although cheaper and more convenient than seeing a doctor, they often get the wrong drug, of poor quality, and at a high price. Through training and licensing, drug sellers are able to provide live-saving treatment for common problems like malaria and childhood diarrhea at reasonable prices. Not only has this model been successful in improving access to essential medicines, but drug sellers quickly proved they could do more to improve health: advise on HIV/AIDS prevention, check symptoms for tuberculosis, and dispense some forms of contraception.
Similarly, in the U.S. programs like CVS’s MinuteClinic and Walgreens’ Healthcare Clinic are broadening the role of pharmacy services from flu shots to screening, treatment, monitoring and other basic health services. Like the accredited drug dispensing outlets, these services are more affordable and more convenient. They are a shrewd business move by the pharmacies, but also a paradigm shift in how we provide health services.
3. Generate revenue while saving lives
Developing countries have also been figuring out how to make the most of limited resources. In Mexico, a tax on soda is providing new revenue for public health — with the added bonus of reducing consumption and improving health outcomes. Unhealthy diets high in sugar contribute to childhood obesity, diabetes and other chronic diseases. Taxes on soda and other sugary foods and beverages could help reduce consumption of these products, especially among children, leading to better health along with a budgetary boost. Efforts to tax unhealthy food (currently exempt from sales tax) in Massachusetts haven’t gotten much traction, but should be a focus of health advocates.
4. Create incentives for prevention
In the latest National Committee for Quality Assurance survey, Massachusetts ranked above the national average on 23 out of 24 primary care quality measures. Yet among more than 150 Massachusetts medical groups there was up to a two-fold variation in performance measures for vital preventive services such as breast cancer screening, colorectal cancer screening and well-care visits for adolescents.
To address quality gaps like these, a growing number of developing countries have introduced performance-based financing (PBF), a system of setting targets, monitoring progress and providing modest incentives for increasing in the quantity and quality of essential health services. Rwanda has used PBF to simultaneously increase performance in medical services for conditions like HIV/AIDS and tuberculosis as well as preventive services such as childhood vaccination, prenatal tetanus immunization and prenatal care. Rwanda reports over 95 percent health service coverage for a population nearly twice that of Massachusetts. This level of coverage — combined emphasis on prevention and improvements in the standard of living — has led to has more than doubling of life expectancy over the last two decades.
Insurance is saving lives in Massachusetts because it enables people to seek care sooner, before health concerns become major health problems. The positive impact of expanding health insurance coverage –especially in underserved areas — provides inspiration for countries around the world, too.
Unfortunately, Massachusetts hasn’t escaped the technological problems that have plagued other state health insurance exchanges, as well as the federal HealthCare.gov. Overly ambitious plans contributed to the failure of the Massachusetts Health Connector website, forcing stopgap coverage measures. In addition to wasting scarce funds, any threat to insurance coverage is a threat to health.
Still, beyond insurance, Massachusetts could be doing even more to improve health. The experience from developing countries shows that in addition to increasing financial protection, there are cost-effective ways to further increase access to services. Strategies like CHWs and accredited drug dispensing outlets bring the health care to your doorstep. Soda taxes and performance-based financing can create incentives for prevention.
As we appreciate the achievements of Massachusetts health reform, let’s also take a moment to draw inspiration from these unlikely places to make the commonwealth even healthier.
Dr. Jonathan D. Quick, a family physician and health management specialist, is President and CEO of Management Sciences for Health (MSH), an international non-profit organization based in Massachusetts with teams in Africa, Asia, and Latin America.