Lessons from developing nations on improving health care
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7448.1124 (Published 06 May 2004) Cite this as: BMJ 2004;328:1124
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In the article, "Lessons from developing nations on improving health
care", Dr. Donald Berwick takes a close look at what he considers are some
of the strengths and obstacles to healthcare improvement within resource-
constrained settings, such as those of Peru, Russia and several Sub-
Saharan countries.
We worked with Dr. Berwick for the last two years on the improvement
collaborative in Peru that he cites. Among the many things we learned
together is that significant improvement can happen, even in resource-
constrained settings. However, we think Dr. Berwick's article mistakenly
abstracts health care improvement efforts from the broad and complex
context of poverty and inequality in which most of the developing world is
immersed. Improvement is indeed "an inborn human endeavor", as Dr. Berwick
says, "and every healthy child will want to try and jump higher or run
faster even without an outside incentive" (p. 1124). But an undernourished
or unhealthy child, as many children of the developing world are, will
probably not be able to run much faster, or run at all, unless we can find
ways to meet his basic needs. It takes more than just good will to
succeed, or the joy of success to sustain improvement. Aims, teamwork,
cleverness to do more with less, and ability to handle the political
interface, are important, yes - especially when initiating the path of
improvement - but they are not sufficient. Most health organizations from
developing nations face resource and structural constraints that cannot be
ignored when pursuing sustainable system changes and improvement.
Improvement in developing countries certainly will not be "even more
feasible than it is in wealthy ones" unless resource and structural
constraints are addressed. For those of us who belong to or have long
worked in a developing country, the barriers to improvement mentioned by
Dr. Berwick, are well known. Awareness of obstacles, rather than
strengths, and the daily struggle to overcome them are deeply rooted in
poor communities. It is important to look, as Dr. Berwick has, at the
strengths of health sector professionals and teams in the developing
world, but we should also focus on what the wealthier nations can learn
from non-wealthy countries about the complexities of poverty in order to
become more deeply engaged in improving healthcare for and with the poor.
Doing so is essential for lasting health care improvement in the
developing world.
As a result, we think that some of the lessons 'from' developing
countries that Dr. Berwick offers (under the heading: Lessons 'for'
Developing Countries, in p.1128), should be read with caution. What may be
waste for a wealthy nation or organization may not be so for an
impoverished one. Two examples:
"Dependency is waste": Sometimes true, but developing and developed
countries relate to each other in many ways. For many organizations,
dependency on donor agencies may be the only means of delivering care to
the poor, or of improving care. Paternalism should be eradicated and self-
sufficiency certainly be pursued, but in every field. In addition,
wealthier nations and organizations providing external technical
assistance need to be prepared to engage the issue of resources and help
promote improvement and self-sufficiency in this arena also.
"Complain is waste": Also true, at times, and at times not. If we had
not complained in 1996, when multidrug-resistant tuberculosis (MDR-TB) was
considered untreatable in resource poor settings because it was `too
expensive' to treat, we could not have started treating our first patients
in Lima. Again, if we had not complained that the drugs were too
expensive, pharmaceutical companies would not have lowered their prices
(by up to 90% compared to 1996 prices). If we had not demanded
international and external financial support, today Peru would not be
providing free treatment for all TB and MDR-TB patients, because it would
be paying its external debt first.
Understanding is important for collaboration among nations. But most
important is the ability and the will of leaders, advisors and donors to
listen and become involved in improving healthcare worldwide. Perhaps
then, every child will have the chance to succeed in the intent to run
farther and keep running.
Rocío Sapag, MD, MPH
Jaime Bayona, MD, MPH
Socios En Salud Sucursal Perú
Competing interests:
None declared
Competing interests: No competing interests
Sir,
The article by Donald M Berwick should be an eye opener for people who
make health policies in a developing country like India. India is full of
villages and small cities from where a patient would have to travel
atleast fifty to sixty miles before he can have access to a primary care
facility which would be less than equipped with basic minimum drugs and
services.India is a living example of politics hindering the growth of
primary health care.Health is the last priority of any government
considering that less than 2percent of the budget is allocated to
health.That is why more and more patients are running to private hospitals
for treatment.This is a big financial burden for the patients.Also there
is no interest shown by the government to improve the sanitary
conditions.The slogan 'Health for all by 2010" seems a distant dream.We
need to learn lessons from countries like Peru and Russsia regarding
primary health care and seriously introspect our health policies and their
implementation.
Competing interests:
None declared
Competing interests: No competing interests
A research letter from India.
E-mail: pramanik_dr@hotmail.com
Abstract: Tuberculosis is re-emerging as a dreaded killer disease in
recent years. Due to delayed diagnosis, aggravation of this disease is a
common feature. Slow growth rate of tubercle bacilli in vitro is a
bottleneck problem. Several attempts have been made till recently to
enrich the conventional L -J medium for accelerating the bacillary growth
rate in vitro. Thyroid hormone induces cellular gene transcription and
promotes protein synthesis. Effect of thyroid hormone in acceleration of
bacterial growth rate was reported earlier. Thyroxine supplemented L-J
medium was used in our study for in vitro culture of tubercle bacilli.
Possibilities of contamination of bacillary seeds by rapid grower species
of Mycobacteria were eliminated after related biochemical tests. Tubercle
bacillary growth rate acceleration was observed in L-J medium and Sauton
medium following thyroxine supplementation (4ug/ml and 8ug/ml
respectively).). Use of thyroxine supplemented L-J medium for culture of
tubercle bacilli may be helpful for early laboratory diagnosis of
suspected tubercular patients as well as for antitubercular drug
sensitivity tests.
Key words: L-J medium, Thyroxine, Mycobacterium tuberculosis.
Abstract from BMJ-16th Nov'2003.
References:
1.Alison Rodger, Shabbar Jaffar, Stuart Paynter, Andrew
Hayward, Jacqui Carless, and Helen Maguire Delay in the diagnosis of
pulmonary tuberculosis, London, 1998-2000: analysis of surveillance data
BMJ 2003; 326: 909-910.
2.Dr.J.Pramanik et al., Detection of tubercular antibody and antigen
in sera of bone and joint tuberculosis.Ind.J.Clin.Bioch.2000,15(1),22-28.
3.Dr.S.K.Biswas, Effect of thyroxine on bacterial growth.
Lancet;1975, 2,716.
4.Dr.J.Pramanik et al., Increased yield of excretory-secretory
antigen with thyroxine supplementation in in vitro culture of tubercle
bacilli. Ind. J. Tub.1997,44, 185-190.
5. J.Robert,A. North Angelo, Izzo: Mycobacterial virulence. Virulent
strain of mycobacterium tuberculosis have faster in vivo doubling times
and are better equipped to resisting growth inhibiting functions of
macrophages in the presence and absence of specific immunity. J.Exp.Med:
1993, 177,1723
Competing interests:
None declared
Competing interests: No competing interests
Re: One Additional Lesson...
Dear Editor,
In relation to the topic of lessons from developing nations on
improving health care, I agree with Dr. Sapag who responded to Dr. Berwick
(1) that improvement in developing countries will not be "even more
feasible than it is in wealthy ones" unless resource and structural
constraints are addressed. It is not by chance that at the beginning of
the third millennium, still some 10.8 million children die in a year in
developing countries before they reach their fifth birthday. And it is
well known why those children die. Most of these deaths are due to acute
respiratory infections, diarrhea, measles, malaria or malnutrition or a
combination of these conditions (1). With the use of the existing
technology, the world would be able to decrease those deaths by at least
60%. WHO and UNICEF developed the Integrated Management of Childhood
Illness (IMCI) strategy, which aims to reduce death, the frequency and
severity of illness and disability, and to contribute to improved growth
and development. It combines improved management of childhood illness with
aspect of nutrition, immunization, and other important interventions that
influence child health, including maternal health (2).
Based on the
evidence it is clear that the time is not for contemplation or
expectation, but for action. Authorities from developed and developing
nations should learn that those problems affecting children in developing
countries are not acceptable in a rational world. More resources should be
allocated for implementation and for research that will support the
implementation of those interventions. As expressed by Dr.Sapag,
"understanding is important for collaboration among nations, but most
important is the ability and the will of leaders, advisors and donors to
listen and become involved in improving healthcare worldwide." We from
developing countries do hope that all authorities, from developing and
mainly from developed nations, can learn that every child deserves a
chance to succeed, to grow healthy, to be happy and to be able to
contribute to a construction of a new and more equitable world.
1. Donald M Berwick. Lessons from developing nations on improving
health care. BMJ 2004 328: 1124-1129.
2. Black RE, Morris SS, Bryce J. Where and why are 10 million
children dying every year? The Lancet 2003; 361: 2226-34.
3. Gove S. Integrated management of childhood illness by outpatient
health workers: technical basis and overview. The WHO Working Group on
Guidelines for Integrated Management of the Sick Child. Bull World Health
Organ 1997; 75 Suppl 1: 7-24.
Competing interests:
None declared
Competing interests: No competing interests