Intended for healthcare professionals

Rapid response to:

Education And Debate

Lessons from developing nations on improving health care

BMJ 2004; 328 doi: (Published 06 May 2004) Cite this as: BMJ 2004;328:1124

Rapid Response:

One Additional Lesson...

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

26 July 2004
Rocío Sapag
Director of Training and Communications
Jaime Bayona
Socios En Salud Sucursal Peru, Lima 06, Peru