7

The Elephants in the Room: Noncommunicable Diseases

Noncommunicable diseases (NCDs), including cardiovascular diseases (stroke and heart attack), mental illness, cancer (but not cervical cancer), chronic lung diseases, and diabetes, represent nearly two-thirds of all deaths worldwide. Eighty percent of NCD cases occur in low- and middle-income countries.¹ They will result in a potential loss of $47 trillion worldwide over the twenty years from 2010 to 2030—the equivalent of 75 percent of the global GDP in 2010—if nothing is done to stop them. Cardiovascular diseases and mental illnesses alone will account for 70 percent of that loss.² Regardless of how we measure it, in terms of lives or money lost, NCDs are costly. Yet for the most part, they are ignored, especially in developing countries.

They are the elephants in the room.

The tremendously negative impact of noncommunicable diseases on global health prompted the United Nations in 2011 to convene a high-level meeting of world leaders to develop a consensus to combat them. The only other health problem that has warranted such action by the United Nations was AIDS.

Noncommunicable diseases are problems in all countries, regardless of income. However, for a variety of reasons, as we shall see, some of the most effective and efficient ways of addressing these problems may come from low- and middle-income countries.

Serious as a Heart Attack

The most common cause of death in the world is cardiovascular disease. Each year, stroke kills 5.87 million people, and heart attacks kill an additional 7 million. Those who don’t die immediately are often left severely disabled.³ All of these are not just preventable deaths—they are easily preventable deaths. By decreasing tobacco use and salt intake and by increasing exercise and improving diets, most of these deaths can be avoided. A small dose of daily aspirin and generic antihypertensive might prevent or reduce risk for the remainder.⁴

Most cardiovascular disease risk factors are related to lifestyle, highly dependent upon behavior, and affected by social networks. A person’s risk for becoming obese may increase by nearly 60 percent if friends gain weight; a similar correlation is found on the impact of social networks on smoking behavior.⁵

This is an area that providers who are part of the local community, know the local culture, work with families in their homes, and are respected and trusted may be particularly helpful and skilled. Task shifting to community providers and settings, which has been shown to be cost effective in improving health outcomes for mothers and children, can be leveraged to improve health outcomes for entire families.⁶

Community health workers can play integral roles in modifying behaviors within communities. These behavioral interventions can include not only habits like hand washing, breastfeeding, and using bed nets. They can also be trained to take blood pressure, monitor weight, encourage exercise and appropriate diet, and discourage smoking. Health workers actively involved in the community can also serve as positive role models and help change strongly held health beliefs that often prevent community members from using lifesaving health care solutions.⁷

Changing behaviors requires community and social support, modification of the environment and, at times, regulatory nudges. However, when prevention does not work and one needs advanced care, that too can be done efficiently in low-resource settings.

Using a Head to Save a Heart: The Case of Narayana Hrudayalaya

Dr. Devi Shetty believes that where you live should not determine whether you live. However, far too often that is exactly the case, as he witnessed in his native India and in Great Britain, where he trained to be a cardiac surgeon. In England people would be treated with medication when they experienced angina chest pain caused by inadequate oxygen supply to the heart. And when the medication did not work or the disease was already too advanced, he could perform a coronary artery bypass procedure or an angioplasty to increase blood flow to the heart. This would help them avoid a heart attack and live healthy lives. In India, however, such chest pain would often be a sure harbinger of death if medication treatment didn’t work because most patients were unable to afford the expensive surgical options.

Dr. Shetty recognized, however, that there were tremendous inefficiencies in cardiac surgery—not just in India, but throughout the world. If he could reduce this inefficiency, he could treat many more people in the same amount of time. The cost of services would fall, access would increase, and many more lives could be saved. But could he make increasing access to care for the poor financially sustainable? He could and he did. By focusing on the process of care, Dr. Shetty did what he intended: he innovatively created a new way to deliver high-quality, high-precision health care to the poor while generating a profit.⁸

Maximizing Efficiency & Effectiveness

Narayana Hrudayalaya (NH), the hospital network Dr. Shetty founded in Bangalore, India, in 2001, has become one of the world’s largest cardiovascular groups. Its largest cardiac facility has 1,000 beds and performs over thirty major heart surgeries per day. In total, the network of hospitals has performed more than 50,000 since its founding.⁹ Dr. Shetty reduces costs by maximizing efficiency and treating high numbers of patients. Each NH surgeon generally performs only specific types of surgical procedures. Patient-related or back-office work is task-shifted whenever possible to nurses, clerks, or technicians.¹⁰

NH is a for-profit hospital network. Those who have insurance or cash, pay. Those who do not, don’t. NH is able do this by offering different levels of accommodation and attention outside the operating room—rather like passengers on an airplane, one flying first class and another in coach. Both passengers leave and arrive at their destination at the same time. They just have different levels of comforts—seat size, food options, boarding order, and in-flight entertainment. But those who can’t afford first-class amenities still get to their destinations safely.

Innovation & Entrepreneurship

NH uses tiered services and amenities (time, rooms, surgeon, and so forth) to create different price tiers. Those who want better amenities, such as air-conditioned, private rooms, pay a premium. And just like an airline, the highest level of service generates much more profit per person served than do lower levels of service.

By maintaining a careful balance of service type, NH can service the poor and not only be financially sustainable but highly profitable. NH is known for such high quality that the hospital attracts medical tourists—people from wealthier countries who come to NH in India because such care is either not available or affordable. For NH provides not only high-quality care, but provides it at a fraction of the cost of its competitors, even in India. The average cost of heart surgery at NH is about 30 percent of the price charged elsewhere in India and only 5 to 10 percent of that charged in the United States.¹¹

The hospital has goals of how many poor people it should serve. And since it can only provide care to the poor based upon the profit it makes from others, it carefully monitors its patient flow, revenue, expenses, and return on investment. In fact, each day, surgeons receive statements that show their billable procedures from the previous day, as well as their costs to the system. The doctors can then make decisions on how best to plan their patient flows to meet targets.¹²

Accountability

NH not only shifts tasks from doctors to nurses and technicians, but also shifts tasks from its cardiac specialty hospital to general hospitals and providers via telemedicine. NH has seventeen coronary units located in remote hospitals, where emergency cases are treated. In addition, it supports over 100 facilities in India and over 50 facilities in Africa—for free. Doctors in other developing countries can receive consultations on cases from NH doctors via telemedicine. In the past ten years, NH has treated over 50,000 patients through its telemedicine services. The technology has also been used to provide remote education and training sessions. Such relationships may facilitate referrals to NH from these countries for patients who can afford it.¹³

Task Shifting

Partnerships have also allowed NH to scale beyond cardiac care to other diseases, including cancer, diabetes, dentistry, and ophthalmology. Its processes in these other specialty hospitals follow the same approach to efficiency used by the cardiac hospitals, and they also share common infrastructure.¹⁴ This allows each hospital to realize the benefits of specialization and economies of scale simultaneously. The hospital’s multidisciplinary network also allows patients with various conditions to remain within a single system they trust—after all, the woman you treat successfully for hypertension today may have precancerous cervical lesions tomorrow. If so, she’ll know where to go to get the care that she needs at prices she can afford.

Scaling

NH has also created an insurance scheme that provides health coverage for only pennies a month by partnering with the government. The program engages businesses, cooperatives, and other organizations to enroll their entire staff or membership for a low premium. Since the likelihood of needing intensive surgery was less than a tenth of a percent, the scheme was able to fund itself by enrolling large groups. Realizing that the program would increase demand for services, hospitals agreed to the lower negotiated rates that were a part of the scheme. The insurance program has allowed the poor access to quality services at a very affordable price, all while paying for itself.¹⁵

Recently, NH has partnered with Ascension Health, a faith-based nonprofit health organization in the U.S., to scale its high-quality service in the Cayman Islands—a quick 50-minute flight from Miami. The goal of the partnership is to become a medical tourism hotspot by replicating the high-quality, low-cost care NH has provided in India. The $2 billion project will include a multi-specialty hospital with 2,000 beds.¹⁶

NH creates local demand by doing community outreach and helping people learn if they are at risk. NH conducts outreach camps to reach remote communities and screen patients for cardiac diagnosis and care. Cardiologists and technicians use mobile vans equipped with ECG machines, defibrillators, and other equipment to conduct these outreach camps. Screenings are conducted at no cost to the patients and are funded by charitable organizations. Any patient needing advanced care is referred to NH hospitals.¹⁷

Creating Demand

By conducting this outreach, NH improves access to quality care in remote communities that otherwise would not receive it. As discussed earlier, NH generated international demand on the basis of its reputation as a low-cost, high-quality provider, through telemedicine connections and its many international partners.

Seeing Possibilities: Eye Surgery for the Poor—The Aravind Eye Center

NH has been a very successful private, for-profit company that provides advanced and specialized health care for the poor, and its model can be replicated for other highly common diseases in densely populated areas. Its ability to bring efficient, high-quality, low-cost advanced care to the poor builds on a model shown to be effective by an NGO, the Aravind Eye Center. Like Dr. Shetty of NH, Dr. G. Venkataswamy, or “Dr. V,” as he was known, also wanted to improve care to the poor in a financially sustainable way. He knew that the government alone couldn’t do so by itself, so he founded the Aravind Eye Care System, an NGO to address the huge problem of vision impairment in India.

Aravind Eye Hospitals is the largest eye care provider in the world, with 2.8 million outpatient visits; it performs over 340,000 surgeries annually. Aravind provides services to the rich and poor alike: some 60 percent of these surgeries are services to the poor at reduced prices or for free.¹⁸ It greatly improves access to high-quality eye care for the populations it serves in a way that is acceptable, affordable, and financially sustainable. How can this be done?

Aravind relies on an assembly-line production system to perform cataract surgery. For example, when a surgeon finishes with one patient, the next one is already anesthetized, waiting only for the surgeon to put on new sterile garb and begin. Likewise, all movements in surgery are essentially choreographed. Virtually every movement and need is anticipated by the surgical assistants in order to maximize efficiency and effectiveness.

This assembly-line approach not only enables the system to provide care for many more patients, it also develops highly skilled surgical staff. As a result, complications are rare, and when they occur they are quickly remedied.¹⁹ Through mass marketing and eye screening camps, Aravind helps generate demand for its services. Quality is carefully developed and monitored, but specialization reinforces this goal, with the surgeons performing more than ten times as many surgeries as other doctors, leading to more experience and higher quality—all facilitated by a system designed for efficiency.

Operational costs are kept low by use of lean operations and other system efficiencies. Aravind even manufactures its own intraocular lenses to control both costs and quality. In addition to keeping costs down, patients who can afford to pay for care receive additional perks to increase their comfort. People who can afford to pay often have many other options for eye care, but choose Aravind due to the reputation for high quality. The higher fees paid by those who can afford them helps Aravind to provide low-cost or free services to the poor and remain financially sustainable.

Maximizing Efficiency & Effectiveness

If you are reading this book and are from a developed country like the United States, you are probably doing so with the help of corrective lenses. In fact, two out of three people in the U.S. use corrective lenses.²⁰ Without them, activities that are basic to our lives, like driving or working, would be nearly impossible. And vision is the primary way we engage with the world and identify others. Without it we would be socially handicapped. Even if we knew with whom we were speaking, we might be unable to read subtle facial cues and react in socially appropriate ways.

Vision impairment and blindness are enormous problems around the world. There are nearly 300 million people in the world who are visually impaired, a population nearly the size of the U.S.²¹ Moreover, 90 percent of them live in developing countries. The visually impaired and those who have to care for them have higher levels of unemployment, increased welfare costs, and fewer educational opportunities. By solving problems of visual impairment, we will see increased independence, self-esteem, and participation in social networks, less poverty and hunger, and decreased gender inequality.²²

Aravind is combating vision impairment in India by providing highly efficient, high-quality care for the poor through efficiencies and a financially diverse patient pool similar to NH’s. Further, Aravind manufactures its own lenses to reduce costs for its prescription eyeglasses and cataract surgeries. Community outreach screening camps improve access, with the mobile clinics screening patients in local communities and referring advanced cases to Aravind’s main facility when needed.

Eyeglasses for the Poor: VisionSpring

Though the majority of people who suffer from visual impairment are over fifty, 19 million children under fifteen suffer from visual impairment, and over 60 percent of these can be easily diagnosed and their eyesight corrected with glasses. In fact, glasses could help 43 percent of visually impaired people.²³ VisionSpring, an NGO operating in India, Bangladesh, El Salvador, and South Africa, uses a microfranchise model to bring vision screening and glasses to those who need them. VisionSpring has sold over 1 million pairs of eyeglasses since 2001 by training local individuals to create their own businesses in screening patients and supplying them with eyeglasses to sell.²⁴

VisionSpring entrepreneurs get a “Business in a Bag” with the supplies needed to get started and a brief training on eye care. The entrepreneurs then provide community education, screenings, and opportunities for people to buy ready-made glasses for less than $4. If someone proves to have a more complex vision impairment, he or she is referred to a more skilled provider.²⁵

Maximizing Efficiency & Effectiveness

VisionSpring trains its entrepreneurs to test customers’ eyesight by using a very simple method. The entrepreneur asks the potential customer to hold one end of a string. With the other end in hand to measure distance, the salesperson walks 10 feet away and holds up a small sign. The customer is then asked to read the symbols of varying sizes on the sign. Based on the responses, the entrepreneur determines which of her premanufactured glasses are most suitable for her customer’s eyes and offers a pair for less than $4. And while the glasses are indeed limited in the kinds of lenses available, VisionSpring is sensitive to the fact that even if they need to see, people still want to look good. If they are going to sell glasses, they are going to have to be low cost, fashionable, and effective—and they are.

VisionSpring anticipates selling a million eyeglasses in 2012, as many glasses as the organization sold in the previous ten years. It has also increased its reach by developing a fee-for-service franchise model to disseminate sales kits to existing for-profit and nonprofit organizations. Vision-Spring discovered that a bottleneck in its ability to scale was its focus on serving the vision technician/entrepreneurs it trained to distribute its products.

Scaling

To increase its ability to scale in developing countries, it began shifting the distribution of its products to entrepreneurs and NGOs that have their own distribution networks. For example, there are many local entrepreneurs already established in rural communities. They know the people, the culture, and the businesses. These distribution entrepreneurs can then partner with local established businesses to test vision and sell glasses to the businesses’ employees. In some cases, the cost of the glasses may be fully or partially subsidized by the employer, since a worker who can see better can be more productive. Such coordinated partnerships can create wins for everyone—for the employer, for the entrepreneur, and for the patients.

Through partnerships with organizations such as BRAC, VisionSpring can sell glasses to millions of people. BRAC also has health volunteers who do outreach in communities and who can sell these glasses as part of that work. This creates a win–win for both: VisionSpring distributes its products and BRAC adds a new service. And since BRAC has a larger portfolio, it is more likely to reach many more people.²⁶

Partner Coordination

Of course, BRAC is hardly the only way VisionSpring can get its product out. As we saw in chapter 6, Smiling Sun in Bangladesh sees 25 million patients per year and has over 9,000 outlets.²⁷ Though it is overseen by a nonprofit, the vendors are for-profit entrepreneurs, as are the CFW Clinics in Rwanda and Kenya. The franchisor manages procurement for the franchisees as well as logistics. Through partnerships with these types of organizations, VisionSpring can benefit from filling large-scale purchases, while partnering organizations receive low-cost eyeglasses, enabling both to be more sustainable.

Community health workers around the world can be a part of addressing vision impairment. Nepal has nearly 50,000 volunteer community workers and Rwanda, 45,000. These workers have incentives to see patients and ensure that they receive good care. Procurement is handled by their governments, which also control the entire public health care delivery systems—clinics, hospital, mobile units—all vehicles through which very inexpensive eye-wear could be sold and distributed, again creating a win–win for everyone.²⁸

High-Access and High-Quality Health Care for the Poor: Can We Have Both?

VisionSpring and Aravind are good examples of our ability to provide high-access and high-quality care in low-cost and appropriate ways. Though custom-made eyeglasses provide more precise vision correction than ready-to-wear lenses, for the vast majority of people who are otherwise unable to see clearly, these low-cost ready-to-wear glasses are an excellent option. They enable people who need corrective lenses but who are very poor to improve their vision in order to get an education, work, and be productive members of their communities.

However, VisionSpring cannot be the only option for the poor with impaired vision. A subset of people with impaired vision will have treatable medical conditions, such as glaucoma or cataracts, that are causing their vision impairment. Such conditions require the attention of providers with far greater clinical skills than a smart microentrepreneur skilled at selling ready-made glasses to manual laborers on their way to work, village women in the marketplace, and children in the schoolyard. These higher-skilled providers must also be available. And as we’ve seen through the example of Aravind, high-quality specialty eye care for those who need it can still be provided at low cost when done efficiently.

In many settings and for many diseases, we do not have to choose whether to provide high access or high quality. By consistently being innovative and entrepreneurial, we can provide them both—at low cost and in appropriate ways.

Care for the Least of These: Community-Based Care for Depression

Depression can creep up on you slowly or seem to attack you all of a sudden. It can make you feel tired and restless, yet keep you from sleeping. It can eat your appetite, consume you in shame, and cloud your thinking. Regardless of whether you’re thinking of the past, the present, or the future, you may feel only sadness and despair and wonder if life is worth living. This is how depression is experienced by many of the 350 million people that it affects worldwide each year.²⁹

Depression is a leading cause of number of years of life lost due to disability in the world.³⁰ This is true for both men and women, but for women, it’s twice as common. Its subtle symptoms—irritability, loss of appetite, depressed mood, difficulty concentrating, loss of energy, insomnia, feeling slowed, feeling guilty—seem all too common, something that everyone gets every once in a while. It’s just that for the depressed, the feelings linger.

Like high blood pressure, diabetes, or cancer, depression is a biological disorder. Depression affects the brain and can be triggered by a host of genetic, biological, environmental, and psychological factors. Yet its impact is far-reaching, particularly for people in developing countries, who generally have no access to formal mental health care. Though people may outwardly appear normal, their work and family life are significantly impaired. Depression makes it difficult to survive, particularly in places where survival is already difficult.³¹

And many don’t. It is estimated that nearly 900,000 otherwise healthy people commit suicide each year.³² Fortunately depression is easily preventable with the systems we already have in place in developing countries and can be scaled.

Multiple studies conducted in developing countries throughout the world have shown that depression can be effectively treated by trained lay practitioners, counselors, and health workers within the community setting.³³ In Pakistan such care was effectively provided by the same community health workers who provide community-based care to women and their families (see chapter 5).³⁴ Therapy groups may be particularly effective in some settings as it may not only help to greatly increase access where there are a limited number of providers, but may also be viewed as an extension of traditional social structures and networks.³⁵

Scaling

Providers are generally trained over the course of a couple of months and do not even need a background in health. Like all community health workers, lay mental health providers require regular supervision by more experienced mental health providers to maintain quality control. Supervision can be provided in person and, when that is not feasible, by phone.

Like other health workers, lay mental health counselors should be linked to more experienced providers and systems to which they can refer more severely depressed patients for more intensive treatment, such as medication or hospitalization when it is indicated and available. In addition, there are also a wide variety of effective, inexpensive, and easy-to-use medications available in developing countries that can treat depression either alone or in combination with a variety of talk therapies. Many of these medications can be prescribed by trained nurses or, in some settings, by trained pharmacists.

Holding the Key

Noncommunicable diseases pose serious problems throughout the world, regardless of income. However, in developing countries they are more likely to be ignored. Developing countries, however, may hold the key for innovative and low-cost ways that we may be able to tackle them throughout the world.

Community-level care by lower-level community providers is an essential part of care in low-resource settings because it focuses on prevention and low-cost solutions that save lives. These community-level providers may also be the most effective in helping to support the difficult lifestyle changes that are needed to control noncommunicable diseases. Developing countries have also provided innovative models for bringing advanced and specialized treatment to the masses of people who need them through high-quality care that is extremely efficient. Innovative and entrepreneurial solutions for NCDs in developing countries may be a key to many of our problems in global health.