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What Emerging Nations Can Teach Us About Health Care

Developing countries have spawned innovative, effective and low-cost ways to provide care.

December 13, 2016

The provision of health care in the United States is undergoing a profound change in its business model: Proactive management of health is replacing reactive sick care, fragmented care is being superseded by integrated systems of care, and reimbursement is rewarding quality and efficiency rather than volume.

As we undergo these changes, we realize that we have, at best, limited understanding of the new world of health care in its mature form. Given this uncertainty, we need to place a premium on innovation — approaches to provider payment (e.g., shared-savings programs), new organizational arrangements (e.g., patient-centered medical homes), new care and operational processes (e.g., care management of a population), and innovative information technology (e.g., remote patient monitoring).

The United States has an abundance of innovation resources: a vibrant private equity and venture market; supportive laws and regulations; extraordinary private and public sector organizations; an exceptional, diverse and talented workforce; terrific academic and commercial research capabilities; and a culture that emphasizes “can do.”

Innovation in the United States, however, is often blinded by proximity and the belief that innovation requires wealth. We confine our search for innovative ideas to our shores and, occasionally, to other developed countries. We assume that innovation requires a critical mass of talent and substantial investment.

We rarely believe that emerging countries have much to teach us about innovation. This is a mistake.

Opportunity meets challenge

In the Western world, health care systems are challenged by growth in chronic diseases, an aging population, rising medical costs and a clinician shortage.

In emerging markets, we see these burdens and more — population growth across vast geographies, limited basic medical care, lack of necessities such as food and water, and troubling infant mortality rates. Preventive care and chronic disease management are often absent, leading to sicker patients requiring more expensive care. In addition, as with Ebola in West Africa and Zika in Latin America, the threat of disease outbreaks, coupled with a rise in lifestyle diseases among the growing middle class, creates a two-headed monster for overtaxed health care systems.

Further complicating matters, rapid economic growth in emerging nations has expanded the health and wealth divide between the haves and have-nots, particularly in urban and rural communities. With the exception of China, health insurance is lacking in emerging countries. Often the rural poor need to sell personal belongings to obtain care at a private center.

In contrast, the growing high-income to middle-class population in more metropolitan areas is creating a demand for Western-style health care and using discretionary income to seek high-quality care at modern, upscale facilities built by private enterprises. Thus, as in the United States, being able to measure quality is becoming a top priority for providers.

Moreover, given that scarce resources must be put to the best use, controlling costs, improving access to care and providing effective interventions is a must in these markets, fueling the need for disruptive technologies and novel operating models.

If emerging countries are to adequately address their complex range of health care challenges — a range more onerous than the significant challenges we face in the United States — they will need to innovate. And they must innovate in ways that are often different — different because these countries often have less-developed capital markets, smaller talent pools, and laws and regulations that hinder entrepreneurs. They must innovate under more adverse economic, legal, educational and cultural conditions. Moreover, these countries might very well choose to follow an innovation path that’s different from the one we have chosen.

In the United States, much of medical innovation has been conducted without regard to the costs of using the innovation. While medical advances have improved care (although we are all familiar with the statistics that indicate our quality is still sub-standard), the advances have helped fuel a rise in costs. Emerging countries are often forced to innovate while paying close attention to costs. Innovation in the United States has also fueled growing specialization of health professionals — a specialization increase that we may not be able to sustain, if for no other reason thatn because we can’t train enough specialists.

Gaining worldly insights

While the conditions faced by the developed and developing worlds are different, we can learn a lot from the innovation efforts in countries such as China, India, Russia, Brazil and parts of Africa. We should consider the following practices employed by emerging markets:

Leapfrogging for success: In emerging economies, numerous drivers of innovation exist without the barriers that can often inhibit innovation in developed markets. As such, emerging markets are able to capitalize on technological change more rapidly than their counterparts in advanced nations. This phenomenon, known as “leapfrogging,” enables the adoption of new technologies without importing earlier iterations first, thereby sidestepping the snags associated with early development and lengthy pilot projects. Leapfrogging is enabling emerging countries to avoid replicating many of the pitfalls experienced by health care systems in the developed world.

In addition, innovation leapfrogging can occur in emerging countries since they often do not have to deal with the baggage that often hinders innovations in the United States, such as legacy information systems and medical technology, institutional culture, professional norms and protectionist instincts, convoluted reimbursement approaches, and regulations.

Appreciating the value of “frugal innovation”: In the developing world, innovation doesn’t necessarily mean creating something sleeker and with more bells and whistles (read, more expensive). Rather, emerging markets allow innovations to be good enough.

This is the concept of frugal innovation, which appears to be serving entrepreneurs in these markets quite well.

In India, for example, a watchful eye is kept on whether costs justify benefits in introducing everything: new business models, surgical techniques, IT solutions and medical devices. For instance, a small hospital in Bangalore may opt to implement a “lightweight” electronic health record, a system that is less full-featured than others but one that certainly delivers the right core set of capabilities.

Creating a convenient consumer experience: In the United States, patients want fast, convenient service with online payments, retail clinics and access to medical care from the comfort of their homes. In developing countries, these wants are needs — patients in rural areas often need to travel for hours on unpaved roads to receive care. Developing countries, therefore, are doing some impressive work in designing systems around patients and bringing care to the patient’s doorstep.

For example, VisionSpring, a social enterprise that has been described as “LensCrafters meets Mary Kay,” works to ensure affordable access to eyewear everywhere. Through its franchise model, a small band of trained “vision entrepreneurs” fan out into neighboring communities to provide eye screenings, sell reading and sunglasses, and refer more advanced cases back to the store to see the optometrist. The model is simple to implement in rural areas, and distribution costs are kept low due to standardized products and information.

Since its inception in 2001, VisionSpring has sold over 1.6 million eyeglasses to customers who typically earn less than $10 a day — in countries such as India, El Salvador and Ethiopia.

Trailblazing when it comes to mobile health: While dispersing a band of medical foot soldiers to care for patients in remote areas may work well in some instances, many emerging markets are also capitalizing on the ubiquity of mobile devices and health applications to make health care more accessible to the masses.

For example, in India, diabetic patients affiliated with Apollo Hospitals Group can text their blood sugar count to clinicians and receive readings and advice, bringing basic care and education within the reach of millions of rural poor. In other parts of the world, patients share body weight and other physical factors with caregivers via text to help predict and prevent widespread malnutrition. Additionally, mobile health, or “mHealth,” has proven to be quite beneficial for activities such as public health surveillance and disease tracking in remote locations.

In fact, a 2014 PwC study found that 59 percent of all emerging market patients use at least one mobile health application or service, compared with 35 percent in the developed world. Likewise, a greater percentage of doctors in emerging economies offer mobile health services than do their peers in developed nations, and more payers cover the cost.

Upping the game in telemedicine: According to the World Health Organization, a variety of telemedicine applications are increasingly bridging the rural-urban divide in less–economically developed countries by allowing distant providers to evaluate, diagnose, treat and provide follow-up care to patients.

In Brazil, Russia, India, China and South Africa, the telemedicine market is expected to reach $1.2 billion by 2020, up from $498.7 million in 2015, and to grow at a compound annual rate of 19.2 percent.

By increasing the accessibility of medical care where physicians, nurses and specialists are in short supply, telemedicine can enable patients to seek treatment earlier, better adhere to prescribed treatments, and improve the quality of life for patients with chronic conditions.

Integrating public health activities into primary care: Primary care, population health management and public health each play a critical, yet distinct, role in providing for the health and well-being of communities around the globe. A growing body of evidence, however, supports integrating public health functions (nutrition, immunizations, smoking cessation, etc.) with primary care to yield substantial improvements in the health of individuals and communities.

Canada has been a leader in developing models that combine individualized approaches to influence personal health behavior with community approaches to influence population health. Similar efforts exist in emerging markets to address a variety of public health issues such as the ever-present risk of infectious diseases.

In India, for example, the government has enacted a policy to focus on primary care and public health issues such as reducing malnutrition, improving the use of essential medicines, expanding immunization, modernizing public hospitals and instituting a better tobacco-control program. In fact, capitalizing on its strengths in mobile health, India’s ministry of health launched an “mCessation” project that supports people trying to stop tobacco use by texting advice and education. This effort operates alongside traditional treatments, such as nicotine-replacement therapies.

Putting patients truly at the center of care: McKinsey & Co. found that health care consumers play a much more critical role in their care and decision making when health workers and resources are less available. This is largely out of necessity as many health care systems in emerging markets have significantly fewer health care professionals than in developed countries.

In an interesting case study on mental health, WHO reports that Rwanda faces exceptionally large rates of depression and post-traumatic stress disorder, traced back to the mass genocide in 1994. To combat the crisis, the government instituted a policy to make providing patient-centered services for all with mental health problems a national priority. Personalized care plans exist for each individual’s unique situation, and care is provided as close to home as possible. Families are viewed as key care partners, and patients are seen not only in terms of their disorders but also in terms of their history, community and current life circumstances.

Doing more with less

It’s cliched but true: Necessity remains the mother of invention.

Amid myriad global health challenges, emerging markets are fast becoming a breeding ground for novel health care innovations including alternative delivery models and effective use of mobile health and telemedicine technologies.

With far fewer resources (financial, human, infrastructure, etc.) at their disposal, developing countries are perfecting the art of doing more with less. Moreover, through their success in leapfrogging, emerging markets can avoid replicating the strategies and approaches that have failed their resource-rich, developed counterparts.

This, of course, provides the potential for these markets to move more quickly in building sustainable, affordable, high-quality health systems — a goal shared by the Western world. While the United States cannot erase the years of struggle or the money invested thus far to achieve its ideal health care state, it can continue to amass new ideas to put into practice.

Indeed, there is terrific work going on in developing nations that can certainly help inform the U.S. health care agenda. In fact, it’s quite possible that tomorrow’s advances in health care might be incubating in emerging markets today. Our colleagues around the globe have much they can teach us.

John Glaser, Ph.D., is the senior vice president of population health with Cerner in Kansas City, Mo. He is also a regular contributor to H&HN Daily.

The opinions expressed by the author do not necessarily reflect the policy of the American Hospital Association.

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