Patients, policy and practice - A healthcare change agenda

Much is made in the Western media of the growing global political and economic importance of China and India.  There is also much commentary about personal rights, financial inequalities and social dissidence.

But in contrast, we hear very little about the actual wellbeing of these populations despite the great impact they will have on the rest of the world in this, the “Asian century”.

The truth is that the health of Chinese and Indian populations is a major determinant of economic development in both countries, and, as a consequence, economic development globally.

From reports in the Western media, it would be easy to conclude that the main threats to the health of people in Asia are infectious diseases such as SARS and avian flu. But in fact these are trivial contributors to disease burden.

It is the emergence of new vast epidemics of diseases such as diabetes, heart disease, lung disease and stroke that is the greatest threat to China and India.

These “diseases of development” are now the leading causes of premature death and disability in most Asian countries.  Moreover, the age at which these diseases affect people in emerging economies is typically 10 - 15 years earlier than in established economies.

These are avoidable epidemics that will only be controlled through radical change in health system reach and performance.

This will not be achieved by modest health reform packages. It will require truly “disruptive” solutions designed to quickly provide essential to care to a much larger proportion of all those who need it. Such solutions must not only be safe and effective, but must also be culturally appropriate, affordable to the poor and scalable in low and middle-income countries.

Solutions must be based on good evidence, both existing and new, as well as on innovations in service delivery, technologies and financing. Finding solutions should be as much the space of entrepreneurs and investors as it is of medical professionals and government.

The need is critical and the opportunity to positively change the lives of millions is unprecedented.

At present, most people who suffer these diseases in countries such as China and India, receive no effective treatment whatsoever. Similarly those at very high risk, usually receive no preventive care. These conditions are already responsible for the crippling rise in healthcare costs being experienced by all established economies and the same conditions are now causing similar problems for China and India. Even in the world’s poorest regions, these conditions will soon overtake the traditional diseases of poverty, such as malaria and tuberculosis, as the leading causes of premature death and disability.

The human consequences of these changes are profound. In the current decade more than 120 million people will die before the age of 60 from chronic diseases such as heart disease, stroke and kidney disease. Road traffic injuries will kill another 20 million and severely disable several times more.

Existing health and social services in most of Asia are poorly equipped to deal with this challenge. Models of care developed in high-income countries for the management of these conditions have limited applicability in other regions in which there are relatively few healthcare professionals, modest public health services and limited health insurance coverage.

Similarly, despite the size of the potential market, very few drugs or medical technologies have been developed specifically with the Asian region in mind.  The region has been dependent on generic drugs and off-patent technologies developed in the West for use in healthcare systems with very different resources.

So what do we need to do? First, we need to secure public and private investment in the development sustainable solutions that can be applied quickly. We don’t need entirely new treatments, but we do need entirely new ways to deliver those treatments we know that work.  This requires re-engineering a number of existing products such that they are fit-for-purpose.

For example, The George Institute is partnering with drug manufacturers in the region to develop treatments for chronic diseases that are tailor-made for the Asian market. The first of these is powerful low-cost combination tablet that should halve the risk of heart disease in those at high risk. Other innovative treatments for diabetes, hepatitis, respiratory diseases and psychiatric conditions are in the pipeline.

We are also working with partners on a range of technologies that have the potential to revolutionize the management of chronic diseases. These technologies are likely to have applications in both emerging and established markets and include devices for remote patient assessment and diagnosis, IT systems for patient management, and therapeutic devices for conditions such as diabetes and hypertension.

Another key component of any sustainable solution is new model of health service delivery. The physician-centred models developed in the West are impractical and unaffordable for most emerging economies. For example, India has around 500,000 doctors today.  If it was to provide the same ratio of doctors to patients as is typical in the UK, India would need 3 million doctors. However, more doctors are not the answer. What is needed is an entirely new primary healthcare workforce comprising “health technologists” trained specifically to use low-cost but sophisticated IT systems to guide the evaluation, diagnosis, treatment and follow-up of patients with common serious diseases, whether infectious or chronic.

We are about begin major collaborative programs in both China and India, in which we will assess the safety and effectiveness of such strategies applied to the care of people in rural communities, where access to effective health services is severely limited.

But there is much more to do, and the resources currently available are woefully inadequate. By 2050, there will be nine billion people on the planet and on the basis of current projections only two to three billion are likely to have reliable access to medical care for those conditions most likely to cause premature death or life-long disability.

Providing effective affordable essential health care for all who need it should be a global priority, as failure to provide this will have financial and social consequences for all.