OpenForum – a blog by the Health and Human Rights community

A number of non-traditional practices are arising in poor and developing communities to fight high maternal mortality rates. One example that has taken hold in many African countries is the use of non-physician clinicians (NPCs) – health care providers who are not licensed physicians but who still provide substantial medical care. The retention rate of these types of practitioners tends to be higher, and the cost of training and deployment much lower, than those of doctors.

At a recent conference, health delegates from 42 countries agreed to implement a new strategy that trains NPCs in emergency obstetric surgery to address the lack of health care workers. Along with other developing areas, most African countries are suffering from a significant lack of medical professionals. This shortage is particularly implicated in the high rates of maternal and infant deaths during childbirth. The WHO has estimated that in sub-Saharan Africa alone, there is a shortage of nearly 1.5 million health care workers; women there face a 1-in-13 risk of dying in childbirth. Most women are unable or unwilling to access medical facilities or workers, even during emergencies; for example, in Ethiopia, only 6% of all births occurred in a health facility.

By expanding the number of NPCs and training them in surgical childbirth procedures, it is hoped that more births will be attended by trained health care workers who can assist women during emergencies. A program in Mozambique that trains midwives in surgical techniques has already achieved significant results. The country is on the way toward meeting several of the UN’s Millennium Development Goals, particularly those surrounding maternal and newborn health. Read more

Many medical professionals and politicians looking toward alternative methods of providing health care are finding examples of communities within the US and in the developing world that have been able to give quality care without skyrocketing costs.

A June article in the New Yorker by Atul Gawande, which is reportedly required reading at the White House, examines the costs of health care by looking at the most and least expensive health-care markets in the US. In particular he studies McAllen, Texas, which has one of the highest costs of medical care per person in the country, and Rochester, Minnesota (home of the Mayo Clinic), which has among the lowest. Rochester also provides some of the best quality health care in the nation. Gawande’s findings led him to conclude that the Mayo Clinic system, which pays doctors an annual salary to keep them from treating their practices like “profit centers”, and emphasizes a peer-review process to improve quality of care, are the best hope for improving American health care. This requires breaking the “untenably fragmented, quantity-driven” systems that are becoming the norm in US medical care.

Gawande notes at the end of his piece that the decisions that need to be made about America’s health care system are greater than the public versus private insurance debate; rather, they involve a total reorganization of the health system. Enacting the principles already in place in the lowest-cost, highest-quality medical institutions in the country – removing any financial incentive for doctors to order unnecessary procedures and taking collective responsibility for patients – require a significant reordering of our priorities.

Others are also looking outside of the political discussions that focus on either “raising taxes or cutting care,” instead seeing a better way: “redesign.” Medical professionals from ten communities across the country with below average health spending and above average health outcomes recently traveled to Washington DC to discuss how changes they have implemented have lowered cost without reducing quality. Gawande, one of the meeting’s organizers, explained that change in these communities occurred quickly, as “[h]alf of these communities used to be high cost and transitioned to low cost over the last decade,” suggesting that national reform is also possible. Read more

Community health worker administering medicine in Rwinkwavu. Photo courtesy of Partners in Health.

[Editor's note: In addition to Dr. Binagwaho, Dr. Fidele Ngabo, Cathy Mugeni, and Niloo Ratnayake also contributed writing to this post.]

Access to care in resource-constrained countries has three major barriers to overcome: finances, infrastructure, and geography. Community health workers (CHWs) are an unavoidable solution for both infrastructure and geography. The Government of Rwanda has recognized that CHWs are necessary in order to improve access to health in rural communities. By using CHWs, with their approach to health at the community level, Rwanda hopes to solve 80% of health problems in the country.

Rwanda has set up a system where each village (100 to 150 households) elects two volunteers to act as CHWs for the general population. Because each community votes on one woman and one man to serve the village in this capacity, becoming a CHW is now a position of respect, raising gender equity throughout Rwanda.

These two CHWs are then trained to monitor growth and development in children, to care for people living with HIV, and to refer sick patients to the nearest health facility. Their training is designed by the Ministry of Health, which enables them to provide services in a harmonized manner throughout the country. By sensitizing the local village and making themselves available, they improve access to care; because of CHWs, a greater number of previously unreachable Rwandan citizens now have access to care. The CHWs trained this year to provide services to their villages are trained to treat certain diseases using amoxicillin and to distribute family planning tools (condoms, contraceptive pills, and injectable contraception). Read more

I’ve been supporting Partners In Health’s project in Lesotho for more than two years – almost since it began. Lesotho is a world away – both literally & figuratively – from the FXB Center office in Boston where I work and where the Health and Human Rights editorial office is based. An independent country completely surrounded by South Africa, Lesotho is home to almost two million people, most of whom have never heard of human rights or the right to health care. However, they can certainly comprehend the injustice of suffering from treatable disease without access to treatment. Read more