What can we learn from Indian healthcare?
Over the last few days, the Prime Minister has led a large, high-powered delegation to India promoting greater collaboration between the UK and India in areas as diverse as health and science to trade and climate change and education. Vince Cable, the Business Secretary, was very impressed by what he saw in the Narayana Health City (one of the largest medical facilities in the world) in Bangalore (one of the top four technological hubs in the world). The Narayana Hospitals (between Bangalore and Kolkata) currently have 5000 beds in India and aim to have 30,000 beds in the next 5 years in India. In terms of cardiac care they are doing some amazing work there against the odds: treating patients from 73 countries with complex heart disease and doing the largest number of heart surgeries on children in the world. No wonder Vince Cable was impressed.
In countries such as India, patients can have a massive array of procedures from cataract surgery to coronary artery bypass graft surgery at a fraction of the cost in the Western world. The massive growth of the private health sector in India has increased efficiency and quality. In the UK, medical tourism has been authorised for certain procedures as a way of reducing costs and waiting lists, and increasing consumer choice. This trend is set to increase after the European Court of Justice established the right of European citizens to seek treatment abroad if they are entitled to it in their own country but have suffered an unreasonable delay. There are now a massive number of medical tourism companies which will organise all aspects of healthcare abroad and a relaxing holiday afterwards. The Confederation of Indian Industry estimated that 150,000 medical tourists came to India in 2005, and the health care market, which includes health insurance, is set to expand by 2012 from US$22.2 billion (5.2% of GDP) to US$69 billion (8.5% of GDP).
There is another side to this coin. India has probably the worst health and wealth inequalities of any country in the world. The new “multidimensional poverty index” designed by the Oxford Poverty and Human Development Initiative showed that Bihar, the poorest state in India, has more poor people (95 million) living there than do nine of ten poorest countries in Africa. In 2001, India had only 35 well-equipped centres for modern diagnosis and treatment, mostly located in the six metropolitan cities; this is grossly inadequate for a vast country with an immense population such as India. The Narayana Hospitals currently do 12% of all cardiac surgery in India. That probably tells us that across the population there is not that much heart surgery going on.
The problem of inadequate resources is compounded by the fact that despite being one of the world’s major sources of medical staffing, the number of physicians per 100,000 population is less than 50. To plug the “brain drain”, the Indian government is starting a shortened, rural medical training programme to train and retain doctors in the poorest areas of the country. This is an innovative scheme which other developing countries will be watching closely.
So what can we learn from Indian healthcare? Firstly, sophisticated, world-class healthcare can be performed at a fraction of the cost of healthcare in the US and the UK with equal if not superior quality in the private sector of developing countries. Secondly, private healthcare does not at all reflect the health of the nation and often broadens health inequalities. On this point, the Narayana Hospitals are truly remarkable as they incorporate many societal initiatives such as microfinance and education. Thirdly, as flows of patients, doctors, and resources across country borders are all likely to increase in the future, improvements in the planning of our own healthcare resources and the way we interact with other countries (such as India) are a necessity.
How to manage healthcare systems when the pursestrings are tight
is not hitting news headlines as much as last year. However, the question of how to reduce healthcare costs in a difficult economic climate still seems to be grabbing headlines across the world.
First came the news that Donald Berwick , founder of the Institute for Healthcare Improvement and pioneer of EBM, was appointed by President Obama as the Head of the Centers for Medicare & Medicaid Services (CMS), which delivers America’s piecemeal state healthcare system. Berwick has a proven track record in putting EBM into practice and improving the quality of patient care. He has long been an admirer of the UK’s NHS, saying that, “The decision is not whether or not we will ration care - the decision is whether we will ration with our eyes open.”. Unsurprisingly, his appointment has been criticised by Republicans, who fear that he might actually do something about America’s spiralling healthcare costs. His appointment will hopefully bring accountability and some transparency (and hopefully some EBM) to America’s industry- and private sector-dominated health systems.
Germany has a national health insurance system largely funded through employers’ contributions, but now spends more on health care as a proportion of GDP than any country apart from the USA and Switzerland. Health reforms were pushed through last week which resulted in capping of employer's contributions, but also allowed Germany's health insurance providers to demand unlimited top-up fees from individuals. In short, Germany has chosen reduced coverage of healthcare rather than evidence-based reductions in costs.
Recently, development aid for health has increased substantially, from $5.6bn in 1990 to $21.8bn in 2007. With increases in spending by the poorer countries themselves, a BMJ article calls for greater rationalization of health spending, based on local needs and demands, and not the demands of international stakeholders and NGOs. The authors give the example of Rwanda where earmarking of funds for HIV/AIDS and target-setting led to just $1m for the integrated management of childhood illnesses, compared to $47m for HIV/AIDS, grossly disproportionate in a country with a 3% infection rate." This meant that "physicians employed by NGOs to deliver HIV/AIDS services are paid almost 6 times as much as physicians paid by the state, making it impossible to keep well qualified health personnel in the public sector."
Disdain for externally-set targets is shared by the UK’s coalition government, which has been quick to criticize Labour’s targets as it sets out its health reform stall. The two main aspects seem to be more power to GPs to commission services that are more aligned with patient needs and and independent sector providers will be encouraged to compete for patients. The problem is that in order to cut costs and improve services, there is going to have to be some measurement. And so the Health Secretary, Andrew Lansley has given us some political waffle to get our teeth into, saying that he wants to move from national targets to a "set of national outcome goals". New metrics and standards of healthcare are currently being designed and the first set of new standards is due by April 2011. The plan is for the new NHS commissioning board to use them to hold GP groups to account. Good evaluation using good measurement tools (yet again, evidence-based healthcare) are essential for any such plans to work.
Serious conflicts of interest of Avandia panel member
If you weren’t aware last week, Rosglitazone or Avandia as it is known in the trade, was in front of the Joint Meeting of the Endocrinologic and Metabolic Drugs Advisory Committee and Drug Safety and Risk Management Advisory Committee at the FDA to see if it should remain on the market.
Overall the panel voted 20-12 to keep it on the market. That means 1/3rd of the panel wanted the drug removed from sale as they considered the harms so bad they outweigh any potential benefits. 17 of the panellists in favour wanted either tighter prescribing restrictions or more warnings about cardiovascular risks. Based on the evidence I'd have voted for its removal.
This is where it gets bad. Endocrinologist David Capuzzi, who was on the panel confirmed he has been a Glaxo's speakers for several years. Get this ‘he doesn't see the relationship as a conflict,’ of course not. Capuzzi defended the drug during the meeting. Oh, by the way he was one of three members who wanted the drug to remain on the market with no additional earnings or restrictions.
Dr Capuzzi received $3,750 from GSK between April 2009 and March 2010. He has also received $8,000 in speaking fees form GSK before that period and $3,000 in the 2nd quarter of this year, total $14,750.
One member who voted to keep Avandia on the market, Arthur Moss , said "I'm surprised we weren't told.” Do you know what, I’m not surprised, are you? It seems the information was never given to the committee or to the public, and the FDA is investigating.
Because they didn’t get 32 individuals without conflicts they should hold the panel meeting and vote again. Outrageous!
Peer review, what's the fuss?
For a researcher, the arrival of a peer review article may set off feelings of angst, duty, resentment and sheer frustration. On a good day, the article fits with the research agenda, is of sufficient relevance to impact on healthcare, and it feels a worthy duty to undertake the review.
Recently, there has been considerable interest in the limitations of peer review as a credible system for improving the quality of submitted research.
Henderson’s article in the BMJ this year highlights leaked emails at the Climate Research Unit, the Lancet’s retraction of the Wakefield paper ‘the most controversial medical paper of the past 15 years’ and allegations in stem cell research peer review was failing their field.
With regard to the latter Professor Lovell-Badge states: "It's turning things into a clique where only papers that satisfy this select group of a few reviewers who think of themselves as very important people in the field is published."
One major problem is studies which are scientifically flawed, or offer modest increments in the evidence-base often attract undue attention, particularly the media. Whilst at the same time truly original findings may be delayed or rejected. If you are not convinced then consider the case of H Pylori. The Gastroenterological Society of Australia rejected Barry Marshall’s abstract to present his research at their yearly conference. They deemed it in the bottom 10% of papers submitted. In 2005, Barry Marshall with Robin Warren were awarded the Noble Prize for the discovery that peptic ulcers were caused by Helicobacter pylori.
Some notable changes have occurred in the journals, principally reviewers are now asked to sign reviews. The BMJ undertook a randomised controlled trial of signed versus unsigned reviews and found “it was acceptable to authors and reviewers, and that it made no significant difference to the reviews."
This is a two edged sword, in that the quality of the review is probably unchanged. Yet, given there is a slightly greater tendency to recommend acceptance, reviwers are probably less likely to offend common researchers (the ones they know) who may require the reciprocal favour in the future. The BMJ is about to take this one step further—publishing its signed reviews alongside published papers after a second randomised trial found this feasible and acceptable to authors and reviewers.
My one suggestion to improve the review process is, to not see it as ending at the journal publication but starting, thus allowing analysis of trial results over and above traditional peer review.
Publication of all relevant documents, which is now possible with the internet, including protocol reviews, ethic reviews, amendments to the protocol and publication of the raw data, will allow interested parties to further review and discover the truth.
The question is which journal is going to stand up to the plate first?