Emergency care in Africa: There is no free lunch…

Let hunger be ranked first because if you are hungry you cannot work! No, health is number one, because if you are ill you cannot work! – Discussion group ranking; Musanya Village, Zambia1

The basic economic premise states that our wants are unlimited but our resources to obtain our wants are limited. On an individual level this implies that we are constantly prioritising desires in order to afford the most important ones (I’m using the word desire as an umbrella term for needs and wants). Sometimes we prioritize in a conscious way through budgeting, negotiating with our partners, saving for large expenditures or investing. At other times it’s automatic and we are largely unaware of the process. These ‘automatic’ decisions are based on beliefs and values, rooted in our culture, community and environment.

Every so often the desires are mutually exclusive and choosing one option means giving up on another, thus we make trade-offs or sacrifices. Our willingness to make a trade-off depends on the perceived benefit of the chosen option. The trade-off is not always financial, convenience or time might be valued more than cost. If the benefit is unknown or uncertain, the trade-off is viewed as risky and not worth the effort or cost.

Economics 101

  • Humans have unlimited needs and limited resources
  • We can’t have everything that we need or want
  • What you are willing to give up depends on what you get out of it (the benefit)
  • The decision is not always easy

fsdfs

The relation between income, benefit and trade-off can be seen in the triangle. Income represents the ability to raise financial resources to pay for care and it includes savings, obtaining a loan, etc. Benefit refers to treatment outcome and adequacy of emergency care. The trade-off is the sacrifice made to afford the benefit.

For people living in Africa the benefit is murky and the cost high. Ambulance services are rudimentary limiting the ability to obtain care at the site of injury, transport to definitive care or care during transit. Upon arrival at the health facility, Africans are burdened with out-of-pocket payments prior to stabilisation, resuscitation or basic care. In addition, due to low government investment, healthcare facilities create alternative funding methods to afford supplies, staff etc. These methods generally involve requesting (demanding) supplementary payments, known as informal payments, bribes or gifts. Paying these allows the patient to skip the queue, get a bed and receive care. Other cost considerations are the ‘hidden’ or indirect costs including the travelling costs, transportation, carer accommodation, waiting time and lost income opportunities.

Sadly, these expenditures are incurred to obtain care in facilities where infrastructure is lacking. Running tap water, electricity, basic equipment or medication are not a given. Also healthcare providers are often not well-equipped with basic emergency care skills.

Trade-offs are made in order to afford the care and may include

  • Reducing the household’s food consumption and budget
  • Selling a girl child into underage marriage
  • Selling assets such as livestock or dwelling
  • Removing children from school
  • Child labour
  • Selling foodstuffs like maize
  • Taking out loans at a high interest rates
  • If there’s more than one patient, prioritising care for one member at the expense of another

Basically, accessing emergency care requires massive trade-offs for a very uncertain benefit. An alternative is to not access care and hope for the best. This becomes a reasonable option when one considers that each year approximately 25 million Africans are pushed into poverty due to healthcare expenditure. Catastrophic health expenditure is calculated in various ways; however most methods exclude informal, indirect costs and the depletive sacrifices. The entire household suffers the repercussions of financial ruin.

tradeoff-for-blog

Emergency care benefits only the patient. The household makes the sacrifice so that one person can potentially benefit. It’s further complicated due to the urgency, emergency care requires time-critical interventions and delaying care can be devastating. The decisions taken shortly after a traumatic incident are probably not well-thought through, rational or informed. Predicting the required sacrifices is confounded due to different types of cost, changing costing structures and a whole lot of unknowns. It’s a tough call.

When we are involved in developing and strengthening systems in other communities than our own, we need to be aware that as outsiders we don’t understand the daily reality of those we serve. We can’t assume the local needs, wants, trade-offs and norms. Our observations are clouded by our own bias. This can be overcome by establishing ways to enable community participation that allows the implementation of sustainable and locally owned interventions.

On another level, advocacy for the greater good of accessible care includes continued lobbying for universal access to healthcare. Emergency care, especially out-of-hospital systems can significantly reduce cost as a barrier to access care.

                        For me a good life is to be healthy1 – Old Man Ethiopia

This blog includes some aspects that I addressed at the BADem symposium regarding the trade-offs that people make in Africa to access healthcare.

  1. Dying for change, poor people’s experience of health and ill-health. World Bank Study 2000. www.worldbank.org/poverty/voices

 

 

 

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The logframe…time to move on?

‘Those development programs that are most precisely and easily measured are the least transformational, and those programs that are most transformational are the least measurable.’ (Natsios, ex USAID 2010)

Are resource rich funders obsessed with linear planning methods that have measurable interventions? Logical frameworks, showing the trajectory of the proposed project seems to be a prerequisite by most funders. 

The logical framework (logframe) forms the methodological basis for the project.  The framework is designed in such a way that activities lead ‘logically’ to outputs, outcomes and impact.  Six elements are used to evaluate the activities namely relevance, efficiency, effectiveness, impact, sustainability and contribution.  The logical, linear approach forces the project planning team to think about the required steps in order to achieve the outcomes.  

A concern with such a well-planned trajectory is that once set, it becomes rigid leaving little space to learn by doing or make adjustments as the projects progresses. And because it is logical and linear, it runs a risk of being overly narrow and focused.  In some projects focus and rigidity is good.  However in projects that involve multiple stakeholders, focused rigid outcomes runs the risk of reducing the project to simple measurable interventions as opposed to harder to measure sustainable long-term change.

For example community projects with multiple stakeholders are complex with unknown realities and variables. Considerations during the planning phase include multiple stakeholder priorities, diverse cultures, genders, educational backgrounds and experiences. Establishing appropriate indicators prior to commencing the project is difficult.  Some factors will change as the project matures and the rigid ‘logical’ framework may be unable to respond to the emerging knowledge. As such logframes could prevent learning from doing and it prevents tapping into innovative local solutions.

Thus Logframes are not feasible for every project. Participatory approaches including sense-making and PDCA cycles are alternatives that funders need to consider as opposed to linear progression.  In most participatory approaches monitoring is perceived as a learning process whereas in logical frameworks there is a strict separation between planning and implementation. Participatory approaches engage all stakeholders and allow flexibility. On the downside it costs more, is labour intensive and the outcomes may be less measurable.

In the end the method chosen consider the type of project and the priorities.  Participatory approaches work well in complex multi-factor projects requiring change and innovative concepts.  Logframes work well for straightforward projects e.g. vaccination campaign. 

 

 

EFAR: a sustainable way to increase access to emergency care

Low and middle-income countries not only suffer the highest rates of every category of injury, they also have the highest rates of acute complications for communicable disease, maternal death and under-5 mortality (Jamison et al., 2012). Sadly these countries are the least likely to have established and effective emergency care systems.

When developing emergency care systems, lower-income countries often strive to duplicate systems from higher income countries. Implementing what has worked in high-income countries is a problematic strategy for various reasons: high-income countries have enabling infrastructure in place.  This is external from healthcare and includes roads, technology, telecommunications, and developed micro-financing/other insurance schemes.  Legislation and government policy also influences the success of the healthcare system.  Higher income countries government expenditure on healthcare is typically much higher than the expenditure in lower-income countries.

A strategy that might be more appropriate in lower-resource settings is to involve the community.  Engaging communities through the EFAR concept is a low-cost, context-appropriate strategy.  It allows for the community to bridge the gap whilst infrastructure and formal health systems are advanced.

So you might be wondering how teaching people first aid could be considered a national strategy.  There are two main differences between EFAR and first aid.  The first is that EFAR’s are integrated with the coordinated response system.  Secondly EFAR programs are designed to be context-specific and are adapted to the needs within the specific location.  This is a very different from ‘formal’ first aid courses that are designed to be generic.  EFAR training is aimed at teaching participants to manage conditions that they are likely to see within their context.  As example in Ghana out-of-hospital systems are not yet adequate, and long-distance truck drivers are likely to be on scene first.  Thus Ghanaian truck drivers were taught the basic principles when treating motor vehicle accident patients and basic scene management.

efar

THE EFAR CONCEPT

 

EFAR was also implemented in the gangster-ridden areas of Manenberg and Lavender Hill in Cape Town.  Cape Town has a well-established ambulance service, however there is some difficulties responding into gangster-ridden areas and informal areas with unmarked roads etc. There have been some difficulties with sustaining EFAR in these areas and it’s been suggested that integrating the informal system into a well-developed system is trickier than when the system is not yet matured.  For example in Zambia, EFAR has been rolled out to some of the country’s most rural areas.  This project has been ongoing since 2013 and a recent site visit (formal report pending) suggests that it is functioning well.

In Cambodia and Iraq healthcare workers were trained to be ‘paramedics’.  They then trained 2 800 community members. In the first two years of the project the community members managed approximately 800 patients and the mortality rate from trauma dropped from 28.7% to 9.4%.

EFAR as a strategy to enhance the capacity of emergency care systems are a feasible solution in low-resource settings.  In fact is appears to be more feasible than copying ‘international practice’ from well-developed systems. However EFAR is a bridging strategy whilst the formal emergency system is maturing, it is not a replacement strategy.  It is a cost-effective and easily implemented method to establishing out-of-hospital capacity.

References

Jamison, D. et al (editors) (2006) Disease control priorities in developing countries.  NCBI bookshelf http://www.ncbi.nlm.gov/books/NBK11728/

EFAR website: http://www.efarsystem.com/

Husum H, Gilbert M, Wisborg T.  Training pre-hospital trauma care in low-income countries: the ‘Village University’ experience.  Med Teach 2003: 25: 142-148

Sun JH, et al.  A strategy to implement and support pre-hospital emergency medical systems in developing resource-constrained areas of South Africa.  Injury (2012) http://dx.doi.org/10.1016/j.injury.2012.08.015

Wisborg T, Murad M, Edvardsen O, Husum H.  Prehospital trauma system in a low-income country system maturation and adaption during 8 years.  J Trauma 2008: 64 (5)1324-1348

And it is limited to low resource settings anymore.  Scotland are rolling out a system http://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-14-460

 

Vertical and horizontal development in hospitals

Whilst facilitating training in Tanzania last week, we spent time in an emergency centre where immense development and improvements has taken place.  The development has been possible due to financial aid of an external donor.  In addition the external donor has enabled international health care professionals to share their expertise whilst working within the unit on a rotation. Despite the fact that the donor program does not extend to the rest of the hospital, some of the practises has no doubt diffused beyond the emergency centre boundaries.

The ability to render better immediate emergency care and resuscitation has led to improved Emergency Centre (EC) resuscitation survival rates; resulting in more admissions into general hospital. Can the ICU and wards cope with the increased demand, as there has not been foreign aid and focus on their departmental development?  How much stress is the improvement in the EC placing on the rest of the hospital? 

In this blog I attempt to answer a few of my own questions including: can we afford to focus on only isolated parts of a hospital system? How much can we improve before the improvement cause bottleneck somewhere else, or before our improvement boomerangs back and cause problems in the “improved” department?  Is it feasible to start with one part and once it is greatly improved move on, or do we start with a full system?

Within the global health arena the phenomenon of vertical versus horizontal development is extensively debated.  The horizontal approach is focused on integrated health care for the greater community and all aspects of disease and disease prevention.  In-Hospital this means a development program where all aspects of the facility is strengthened simultaneously.  

Vertical development is focused on a specific target population and/or target disease.  In Africa the trend has been for external donors to invest heavily in vertical improvement projects.  Possible reasons includes the relative ease of investing in vertical health programs, measurable results, shorter timeframes to demonstrate improvement resulting in higher and faster return on investment, increasing the attractiveness. 

On the flipside vertical development is criticised for weakening the local health infrastructure and creating dependency on foreign donors.  There is a risk that if external funding is withdrawn the efforts and improvements may fall flat, raising questions on sustainability.  Further criticism of vertical development programs includes that the focus on diseases like HIV/TB has been at the expense of other diseases, resulting in skewed development and luring resources away from further vital health care aspects.  It is stated that vertical development is top-down approaches and the external funder may have preconceived ideas of the problem and how to best solve it disregarding local factors.  I think that these comments are best judged on a case to case basis, what is clear though is that vertical development within an in-hospital setting can result in fragmented care and loss of communication or synergy between departments.

The WHO 2010 World Health Report estimates that 20-40% of all global health spending are wasted through inefficiency and poor governance. It’s believed that this percentage is much higher in Africa and the rest of the developing world.  This poor governance counteracts the fact that horizontal development programs may be more cost effective over the longer term.  In addition one should question the strength of African health systems and whether these systems can cope with the implementation of a full system approach.  In some African countries the risk to invest in horizontal programs are unattractive due to high levels of corruption, political motivation and unrest.

Horizontal health system improvement is dependent on interrelated factors external to the health care which can analytically be allocated to different levels of the system (macro, meso, micro).  All of the above makes vertical developments with quick wins sound so very appealing!

Taking a few lessons from global health; I think that the negative impact of a vertical development program would be more pronounced within the in-hospital setting due to the strong dependency of departments on each other and the patient flow; patients are served by more than one department at any given time during their patient journey.   Any major change in service delivery from one department to another will have a dramatic impact on the patient and on the other departments.

In-hospital systems required synchronization from all the parts/departments and the contribution of one department is always strongly dependent on another department.   The Emergency Centre is dependent on theater, ICU and ward capacity.  The entire hospital is dependent on pharmacy and supply chain factors that are managed from pharmacy.  The entire hospital is dependent on cleaners, porters and administrative services in order to render care.  The advanced technical aspects of EC, ICU and theatre need up to date clinical engineering insights and availability of resources for calibration and servicing of advanced equipment. 

We create boundaries in systems so that we can manage, understand and even manipulate it.  These boundaries are arbitrary and every tiny part of the system is interrelated with other parts that might not be within the boundaries created.  You cannot improve a full system by only focusing on a tiny aspect of it. 

The crucial success factor in making the system work is not the individual parts or how brilliantly they perform independently.  The make or break of a health system or an in-hospital system is the seamless transitions between the various subsystems.  The patient should not even be aware that they are being served by various subsystems; they should experience it as one fully functional system.   The old cliché applies that the strength of a chain is not determined by its strongest link, it is determined by the weakest link.  As such the strength of an in-hospital service is not determined by the best equipped and advanced service provider, but the weakest.

Vertical development such as the approach that I have witnessed is a fantastic and worthwhile first step. The important part of the development is however the next step: evolving into a horizontal approach.  Maybe an appropriate question would be how to decide when to transition successful vertical development into a more horizontal approach?  Examples of such case studies exploring the transition in health care seem to be scarce and it would be interesting to know whether there are any success stories.

Summary

So to answer my questions: We need the parallel development of capacity integrating vertical projects into full horizontal system development.  One of my concerns with horizontal development is the time frame before results are seen.  Momentum is an important push to maintain development.  As such a few select vertical projects with quick win strategies may be a great start, but it’s should never be the end of the process. 

 

 

Access to Emergency Care. The 5 A’s

Access to care is not well described in literature and is sometimes defined as the entry point into the health system and other times as the factors influencing use of care.
I prefer the concept by Penchansky and Thomas (1981) who described five interrelated dimensions including both entry point and the factors influencing choice to access care. The combination is holistic with access being only as strong as the weakest link in the system.
From a systems view, access to care is the fit between the system and the individual.

Case example: a baby sustains serious burn wounds at home.
Mapping it from injury until appropriate facility is reached the following may support or hinder access to care within the dimensions of the 5 A’s

1. Availability of care
Available technology to call for help (telecommunication system)
Local or community knowledge to render first aid: community first responder programs
Available infrastructure and resources to render first aid: in this case availability of onsite water source, well water, bore pipe or preferably running tap water to cool the burns
Coordinated means to access care: availability of prehospital system with emergency telephone numbers for police, fire, health services and target times to respond and access patient
Availability of transportation to health facility: formal or informal (taxi, bicycle, ox wagon or ambulance)

2. Accessibility
Refers to geographic accessibility – rural, peri-urban or urban setting
Infrastructure allowing transportation to access and transfer child (roads, maps, signage of roads, traffic congestion)
Distance covered by ambulance service as it has an impact on time to initial treatment, time in transit and time to definitive care
Access to a facility that is able to manage the patient and the specific problem, not all facilities are created equal. This is referred to as appropriate facility

3. Accommodation
Operating hours of ambulance service and health care clinics, availability to manage after hour emergencies
Ambulance service: formal method to prioritize calls and dispatch an adequate level of care dispatched
Trained ambulance practitioners that are able to render care during transportation
Ability of health facility to provide level of care thus appropriate facility

4. Affordability
Means to pay for transport whether cash, credit or covered by insurance
Means to pay for care rendered
Means to purchase medication
Means and logistics for both facility and ambulance service to afford medication and equipment needed to render care

5. Acceptability
Equity in obtaining care
Propensity to access care; culture and beliefs about first aid, medical care and natural remedies (Traditional practice)
Trust in health care workers capacity to guarantee anonymity, confidentiality, dignity, right to choose and participate in treatment (Batho Pele principles)

In summary
At first sight this may seem like a wide and disjointed list, so what does it imply? For one it means that improving access to care is complex and needs to be approach from more than one angle simultaneously. It means that policy makers, funders and managers at facility level need to look at a wider picture and realize how factors that fall outside of their direct control impact on their patient care, policies and decision. It again demonstrates the case for horizontal system strengthening initiatives.