We Need to Break Out of the Bubble – My Response to the HCC Report “How do Canadian Primary Care Physicians Rate the Health System?”

This article appears on the Health Council of Canada‘s blog Canada Values Health and can be viewed, along with several other commentaries on this report (here and here), on their site.

Because of our need to strengthen capacity within the primary care system, it is of extreme importance that we pay attention to the perspectives of those working within it. Today, the release of the report “How do Canadian Primary Care Physicians Rate the Health System?” provides such a perspective, and should signal our need to evolve not only discussion, but innovation, on how to ensure that Canadians continue to see value for money spent on healthcare.

For decades, Canadian health policy experts and practitioners have wrestled with the question of how to improve Canadians’ access to primary health care. This debate has taken place within a fractured and fragmented health care delivery system, which by all rights can hardly be characterized as a national system at all. Rather, high quality health care is frequently delivered within confined bubbles, few of which are connected in any pragmatic way that is easily navigable for patients or caregivers. An effective health care system must have seamless linkages between community care, primary care, acute care, and continuing care, something that today’s report finds is lacking in Canada. We need to focus more on systems, rather than on individual problems.

Regrettably, progress has been lamentably slow. As today’s report notes:

“Canada ranks poorly compared to other countries on many factors related to access to primary care and coordination of care between primary and specialist providers.” This is not a new problem, nor is it one that has suffered from a lack of investment. Rather, a considerable number of projects and alternative models of practice have been initiated throughout Canada, some with considerable success, and many that have lacked scalability outside of the confines of the practices where they have been initiated.

What we must acknowledge is that many of the constraints faced in accessing primary care must be addressed through considerable structural reforms to the governance and organization of Canada’s health systems (and they are a plurality, rather than one cohesive system). Far too few clinicians are able to practice to the full extent of their scopes of practice, limiting the “bang for our buck” in training and deploying them; effective referral networks and procedures are often lacking in many systems or are stymied by bureaucratic and procedural constraints that make referrals or collaboration impractical; health information systems have been deployed to collect large quantities of health information, yet frequently fail to manage information in a meaningful way across different providers and care systems.

While much has been written with regard to our need to improve healthcare in Canada, we need to move beyond simplistic solutions that have largely focused on change, rather than reform. Proposals such as interprofessional education or electronic charting have arguable potential to enact these changes, but have been poor at actually reforming the structural, regulatory, or institutional barriers that impede the optimal roll-out of these innovations. Clinicians who are not empowered (or allowed) to initiate, titrate, or discontinue treatments or refer patients to colleagues in different professions are unlikely to provide optimal interprofessional care nor see the benefits of interprofessional education. Computerized charting or imaging that offers no ability to transfer records in a useful way across health authorities or clinics offers no advantage to patients nor health systems. What’s more is that front-line clinicians identify inefficiencies and deficiencies within these systems and develop work-arounds to them, which may directly undermine investments made.

Considerable work remains if we are to see Canada’s primary health care systems ranked among the best in the world. However, this cannot be achieved in absence of coordinated reforms to link innovations and ensure the constructive evolution of Canada’s healthcare delivery systems. We currently have pockets of innovation and excellence, and what we need is a coordinated scaling-up of modern systems geared toward prevention, treatment, and accountability.

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World Pneumonia Day 2012

Today is World Pneumonia Day. While #WPD2012 should lead us to be optimistic about the capabilities we have to prevent and treat pneumonia around the world, it also provides a solemn reminder that despite being preventable and treatable, pneumonia continues to be the leading cause of death in children.

Looking back at the past year, much of my world has been shaped by thinking of respiratory health and of pneumonia, in particular. In February, I was given the wonderful opportunity to travel to Malawi to see the roll-out of the pneumococcal vaccine there and to see the myriad of ways that people are working to prevent pneumonia in their communities. I wrote about this several times, including some reflections on how the pneumococcal vaccine is being made accessible in low-income countries through an advanced market commitment, which has brought the price of the vaccine down considerably.

While there is much to celebrate since World Pneumonia Day 2011, there is still much work to be done. An effective vaccine exists for preventing pneumococcal pneumonia, but coverage needs to be expanded. In the Democratic Republic of the Congo, for example, a country ranked the third highest in the global mortality from pneumonia rankings, the PCV vaccine was introduced, yet coverage is only 9%. Effective treatments for pneumonia, including basic essential medicines such as amoxicillin and oxygen, exist and are low-cost, yet access to basic healthcare in many parts of the world remains poor. The challenges are vast and require us to think about not only pneumonia, but how to improve health systems so that not only is coverage of the pneumococcal vaccine or treatment of pneumonia expanded, but other health interventions as well. A stronger health system is more capable of preventing and responding to the health needs of the population, including the prevention and treatment of pneumonia.

This point is driven home by the Pneumonia Progress Report released today by the International Vaccine Access Center that says that:

“Nearly all pneumonia deaths occur in developing countries, and three-quarters take place in just 15 countries. The majority of pneumonia cases are preventable or treatable.”

This tells us that targeted interventions could produce big results for reducing child mortality caused by pneumonia. Doing so by strengthening health systems at the same time would undoubtedly deliver major improvements in population health and encourage the roll-out of other effective health interventions. The fact that childhood deaths caused by pneumonia are concentrated in just 15 countries tells us that the ability of the health system to cope with an all-too-common illness is weak; it’s a late indicator of a very sick health system.

As a respiratory therapist, this is an issue of great importance to me. Regrettably, many of my interactions with the pneumonia “world” have been in providing treatment to those who need it. Because of this perspective, I was delighted to read that a major initiative was launched today to ensure that amoxicillin – a first-line treatment option for childhood pneumonia, yet one that is too often unavailable – is available in the ten countries where childhood deaths from pneumonia are the highest (India (400,000 deaths), Nigeria (130,000 deaths), Democratic Republic of Congo (88,000 deaths), Pakistan (67,000 deaths), Ethiopia (41,000 deaths), Uganda (22,000), Niger (20,000), Bangladesh (19,000), Tanzania (18,000) and Kenya (18,000)). This is huge, and is certainly cause for celebration.

So, in the coming year, those of us in the fields of respiratory medicine and public health need to commit to eliminating childhood deaths from pneumonia and advocating for the scaling up of treatment and prevention of this deadly illness. We need newer, better, more innovative approaches to the delivery of basic respiratory health services in low-resource settings. Things that we take for granted, but that are all-too-frequently unavailable, like supplementary oxygen: a vital drug for treating pneumonia, but one plagued by logistical constraints making it rarely available in low-resource settings. We need to be innovators and advocators for respiratory health, and we need to take that responsibility seriously. There is much we can learn from the work that is being done between World Pneumonia Days, but there is still much work left to do.

Be sure to check out some of the many wonderful blog posts that have been posted today:

World Pneumonia Day’s Humble Beginnings – on Impatient Optimists, by Orin Levine

World Pneumonia Day: Remembering the Forgotten Killer – on the One blog

“Cyber-Doctors” Help Conquer Pneumonia in India – on Impatient Optimists, by Saul Morris

The Biggest Scandal in Global Health Today: Why are 2 Million Children Dying from Pneumonia and Diarrhea Every Year? – on Pneumo Blog, by Leith Greenslade

Watch the World Pneumonia Day video

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Eliminating the Harms of Counterfeit and Substandard Medicines in Anesthesia

Poor-quality medicines are found all over the world, and can be of poor quality for a variety of reasons: they might be made with poor-quality chemicals, they may contain toxic substances instead of the proper active ingredients, they may contain inactive or ineffective preparations, or they might be deliberately mislabeled. The World Health Organization calls them spurious/falsely-labelled/falsified/counterfeit (SFFC) medicines.

In cases of deliberate counterfeiting, the products are intended to look like genuine medicines, leaving healthcare workers uncertain as to which drugs are real (and could therefore help) and which drugs are counterfeit (and could cause harm).

In anesthesia, the stakes are high: many of the drugs that are used are given by injection, either into the veins or into the spine. When the drugs that are injected are compromised or contaminated, this could mean that bacteria or toxic substances are being injected directly into the body, causing immediate and severe harm. Anecdotally, we have heard stories of harm being caused in this way, such as pregnant women in Rwanda who received injections of contaminated spinal anesthetics for a caesarean section and became paralyzed. Several other similar stories have emerged as we have begun to talk about these issues.

Regrettably, however, there have been no major studies of anesthetic drugs in low- and middle-income countries that might help us to identify the sources of these problems. Our colleagues are thus left to hope for the best, knowing that the drugs they are using might be of poor quality and, as a result, might cause harm when they administer them.

We want to fix this. Counterfeit medicines are a huge problem around the world that we don’t know enough about, and worse – don’t yet know how to fix. We want to work with our colleagues in Zambia to try and tackle this problem and improve safe surgery and anesthesia. So, we have applied for funding from Grand Challenges Canada to do exactly this. But, we need help to vote for our project and make sure that we get the funding to support our work against counterfeit anesthetics. We need you to register and vote for our project on the Grand Challenges Canada website.

Our proposal is straightforward: We want to figure out the cause of poor-quality anesthetics in public hospitals and see if we can use existing technologies at the point-of-care to identify medicines that are likely to cause harm.

How will we do this?

We want to use an existing device called the TruScan to test medicines in public hospitals in Zambia for their authenticity. The TruScan is a handheld Raman spectrometer (for the science fans, here’s the Wikipedia page) that allows the user to essentially point-and-shoot at a drug, through the packaging, to determine its authenticity as compared to the device’s database. Basically, a front-line health worker can hold a vial up to the device and have it tell them if it is authentic, or not.

Because we don’t know much about why injectable anesthetic drugs are of poor-quality, we need to validate the use of this device in the field before we can say that this is an effective way of preventing harmful drugs from reaching patients. There are a range of other problems that we hope to be able to detect and eliminate – bacterial or fungal contamination, for example – that might not be responsive to this approach. That’s why every drug that we test at the point of care will also be tested in a lab in Canada, to make sure we haven’t missed anything. Once we know and understand the issues, we can figure out how to go about solving them.

What do we hope will come from this project?

We hope that we will be able to show that handheld devices like the TruScan can be used by front-line health workers to identify poor-quality medicines before they are delivered to patients. If our project is a success and we have a high rate of detection, we think that this could save lives and provide us with enough evidence to support integrating this kind of device into other health facilities where we know poor quality medicines are a problem. By empowering local health workers, particularly anesthesiologists, we hope to be able to show that better control of the drug supply chain can be attained by local staff.

If our project is a success, then this gives us solid evidence to support scaling up this kind of intervention. Furthermore, it also will provide us with valuable information on the drug supply in anesthesia: something that we know relatively little about in low- and middle-income countries. Of course, preventing counterfeiting at the source is always preferable, and there are a number of initiatives doing just that, which compliment the work that we are undertaking (like mPedigree or Sproxil.

How can you help?

First, watch our Grand Challenges Canada video, register, and VOTE for us.

Second, share our video with your friends and colleagues and encourage them to do the same.

Surgical care is an integral component of a strong, functioning health system. Regrettably, millions of people are denied access to safe surgical care around the world. There is a growing momentum to strengthen the quality of surgical care available, and ensuring access to safe and effective anesthetics is a critical component of these initiatives. But, we need to know more about what the problems in the anesthetic supply chain are and how to fix them. This project is an important part of this work and we hope that you will support us.

Posted in Anaesthesia, Essential Medicines, Global Health, Humanitarian, International Development, Population Health, Surgery | Tagged , , , , , , , , , , , , , , , , , , , | Comments Off

Health Systems in Humanitarian Emergencies – Monday October 22 at the Canadian Conference on Global Health

My colleagues from the Canadian Red Cross and the Pan-American Health Organization and I will be presenting a workshop today at 13:30 at the Canadian Conference on Global Health in Ottawa. The title of our workshop is Health Systems in Humanitarian Crises: Transitioning from Emergency Response to Health Systems Strengthening, and we’re going to be discussing several important aspects of the evolution of the humanitarian response to major emergencies.

This is a critical challenge for the humanitarian community: knowing when the emergency ends and reconstruction begins. However, health systems strengthening in emergencies is about more than shifting perspectives; as we saw during the Haiti earthquake, many international actors actually further weakened Haiti’s already fragile health system by displacing health workers and taking over clinics – issues that Merlin addresses in a report titled Is Haiti’s Health System Any Better?

So what can be done? How can interventions directed to the emergency response phase of major disasters also contribute to the long-term sustainability and strengthening of health systems? This is what we intend to discuss today. Follow the conference using the #CCGH2012 or #CSIH tags, and by following the conference’s host – the Canadian Society for International Health@globalsante.

Here’s the abstract from our presentation:

This symposium is designed for researchers, NGOs, policy makers, and donors who are involved in emergency humanitarian assistance, post-conflict health systems strengthening, and health services delivery in fragile states. The symposium will present collected evidence and stimulate discussion highlighting current challenges in health systems strengthening in humanitarian emergencies, of relevance to a broad audience – from field-level staff to senior decision-makers.

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Some Thoughts on Using Randomized Controlled Trials in International Development

I recently came across a post on the Council for Foreign Relations’ Development Channel that asked: Are Randomized Controlled Trials a Good Way to Evaluate Development Projects?

This is an incredibly important question because, as the authors note, “International donors have spent well over $2 trillion in development assistance over the past five decades, but there remains significant uncertainty about what works and doesn’t work to reduce poverty and grow economies.” Aid accountability has become an increasingly salient prerogative of many donors, yet showing that aid gets where it is supposed to and achieves desired goals continues to be a challenge because we often propose complex interventions whose outcomes may not be linear (for instance, providing school books or desks should not be equated with learning, but it is much more easily quantifiable) and may be longer-term rather than short-term outcomes.

The randomized controlled trial is a mainstay of biomedical research because it allows us to compare the effects of an intervention – a drug, a therapy, a process of care – in one group (the intervention group) and compare it with the results of another population who receives either nothing (often in the form of a placebo), or receives the usual treatment, which we assume to be inferior to the new intervention. By controlling for a number of variables, we try our best to make sure that the two populations are comparable (equally matched numbers of men and women, in the same age range, with similar burdens of disease, etc.) and that they are representative of the population in which we would like to use this tested intervention in, assuming the results show promise.

Issues of methodological and interventional complexity aside, it’s important that we consider the social contract between researchers and research subjects that allows us to conduct this research in order to advance biomedical science. While the underlying principle of the RCT is to advance medical science, we can’t do so without respect for our patients and our research subjects. That is, we can’t perform experiments on people without respecting their basic human rights, including things like their right to autonomy and their right to not participate in research if they don’t want to.

Taking it one step further, we compare our new interventions against the gold standard in order to show an improvement. If no treatment exists, then providing a placebo may be considered acceptable as a control arm; however, when an effective treatment exists, denying patients that treatment in order to provide a placebo to compare your intervention against, would not. For example, if you want to demonstrate a new formulation of insulin is effective, you would have to compare your new intervention against existing types of insulin. You couldn’t deny patients something that they need or that we know is good for them just to show that your new formulation or treatment protocol works better than nothing.

The reason behind experimentation and the use of randomized controlled trials is that we are answering a question about the intervention, and we are unsure whether the intervention is better than existing treatments, or doing nothing. In short, there is a general uncertainty as to whether a treatment will be beneficial. This is known as clinical equipoise in research ethics.

In international development, we are often uncertain of the models for appropriately scaling up development initiatives, but it would be unfair to say that we are uncertain of the many of the interventions. For instance, we know that funding education or immunizations are important and successful interventions for children or that ensuring access to clean drinking water reduces water-borne illnesses. These are not questions of science, they are questions of political will that allow the absence of these interventions to persist.

What is often unclear is not whether interventions, per se, are effective in a global context, but rather what models best allow them to be scaled up and run sustainably. Testing models of implementation in a randomized controlled trial is notably different from testing the effectiveness of the intervention, itself. So, when we know that the intervention is effective, can we justifiably randomize a population to a model that would result in it being unlikely that they would receive it? I don’t believe that we could.

If we do determine that randomized controlled trials are the way that we should proceed in international development, then I argue that the same safeguards need to be in place for conducting these trials with new medical innovations: they need to be approved by a competent research ethics board, there needs to be an oversight committee capable of determining throughout the study whether the intervention or the control is disproportionately placing participants at risk (and if it is, they need to have the authority to stop the trial/study/intervention), and there needs to be an ethical obligation to publish negative findings. If we are going to apply rigorous scientific methods to international development, we need to apply all of these methods and not only the ones that suit us and our information needs best.

And of course, it’s worth noting that not everything that we know about effective interventions has been proved through a randomized controlled trial. I suspect that the authors of this cheeky paper in the British Medical Journal are still waiting for participants for their randomized controlled trial on parachute use to prevent death and major trauma related to gravitational challenge

References
Gordon C S Smith, & Jill P Pell (2003). Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials BMJ, 327 DOI: 10.1136/bmj.327.7429.1459

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