Reforming the Global Health System
Lessons from Asia

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Reforming the Global Health System: Lessons from Asia

An interview with Nigel Crisp
Independent Peer, House of Lords
Chair, Sightsavers International

This Q&A presents an interview by Asia Policy editor Andrew Marble with Lord Nigel Crisp on Crisp’s call for reform of the global health system. Crisp’s argument has been presented in his new book, Turning the World Upside Down: The Search for Global Health in the 21st Century (London: Royal Society of Medicine Press Ltd, 2010). Crisp’s understanding of global health draws on his own extensive experience, which ranges from running England’s National Health Service, the largest health organization in the world, while serving concurrently as head of the United Kingdom’s Department of Health, to working in some of the world’s poorest countries.

This Q&A is divided into two sections:

• pp. 144–47 overview Crisp’s general argument for reform of the global health system
• pp. 147–51 highlight lessons that Asia offers regarding health care and global health reform

TURNING THE WORLD UPSIDE DOWN

Andrew Marble: Your new book, Turning the World Upside Down, argues that meaningful improvement in the global health system can only come about if we flip the current system of interaction between the developed and developing worlds on its head. Could you describe the current global health system and how exactly it should be changed?

Nigel Crisp: The global health system is characterized by an import-export business in which rich countries export the ideology of Western scientific medicine and aid predicated on this ideology to poor countries. In return the poor countries export a portion of their preciously limited pool of trained health workers back to the rich countries. My argument is that this global health system is failing both the poor and, increasingly, the rich countries, and thus we need to turn the system around: poorer countries should be importing health workers from richer ones and exporting their ideas and experiences about health to the richer countries.

Marble: Why has the current system become so dominated by Western scientific medicine? And why is this dominance now so problematic?

Crisp: Western scientific medicine and the health systems based on them have exhibited spectacular successes in improving health over the last century. [End page 144] Partially as a result, Western scientific medicine has come to dominate medical thinking, habits, and institutions around the world. Western medicine guides not only the bodies that increasingly regulate most global health issues, such as the World Health Organization and professional associations, and the small number of pharmaceutical companies that provide all drugs, but also the collective understanding of health—how to define it and how to achieve it.

My argument is that this Western-dominated global health system is now problematic because Western scientific medicine is no longer capable of continuing to singlehandedly improve the health of peoples either in the richer countries of the industrialized world or in the poorer countries of the developing world. Western medicine needs to adapt and absorb new ideas in order to meet the needs of the 21st century.

Marble: How is the system of Western scientific medicine now failing to improve the health of people in the developed world?

Crisp: In the West, continuing growth in health services and funding is only producing marginal benefits to people’s health. This failure is due in part because the most significant diseases of the 21st century in richer countries are different from those in the 20th century: communicable diseases, infections, general injuries, and accidental death are no longer the central concerns of the health care system, having been in most cases replaced by, and in other cases joined by, long-term conditions and non-communicable diseases, such as cancer, heart disease, and diabetes. Yet we still seek to treat these new diseases by relying on the central features of Western scientific medicine: scientific discovery, greater professionalism, commercial innovation, and massively increased funding. While Western scientific medicine has been extremely successful against 20th century diseases, it is less effective against the major diseases we are now facing. Thus, not only are we seeing just marginal improvements to our health, but patients in the richer countries are also now overinvestigated, overmedicated, and overspent. What we need instead is to design completely new services and systems suitable for the longer-term conditions and chronic diseases we now face.

Marble: Now for the other side of the equation: How is Western medicine failing the developing world?

Crisp: Despite the massive exports of Western scientific medicine, ideas, and aid, developing countries are not following in the steps of developed countries [End page 145] in achieving big health advancements. One of the reasons for this failure is that rich countries import trained health workers from poor countries, leaving these nations the poorer for the loss of their investment in training talent. The World Health Report in 2006 estimated that the global shortage amounted to at least 2.35 million doctors, nurses, and midwives (or 4.3 million health workers of all sorts), with poorer countries worst affected. The report calculated that 57 countries were in crisis: 36 in Africa, 7 in the eastern Mediterranean, 6 in Southeast Asia, 5 in the Americas, and 3 in the Western Pacific. Poor working conditions, poor pay and employment conditions, and the lack of drugs and equipment push many health workers to emigrate in pursuit of jobs and higher wages.

Drawing on the experience of my home country, the United Kingdom, there are many cases where doctors from developing countries, particularly from South Asia, heard via the media or family members that jobs were plentiful in the UK and spent all their savings to come in search of their fortunes. Many more doctors than were needed emigrated, and the vast majority never found jobs. In the end the National Health Service posted advertisements in a number of Indian cities to discourage health workers from coming to the UK in order to try to halt this flow.

Marble: Revisiting your “turning the world upside down” thesis, it is easy to see that poorer countries could benefit from an influx of medical expertise from the West, but what do poorer countries have that could help richer ones?

Crisp: Western scientific medicine has largely rolled over and ignored other traditions, whether Islamic, Chinese, or local, and become the model of choice on every continent, regardless of the success or failure of this model in its home countries. This has obscured the West’s ability to realize that richer countries can benefit from the ideas and experience of poor countries regarding health care.

Marble: What kinds of ideas and experience are you referring to?

Crisp: There is much that richer countries might learn from the experience in these poorer countries. Precisely because they have so few resources, poorer countries have to learn how to engage patients and communities in their care, how to prioritize promoting health over tackling illness, how to deploy new technologies effectively, and how to manage the ever-growing burden of costs. In the absence of a full battery of equipment, [End page 146] nurses and doctors have more time to examine the patients more carefully, to talk to them, and to listen to them. In the absence of large sources of centralized funding, many poorer countries rely on a greater number of service-providing organizations created outside the hospital. Many of these countries also have a view of health that includes much greater integration into other aspects of the patient’s life—such as education, employment, and leisure activities—in order to promote health and independence rather than just treating disease. These countries also have constructed community-based education systems that emphasize learning from the field rather than just in the classrooms. These are exactly the sorts of ideas, institutions, and processes that need to be grasped in richer countries as they come to terms with the diseases and long-term conditions of the 21st century.

LESSONS FROM ASIA

Marble: A big part of your thesis centers on the unique benefits provided by the “bottom-up” approach adopted in poorer countries to providing health care. Could you give an example of how this approach has become institutionalized in Asia?

Crisp: A wonderful example is the Bangladesh Rural Action Committee (BRAC). BRAC is a volunteer organization, possibly the largest NGO in the world. Founded in 1972, BRAC now has a staff of 100,000 and over 70,000 volunteers. The organization brings together literally millions of Bangladeshis in local groups to plan and organize services. BRAC deals not only with health issues, such as by offering clinics and hospital services to the poorest people in the country, but with education and other public services as well. It runs empowerment groups for women, teaching them how to take action to improve their lives and those of their families. It has its own microfinance bank to provide small loans to enable people, mainly women, to earn a living, allowing them to purchase seed or farming tools or to buy goods that they can sell on the local markets; BRAC Bank already has 6 million borrowers and a turnover of $4 billion. BRAC also runs a university and shops and is prepared to be involved and invest in any practical approaches that benefit the poor. The organization thus is a remarkable example of people who are not prepared to wait for others to help them but have taken the future into their own hands and are creating their own solutions. The way BRAC does things challenges the top-down, [End page 147] professionalized, and commercialized mind-set that is so common in richer countries.

Marble: Could you provide an example of a successful BRAC bottom-up effort to provide health care and improve health outcomes?

Crisp: In 1979 BRAC decided to launch a campaign to teach families how to care for children with diarrhea. Millions of children in poor countries have died simply because nobody knew how to rehydrate children who were suffering from diarrhea; in Bangladesh with its annual floods, children are particularly susceptible to drinking dirty water and succumbing to this illness. So BRAC used its extensive network of village and women’s groups as well as schools and classes to teach people how to tackle the problem. Ten years later 13 million households out of 15 million nationwide had learned to prepare an oral rehydration solution. Deaths of children under the age of 5 fell from over 200 per 1,000 to about 80 per 1,000 between 1990 and 2005; this figure is better than the sub-Saharan record of 137 for 2005.

Marble: Are there examples of bottom-up institutions from other Asian countries that come to mind?

Crisp: Another excellent organization is India’s URVAL, a weavers’ cooperative in Western Rajasthan established in 1986 to promote economic and social development of remote communities in the Thar Desert. URVAL has a powerful vision: to lead the poor toward self-reliance by making available to them a package of development services that they themselves decide on, design, implement, and eventually finance. URVAL thus improves health care by tapping into the natural strengths of these locales, the sense of community and family, and the desire for self-determination. URVAL links health with other issues, such as education and employment, and is dedicated to finding ways to reconcile local practices and culture with the Western scientific tradition.

Marble: How has URVAL’s broader emphasis on education and employment had a concrete impact on people’s health?

Crisp: URVAL first came into being when more than 300 self-employed weavers, each working from a loom at their own home, came together as an organization that could share the purchasing of raw materials and the [End page 148] marketing, production planning, and sales that kept them in business. Not only did this allow the weavers to design their own route out of poverty, but economic strength and organization have since allowed URVAL to expand into other areas. Eye health is one. Eyes suffer in the dry, dusty, and often windy conditions of the Thar Desert. URVAL thus went into partnership with Sightsavers International to run eye camps, bring treatments to remote areas, and find ways to rehabilitate people who had become blind—for instance, by teaching them to cook and sew, which allows the blind not only to care for themselves but also to earn a living. In sum, the same themes that we saw in BRAC are evident here: the effective combination of social enterprise, economic empowerment, and the treatment of health.

Marble: Education in particular seems to play a crucial role in health. Could you offer an example in Asia of how raising education levels in general can have a concrete impact on health?

Crisp: For the Indian population at large, 1 in 200 births still result in the death of the mother, while an equal number lead to painful injuries. However, a child born in India to a mother with five years of education has a 40% better chance of living to five years old than a child whose mother has no education. The crucial variable in this case is that the mother has some education—any education, not specifically health-related education. Even just five years of primary education gives the mother a greater ability to think for herself and understand the world. Furthermore, two multinational surveys showed that children of mothers with no education had 2.2 times higher mortality than children of educated mothers. These surveys also showed that rural mortality was 2.5 times higher than mortality in urban areas, reflecting the different conditions and poorer access to education and services, and that poorer children overall had 2.5 times higher mortality. The lesson is clear: educated mothers are essential for the healthy and safe upbringing of their children. A mother’s education profoundly affects how likely her children are to live. That is why the broad efforts of such institutions as URVAL to increase general education levels are so important for health in India.

Marble: Are the unique methods and institutions that arise to meet the needs and challenges of the developing world as applicable to the developed world?

Crisp: The point is not for medical professionals and institutions in the West to replicate exactly the institutions of the developing world, but rather for [End page 149] them to be open to absorbing new ideas and methods. Western institutions are so invested in maintaining and developing the old models of delivery and behavior based on the essential features of Western scientific medicine—scientific discovery, greater professionalism, commercial innovation, and massively increased funding—that they find it difficult to create new ones and are themselves becoming part of the problem.

The West must—and is actually beginning to—explicitly learn from what is happening in these developing countries. For me personally it has been interesting to hear from UK doctors who have worked in Asia or other poor regions about how, when faced with enormous numbers of patients and little in the way of equipment or drugs, they have been forced to improve and invent ways to help patients. Many doctors have found this greatly exhilarating. Free of the many protocols, procedures, and policies so common in the West, they have had to rely on their own resources and behave, as one radiologist friend told me, “like a proper doctor.”

The greatest learning comes in two areas. First, as we have seen with BRAC and URVAL, it is possible to organize services in different and very non-industrial ways, based around families, communities, and social enterprises. Secondly, a great advantage can be gained from training people for the job at hand rather than just for the profession. What I mean by this is that there is scope to train more mid-level workers to do things such as cataract surgery or caesarian sections rather than always relying on highly trained, multi-competent traditional professionals, who then have to work below their full capacity to undertake these more routine procedures. Both professionals and mid-level workers are needed, but not everyone in a system needs to be a professional.

Marble: Changing the system by shifting the paradigms of Western doctors one by one would be a painstakingly slow process. Are there other ways that the ideas of the poorer countries are working to change the global health system?

Crisp: Many Asian countries, already free from the constraints of a system based so rigidly on Western medicine, are much more nimble and are able to develop even new, international-class health institutions. For example, a number of Asian countries—including Thailand, Singapore, and India—now provide private health services for “health tourists” from the rich countries and are challenging the long-established providers of the United States and Europe on both quality and cost. These countries are responding creatively to the growing demand for high-quality health care from people who are willing [End page 150] to travel to obtain international standards and can afford to do so. Singapore is within a seven hour flight of 40% of the world’s population—a whopping 2.5 billion people.

Moreover, Singapore and its competitors can anticipate a growing market and in turn will need the staff to deliver. This is one example of a larger trend where the global movement of trained health workers is increasing as the newly rich countries of Asia—especially India and China—demand a greater share of this scarce resource. These countries will draw health workers from rich as well as poor countries, which in turn will put more pressure on the poor countries. Singapore is an interesting case in point. It only recognizes the qualifications of doctors trained in five countries—the UK, the United States, Canada, Australia, and New Zealand—and actively recruits from them all.

Marble: So we are seeing how countries outside the Western industrialized sphere are already working to change the global health system. Is this a trend that you think will continue?

Crisp: Yes. I note that international aid and development is itself going through a period of great change at the moment. The established agencies and donors, largely from Western democracies, have created one pattern of giving that, in theory at least, is consistent across the world. However, some of the other great and emerging powers, such as India and China, have different ideas and are engaging in bilateral negotiations with poorer countries to gain preferential trade agreements and secure natural resources. China, in particular, has been generous with its help for major infrastructure projects, often in return for access to mineral deposits, seaports, and open markets for its vast manufacturing output. In this century, the total amount of investment into Africa has overtaken international aid for the first time, with China playing a major role.

Of course, we don’t yet know how foreign policy and international relations will develop, beyond recognizing that power is shifting from west to east and that the policies of the big new economies of China, India, Russia, and Brazil will have greater international significance and impact. I would not be surprised if these changing development patterns were to help reduce the dominant role that Western scientific medicine has played in global health. [End page 151]