Access to health services remains a key problem in rural areas and lower and middle-income countries (LMICs), where skilled health workers and digital health options are often in short supply. Focusing on the “three Cs” of health delivery — community-led, connectivity and collaborations — can help to build more flexible health systems for hard-to-reach populations.
The views expressed are those of the author and do not necessarily reflect the position of FORESIGHT Global Health.
Over half the world’s population still lacks access to essential health services. Many live in rural regions in low- and middle-income countries (LMICs) where traditional health systems don’t reach and there are chronic shortages of skilled health workers. Typical digital health services also don’t work in these low-connectivity areas – we need to remember 3.7 billion people are not connected to the internet.
Clearly this presents a significant challenge to combatting the global NCD epidemic, with four out of five people with an NCD living in LMICs. As we work through the Covid-19 recovery, we must build health systems that work for everyone on earth. Health systems that are designed around the needs of the people and communities are more effective and cost efficient. We must recognise the reality of the patient experience in many parts of the world and work to alleviate inequal access to health systems by focusing on the 3Cs: community-led, connectivity and collaborations.
BUILDING FROM THE GROUND UP
Where patients live long distances from healthcare providers and funding is limited, health systems must be community-led to create a more level playing field. Residents living in rural regions where we work typically have to travel over an hour to expensive private clinics for basic tests for glucose, HbA1C and cholesterol. A comprehensive diabetes test panel costs approximately $50 in a private hospital or outpatient diagnostic centre, 10 times more than the average daily earning of a resident.
Community-led health systems in which the communities themselves are empowered to take control of their health services are the means to provide more accessible, quality care. There must be a rapid scale up of Community Health Workers (CHWs), given the predicted shortage of 18 million health workers by 2030. But it’s not just about the numbers – it’s about providing proper recognition, pay and capability building through a shift away from traditional classroom training and manuals. What our CHWs across South & Southeast Asia most want is mobile-based learning, checklists and diagnostic tools to support them in doing their job and dealing with problems on the front line.
Informal healthcare providers (IHPs) can be trained to overcome the workforce gaps in hard-to-reach regions. Examples include the Novartis Foundation’s ComHIP model in Ghana, which enabled local businesses to provide blood pressure screening, and a key part of our own model at reach52 is equipping community members to provide a marketplace of health products in their communities. Equipping a ‘lay person’ to manage last-mile health services is not without its challenges, it’s getting the right mix of recruitment (entrepreneurial community members), upskilling (don’t underestimate the level of hands-on coaching involved) and rewards (fair and achievable incentives) to motivate performance.
But investment in both groups is worth it, not only to address the workforce shortages and support ‘decent work and economic growth’, but also to build trust in the health services. In less accessible regions where there is misinformation and unhealthy practices, patients often trust the advice of fellow community members more than outsiders; this can help to drive the health-seeking behaviours needed for NCD prevention and management.
BRIDGING CONNECTIVITY GAPS
The pandemic has accelerated the adoption of technologies across global health, and digital health is essential to building health systems that work everywhere. But the reality is many digital health solutions are of little use to patients in regions with low to no internet connectivity. There’s been a lot of fanfare about telehealth over the past 12 months, but if you’ve tried doing a basic video call or even phone call with people in rural regions in some LMICs, you’ll understand the limitations.
First and foremost, health tech services must be designed to be ‘offline-first’; in other words, they can function with or without the internet. This enables roaming health workforces to use mobile applications and devices to provide patient services for NCDs in offline areas, and then sync the data when back online at specific locations. Patients can also be connected directly to health services through offline-first mobile applications, so long as they’re designed with a simpler user experience and work on basic versions of mobile operating systems. It’s not just about the tech; we must also invest more in digital literacy programmes to equip patients to use the tech. Digital health literacy needs more focus as a social determinant of health, ensuring everyone benefits from digital health. For example, the Bangladesh Government in partnership with Huawei and Robi Axiata jointly launched the Digital Training Bus project to bring digital skills to women in the heart of rural Bangladesh.
Collecting and sharing data between providers is the foundation for strong, connected health systems. Application of this data is essential to more preventative healthcare. Yet efforts in this space in primary health centres in rural areas are often flawed – doctors describe to us how they get provided a computer, but no budget, no internet and no support, so have to pay for the internet themselves and end up continuing to use paper-based systems. We should view these efforts as an opportunity to avoid the interoperability problems of health systems in higher income countries, and see them not just as a cost, but as an investment in building more efficient, data-driven health systems from the start. Getting basics in place would at least lay the foundation for making access to health systems more equal by establishing common data standards, more user-friendly platforms, staff training, and alternative power sources to run it. Government regulation can be catalytic, such as India’s Universal Service Obligation Fund (USOF), used to build fibre cables across rural and remote areas, into which telecom service providers pay 5% of their adjusted gross revenue.
ENABLING NEW PARTNERSHIPS BETWEEN MULTIPLE STAKEHOLDERS
Collaborations between different health actors (including patients, healthcare providers (HCPs), government, civil society and private businesses) are essential for any effective health system. But new types of collaborations are needed to establish health systems that reach everyone on the planet. The constraints in resources, funding and capacity can be used to fuel innovation between new partners in new ways.
The World Health Organisation has already advocated the need for a comprehensive approach across all sectors (health, finance, transport, education, agriculture, planning and others) to lessen the impact of NCDs on individuals and society, and the inequalities that they create. We need to reframe the challenge away from filling the system gaps to shaping preventative systems. This means collaborations with financial services businesses to expand affordable insurance, because the fear of health expenses is often bigger than the fear of an NCD, putting people off seeking treatment until it’s too late.
This involves collaborations with schools to promote healthy diets to reduce treatment costs for diabetes and cardiovascular conditions. It also requires collaborations with tech companies to harness social media for positive health promotion and leverage AI capabilities, such as Google’s AI for Good projects, to predict risks for expectant mothers in India. As WHO Director General Tedros Adhanom Ghebreyesus, advocates “Reach beyond the health sector to tackle the social, economic and commercial determinants of health”.
There needs to be greater collaboration between traditional competitors. There have been unprecedented partnerships on COVID-19 vaccine development (such as Sanofi and GSK), but such collaborations don’t happen enough in expanding health services for all and there is too much re-inventing the wheel. The problem is too big for one organization to solve – working together to pool resources and share capabilities to develop health systems will benefit everyone.
Increasing collaboration with the patient themselves in health systems is central to all of it. This means empowering people by bringing health services closer to where they live, involving them through shared-decision making about their care, and putting health information at their fingertips through a mobile device already in their hands.
New mindsets are needed to drive new collaborations. In particular, we need to reframe ‘health for all’ as investment in GDP and growth, not just a cost to be managed. We need to shift from siloed programmes to scalable, sustainable models of care. And we must emphasise faster action to support policy statements. By doing so, together we can build the health systems everywhere that work for everyone, protecting lives from NCDs and driving inclusive growth for all. •
TEXT – Rich Bryson is the Chief Strategy and Marketing Officer at reach52, a tech social enterprise delivering health services in markets others don’t reach across the world.