Some Lessons American Health Policymakers could learn from the Healthcare System in Uganda.
on Random Uganda (Uganda), 16/Mar/2010 09:10, 34 days ago
Last night was the Uganda Irish Society’s St. Patrick’s Day Ball. Guinness was flown in all the way from Dublin. As was the band. There may have been irish whiskey as well… and dancing on tables… who knows… I’m pretty much denying any firsthand knowledge of anything that happened after midnight. Any videos circulating on Youtube have obviously been doctored. All this to say that I’m writing with a wee bit of a headache and a queasy stomach. And this may make me just a bit of a contrarian.So, yes, I do understand that really I’m supposed to be here teaching the Ugandan doctors what they can learn from American medicine, but, unfortunately, there is no way in hell that Uganda will ever be able to afford American-style medicine (neither, if truth be told, can the United States). It would take a hundred-fold increase inhealthcare spending to bring medicine in Uganda within sight of medicine in the developed world. And, given that over ninety percent of the public healthcare budget in Uganda is provided by foreign aid, it is unlikely that the aid-giving countries would go along with such a ramping up of the budget. (Maybe this is the first lesson we could learn. Maybe we need to get our healthcare system is such disarray that the EU will take pity on us and we can get their taxpayers to pay for our healthcare. Don’t laugh, many of our healthcare statistics are drifting down to third world levels.)Lesson 1: Free basic healthcare for everybody.Okay, so nothing is free, let’s say taxpayer-funded access to basic healthcare for everybody. As a Ugandan citizen you can walk into a Ministry of Health (MOH) hospital anywhere in the country and be seen by a doctor or a nurse and, if you need to be admitted to the hospital, you will be assigned a bed, or a mattress, or a little piece of floor space. All for free. I can hear you saying that in America you can walk into any ER and get treated without paying a cent, and this may be the case, but always a bill is generated that most people can’t begin to pay. If you are truly destitute, sure, it’s free for you (wasn’t there a Janis Joplin song about that?), but for the rest of us, struggling to keep our hamster-wheels spinning, if you don’t have insurance (and sometimes even if you do), that bill will screw up your life.Sure. In Uganda, basic healthcare is very basic. Very very basic. Appallingly, horrifyingly basic. But if congress can put together a trillion dollar healthcare bill, certainly we can decide upon an acceptable level of basic healthcare and find a way to pay for it. We have decided, for example, as a country of taxpayers, that we will pay to educate our children K-12. Basic education. Additionally we have decided to subsidize higher education. Surely we could determine what constitutes basic healthcare—annual health visits, childhood vaccinations, prenatal and postnatal care, emergency care, hospitalization, etc—and what would be covered entirely, and what would be subsidized.Lesson 2: Price tags.At Mulago, basic care is provided to all, without charge. Depending on what is in stock, this may include IV fluids, some medications, or a CBC (complete blood count). If you need a CT scan, however, it will cost you 150,000 shillings (about $75). A night in the ICU—300,000 shillings. A month of dialysis—3M shillings.In most cases, the extra fees are demanded upfront. In cash.In America, in contrast, nobody really knows what things cost. A CT scan might be $1200, but this price isn’t out in the open, it’s buried in a computer program somewhere—and Blue Cross might pay $605 for it while Aetna pays $660 and Medicaid pays $300. The true cost of the CT scan, however, would be a few cents for electricity and digital storage, a few dollars of time for the technician runningthe machine, fifty dollars or so to the bank that financed the purchase of the multi-million dollar scanner, and maybe throw in a few extra dollars of profit for the hospital—or, about $75.In American healthcare, neither the provider nor the consumer has a complete grasp on the cost of the service. We all want the best possible healthcare, we want it immediately, and we want someone else to pick up the bill. And, oh yeah, while your at it, don’t even think about raising our taxes. You don’t have to be a Greenspan or a Keynes to figure out that this is not a sustainable economic system.Only by putting price tags that actually reflect what things cost and making those price tags readily available, can we, as a country and as individual consumers, can make educated choices as to how our healthcare dollars are going to be spent.Lesson 3: Re-involve the family.In Uganda, a patient comes to the hospital with one or many family members. While the patient is in the hospital, among other things, the family will keep the patient clean, feed the patient, and help the patient move to the toilet. If, for instance, the patient is suffering from some sort of meningo-encephalitis related to his advanced HIV and is delirious and thrashing about in bed, the family will calm the patient, keep the patient from harming himself, and clean up the urine and fecal matter afterwards. In the US, the restraining of an agitated patient would divert most of the staff from a ward or unit, it would significantly disrupt care for all of the other patients on the ward, and the fact that strangers were involved would exacerbate rather than sooth the patient’s delirium.Granted, a patient that comes to a MOH hospital in Uganda without family can actually starve to death on the ward. But there are ways around this. Family members for hire, for instance.Having family present on the ward leads to a better transfer of information about the patient’s condition and better ongoing care when the patient is discharged. And the family that better understands the medical conditions is better educated to make the financial decisions involved (see Lesson 2). Will the family choose to continue grandma’s dialysis, or will they choose to spend themoney on the grandchildren’s University? I can hear the gasps of shock and indignation already. But isn’t it more honest to make these decisions at a family level than to defer the decision to Congresses’ budgetary obfuscation? (What? You don’t believe that there is a relationship between the cuts in funding for higher education and the tremendous costs of healthcare in the last year of life? And just exactly how does the easter bunny get all those eggs painted?)Lesson 4: Let hospitals be hospitals.Nowadays, hospitals in the US are judged more on the quality of the double latte at the espresso stand in the grand atrium with the dynamic sculpture garden and water feature, and less on the bacterial resistance of the bugs in the ICU. Hospitals in Uganda don’t serve lattes. They don’t have customer service representatives. But, with the exception of a few that, due to plumbing issues, don’t have running water, most hospitals have the basics that a hospital needs: beds, nurses, doctors.Let’s go back to building hospitals (yes, as a matter of fact, I am advocating the building of new or the reopening of old public hospitals) designed for the practice of medicine and stop with the idea that a hospital should look like a Grand Hyatt and have a five-star restaurant to match. A hospital should not be a place that you look forward to visiting.Let the families (see Lesson 2) take care of the patient’s food and bedding. If the family wants to bring poached salmon and 1400 thread count linens, so be it. Let the hospital worry about the competency of their medical staff, not the quality of their catering.Lesson 5: The ER is for emergencies.The American ER has morphed from a single room into one of the most efficient (and expensive) places for accessing healthcare. And success is burying it. The American people like waiting for their CT scan just about as much as they like waiting for their Double Cheeseburger. The definition of what constitutes an emergency has been diluted to the point of absurdity. Additionally, the unfunded mandate that isEMTALA(emergency medical treatment and active labor amendment) makes the ER the only place that many uninsured and underinsured patients can get healthcare.The entrance to the casualty ward at Mulago has a sign in English and Lugandan. It says that if you don’t have a life or limb threatening problem you should go away. When you enter the lobby area, the eyes of dozens of sick or injured patients scan you for outward signs of illness or injury—a mental triage to decide if you are going to bump them further down the waiting line. You are ushered behind the triage curtain and the nurse takes your complaint and vital signs. The nurse’s assessment may take a few minutes. If the nurse thinks you have an emergency she makes a color-coded dot on your chit, signifying your priority in the queue. If she doesn’t think you have an emergency, shemay refer you to one of the outpatient clinics. She may just tell you to leave.Lesson 6: More creative use of floor space.Most of America’s hospitals are operating near or over capacity—either they actually have all the beds full, or they don’t have the nurses to staff the ones they choose to leave empty. What this means to you is that if you are sick and in the ER and need to be admitted to the hospital, you may lie for hoursor even days in a corridor of the ER until a bed comes ready in the hospital. And it may mean that the ambulance that you think is taking you to the hospital where your doctor works may get ‘diverted’ to another hospital miles away because your hospital is closed. It also means that hospitalsin the US have no ‘surge capacity’ as seen this past flu season when many US hospitals were overwhelmed by the relatively mild H1N1 pandemic.Mulago doesn’t close. There’s always room for another patient.Ward 3BEM is the holding ward for medicine admissions. Anybody that is admitted to the hospital from the casualty ward after 4pm has to spend the night in 3BEM before going to the wards. The ward was designed for 18 patients. Currently there are beds for nearly 40 patients and, in the far corner, a tall stack of foam rubber mattresses. When the beds run out, the patients’ families come in and pull a mattress over find a piece of floor space. When the floor space runs out, the patients spill out through the door into the hallway.Lesson 7: More clinical involvement of the medical students and residents.Back when I was a medical student (and it wasn’t that long ago, okay, so maybe it was along time ago, more than two decades) an intern was left to supervise us on the medical or surgical wards, while the residents and the attendings were off doing important stuff like heart surgeries or colonoscopies or lunch or something. Nowadays, things like that don’t happen. Medical students are barely allowed to touch patients, let alone make decisions about their care. Interns and residents are no longer allowed to act independently as physicians—every patient interaction needs to be overseen and countersigned by an attending (a board-certified, residency trained doctor).This is the result of several things: fear of malpractice suits, legislation limiting the work-week of a physician in training, and convoluted Medicare billing regulations. The result is that medical students and residents get less hands on clinical teaching and practice now then they did twenty years ago. It means that they’ve been educated in a system of fear and paranoia that hasn’t taught them basic clinical skills (such as the physical exam) and has taught them to mistrust the clinical skills they do have and only feel comfortable when they’ve ordered several thousand dollars worth of imaging studies and labtests to back up even the most insignificant decision.At Mulago, if you see anyone with a white coat, that person is likely to be a medical student or an intern. Most of the care is provided by the interns (the interns actually show up to work, as the internship is a requirement for registration in medicine in Uganda) under the intermittent supervision of the residents. It is a rare thing when a consultant walks the public wards. I’m not saying that the interns always make the right choices. Far from it. But at least they are out there day after day, meeting the patients, examining the patients, learning how to make medical decisions based on a very small amount of information—not just reading about it, or practicing ona computer simulator.