Public Private Partnerships in Global Health: Let’s Not Be Too Smug

Some people seem to think that it is wrong to enter into partnership with any company whose product(s) can harm the public health. This is cobblers. Manufacturers of legal products are all part of our society and of our economy. The companies are only prosperous and profitable because their products are widely consumed and appreciated. I know that alcohol is bad for my health, but I choose to consume it. It is a trade-off that I am entitled to make as a free agent. I know that flying in aeroplanes and driving cars is bad for the planet. Yet I fly and drive. In so far as these things are unhealthy, we should tax them at source or regulate more heavily. However, we should overcome the hypocrisy implicit in using these products and then the saying that we cannot partner with relevant industries to tackle issues in global and the public health. Enough virtue signalling. Time for some guidelines. A thoughtful article on engagement with industry was recently published in the New England Journal of Medicine and I strongly endorse the nuanced approach recommended.[1]

— Richard Lilford, CLAHRC WM Director

Reference:

1. Iliff AR & Jha AK. Public-Private Partnerships in Global Health – Driving Health Improvements without Compromising Values. N Engl J Med. 2019; 380: 1097-9.

Challenges in Doing Research Overseas

I was asked by the NIHR to give a talk on the above subject at a recent meeting for directors of NIHR Global Health Units and Groups. I guess my qualification to speak was that I direct one Unit, lead a Work Package for another Unit, and collaborate on six Group grants. There are, of course, many challenges in global research. In my opinion, the main operational difference between overseas and UK research relates to greater time pressure in global research than in UK research. The time constraint with global research applies particularly to establishing the research programme. All of the following take more time in global health than in local research:

1. Ethical clearances. These are required both in the UK and in each overseas centre. Some overseas centres will not accept an application until it has first cleared UK ethics. In some countries the process is long – up to four months for an initial opinion in Bangladesh, for example.
2. Local permissions. Arranging a memorandum of understanding with UN-Habitat took over one year. Although this is an extreme example, establishing the appropriate agreement with collaborating institutions can be very time consuming, involving long delays in both the host and overseas institution.
3. Financial transfers. Because of understandable risk aversion, institutions can be extremely nervous, not just about sending, but also receiving money. Note that some institutions will only process collaborative agreements and ethics committee approvals in series, so the whole process of establishing a research programme is at least twice as long, on average, in the UK.

Centre or programme grants in the UK or US are typically awarded over five year periods. They are limited at five years on the premise that longer funding would reduce competitive incentives and limit ‘creative destruction’, whereby the most promising ideas and researchers can displace those that have become less competitive (Figure 1). Thus, if it takes one year to establish a centre, that leaves four years for it to prove itself. Yet, NIHR Global Units are funded for four years and take more like two years to establish themselves. Thus, the research programme is shoe-horned into two short years – not long enough for a trial, for example (Figure 2). Since group grants receive only two-and-a-half years funding, the situation for them is even more acute.

Figure 1. Why is research centre funding limited to five years?

Figure 2. Clinical trials with four years funding: example of an (unusual) trial requiring funding for only one year.

— Richard Lilford, CLAHRC WM Director

The Beneficial Effects of Taking Part in International Research: an Old Chestnut Revisited

Two recent and well-written articles grapple with this question of whether or not clinical trials are beneficial, net of any benefit conferred by the therapeutic modalities evaluated in those trials.[1] [2]

The first study from the Netherlands concerns the effect of taking part in clinical trials where controls are made up of people not participating in trials (presumably because they were not offered entry in the trial).[1] This is the topic of a rather extensive literature, including a study to which I contributed.[3] The latter study found that the putative ‘trial effect’ applied only in circumstances where care given to control patients was not protocol-directed. In other words, our results suggested that the ‘trial effect’ was really a ‘protocol effect’. In that case the effect should be ephemeral and disappear as greater proportions of care become protocolised. And that is what appears to have happened – Lin, et al.[1] report no benefit to trial participants versus non-trial patients for the highly protocolised disease Hodgkin lymphoma. They speculate that while participation in trials does not affect individual patient care in the short-term, hosting trials does sensitise clinicians at an institutional level, so that they are more likely than clinicians from non-participating hospitals to practice evidence-based care. However, they offer no direct evidence for this assertion. Such evidence is, however, provided by the next study.

The effects of high participation rates in clinical trials at the hospital level is evaluated in an elegant study recently published in the prestigious journal ‘Gut’.[2] The team of authors (that includes prominent civil servants and many distinguished cancer specialists and statisticians) compared outcomes from colon cancer according to the extent to which the hospital providing treatment participated in trials. This ingenious study was accomplished by linking the NIHR’s data on clinical trials participation to cancer registry data and Hospital Episode Statistics. It turned out that risk-adjusted survival was significantly better in the high participation hospitals than in lower participation hospitals, even after substantial risk-adjustment. “Residual confounding” do I hear you say? Perhaps, but the authors have two further lines of evidence for the causal explanation. First, they documented a dose-response; the greater the level of participation, the greater the improvement in survival. Of course, an unknown confounder that was correlated with participation rates would produce just such a finding. The second line of evidence is more impressive – the longer the duration over which a hospital had sustained high participation rates, the greater the effect. Again, of course, this argument is not impregnable – duration might not serve as a good Instrumental Variable. How might the case be further strengthened (or refuted)? By unravelling the theoretical pathway between explanatory and outcome variables.[4] Since this is a database study, the process variables that might mediate the putative effect were not available to the authors. However, separate studies have indeed found an association between improved processes of care and trial participation.[5] Taken in the round, I think that a cause/effect explanation holds (>90% of my probability density favours the causal explanation).

— Richard Lilford, CLAHRC WM Director

References:

1. Liu L, Giusti F, Schaapveld M, et al. Survival differences between patients with Hodgkin lymphoma treated inside and outside clinical trials. A study based on the EORTC-Netherlands Cancer Registry linked data with 20 years of follow-up. Br J Haematol. 2017; 176: 65-75.
2. Downing A, Morris EJA, Corrigan N, et al. High hospital research participation and improved colorectal cancer survival outcomes: a population-based study. Gut. 2017; 66: 89-96.
3. Braunholtz DA, Edwards SJ, Lilford RJ. Are randomized clinical trials good for us (in the short term)? Evidence for a “trial effect”. J Clin Epidemiol. 2001; 54(3): 217-24.
4. Lilford RJ, Chilton PJ, Hemming K, Girling AJ, Taylor CA, Barach P. Evaluating policy and service interventions: framework to guide selection and interpretation of study end points. BMJ. 2010; 341: c4413.
5. Selby P. The impact of the process of clinical research on health service outcomes. Ann Oncol. 2011; 22(s7): vii2-4.

On Foetal Growth Charts – the WHO May Have Adopted the Correct Policy for the Wrong Reason

The journal ‘Science’ reports a controversy over two studies of foetal growth across countries [1] – the first study showed very similar growth rates across eight countries (Brazil, Italy, Oman, UK, USA, China, India, Kenya).[2] They conclude that a common threshold should be used in countries to identify slow-growing foetuses. The second study looks only at the socio-economically advantaged populations across ten countries, ranging from Norway and Denmark to India and Egypt.[3] It finds markedly different rates across countries among socio-economically advantaged segments of the population. So that would suggest the use of country-specific thresholds.
I am not so sure – I question the assumption that the search for the growth-retarded foetus should be based on a fixed proportion of the foetal population – say the slowest growing 5%. The risk of stillbirth is higher in the countries with slower foetal growth (e.g. India and Egypt), than in those with higher growth rates (e.g. Norway and Denmark). So the cut-off threshold for foetal growth as a screening test should, logically, be set at a higher point in high-risk countries than in lower-risk countries. If it is set to identify the ‘bottom’ 5% in low-risk countries it should be set at, say, 10% in high-risk countries. This suggests that the WHO (which recommends a universal chart on the basis of the first study above) has the correct solution for the wrong reason. The universal chart will identify a higher proportion of still-births in the high-risk countries – just what one would want.

— Richard Lilford, CLAHRC WM Director

References:

1. de Vrieze J. Big studies clash over fetal growth rates. Science. 2017; 355(6323): 336.
2. Papageorghiou AT, Ohuma EO, Altman DG, et al. International standards for fetal growth based on serial ultrasound measurements: the Fetal Growth Longitudinal Study of the INTERGROWTH-21stProject. Lancet. 2014; 384: 869-79.
3. Kiserud T, Piaggio G, Carroli G, et al. The World Health Organization Fetal Growth Charts: A Multinational Longitudinal Study of Ultrasound Biometric Measurements and Estimated Fetal Weight. PLoS Medicine. 2017.

Let the Second Sanitary Revolution Begin

Despite the gains in recent years, far too many children still die before their fifth birthday. Childhood mortality in low income countries is 76 per thousand live births compared with 7 per thousand in high income countries.[1] Now that pneumococcal vaccine is in a widespread use we may expect diarrhoea to take over from pneumonia as the number one killer of children. Certainly in slums – soon to be home to over 1 billion people – diarrhoea is the greatest threat not just to life, but also to child health. Diarrhoea predisposes to chronic enteropathy, especially in malnourished children, which in turn predisposes to stunting and perhaps reduced cognitive development.[2]

But it does not have to be this way. The first ‘sanitary revolution’ in the second half of the 19th century in Europe and North America yielded massive gains in child survival.[3] Less than 4% of all development assistance has been allocated to urban water and sanitation improvement over the last few decades, according to Prof David Satterthwaite. Moreover, it is not as though Europe and America were awash with money; the per capita GDP of Britain in the 1860s ($703.1)[4] was roughly equivalent to that of Rwanda today ($697.3).[5] This suggests that a lack of political will is also to blame for poor sewage and water installations in modern day slums. And the pitiful state of sanitation in modern slums has been thoroughly documented.[6] Hardly surprisingly, improving sanitation is the number one priority for people who live in slums.[7] Water and sanitation is not a middle-class concern foisted on slum dwellers; it is a critically important issue that results in millions of child deaths and that local people want tackled.

There are of course barriers to tackling this problem relating to relative powerlessness of people in slums, poor local governance, immature financial markets, and so on. But there is another problem that is created entirely by a certain type of armchair academic – this is the pernicious idea that nothing can be done pending improvements in local and national governance. Such people argue that it is first necessary to improve security of tenure, functioning financial markets, and so on. An extension of this argument, for which empirical support is absent, is that water and sanitation is not enough; it must be part of an improvement in the whole slum ‘nexus’ to include solid waste disposal, street drainage, home improvement, etc. We cannot wait for extractive elites to disappear, the judiciary to be made independent, or every slum holder to achieve title before acting; Paris famously installed a functioning sewage system during the dictatorship of Napoleon the third following his coup d’état. Fortunately water and sanitation was prioritised at a recent WHO Technical Working Group on “Addressing Urban Health Equity Through Slum Upgrading” attended by the CLAHRC WM Director.

So, let the water and sanitation revolution begin. Let it be driven by political and social zeal but do not let it be undisciplined, and let us never forget that water and sanitation is a socio-technical innovation – it needs to be supported (ideally initiated) by local people themselves. Ensuring proper use and maintenance of sanitary facilities requires alignment of supply and demand.

A number of international organisation promote water and sanitation in low- and middle-income countries, for example the UN-HABITATs Water and Sanitation Trust Fund. But good intentions are not enough when it comes to sanitation – even where sanitation and water have been improved, the benefits on health are often nugatory.[8] [9] This is because the installations are inadequate, and/or because facilities are underused or poorly maintained. It is thus crucially important that interventions meet local needs, that they can be maintained, and that their effects in reducing exposure to infection and improving health are evaluated. Installation of improved water and sanitation utilities needs to be accompanied by research into how to make this socio-technical intervention work well and also summative evaluation of the effects on health and well-being.

— Richard Lilford, CLAHRC WM Director

References:

1. World Health Organization. Under-five mortality. WHO, 2016.
2. Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B. Developmental potential in the first 5 years for children in developing countries. Lancet 2007; 369: 60–70.
3. Szreter S. The Population Health Approach in Historical Perspective. Am J Public Health. 2003; 93(3): 421-31.
4. Broadberry S, Campbell B, Klein A, Overton M, van Leeuwen B. British economic growth and the business cycle, 1700-1870. 2011. Working Paper.
5. The World Bank. GDP per capita (current US$). 2016.
6. Ezah A, Oyebode O, Satterthwaite D, et al. The history, geography, and sociology of slums and the health problems of people who live in slums. Lancet. 2016. [ePub].
7. Parikh P, Parikh H, McRobie A. The role of infrastructure in improving human settlements. Urban Design Planning, 2012; 166; 101-18.
8. Wolf J, Prüss-Ustün A, Cumming O, et al. Assessing the impact of drinking water and sanitation on diarrhoeal disease in low- and middle-income settings: systematic review and meta-regression. Trop Med Int Health. 2014; 19(8): 928-42.
9. Fewtrell L, Kaufmann RB, Kay D, Enanoria W, Haller L, Colford JM, Jr. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis. Lancet Infect Dis. 2005; 5(1): 42-52.

CHWonomics

Watching NoCounter interact with “Aunty” Martha (not their real names) in Mahwaqe, South Africa, and learning about NoCounter’s roles as Martha’s health advocate, personal trainer and medication manager was anything but dismal. So as a dismal scientist, I was fascinated by how Community Health Workers (CHWs) seem to contradict one of our most famous founders, Adam Smith. To help explain one of the concepts for which he would become famous, “the invisible hand”, Smith wrote: “I have never known much good done by those who affected to trade for the public good”.[1]

To consider whether NoCounter and other CHWs are an exception to this statement, there are three questions that need to be considered:

Is the CHW doing good?
Almost all of the available research evidence suggests that CHWs are effective in enhancing the health of their communities,[2] and since the World Health Organization also see CHWs as playing a pivotal role in helping countries achieve health-related Millennium Development Goals,[3] it is most likely that CHWs are “doing good”. In Mahwaqe, we saw how NoCounter helped Martha do the chair yoga exercises that now mean she can walk and explained her medications, which helped Martha understand the importance of adherence.

Is the CHW trading?
NoCounter is giving up her time (working around 50% FTE) and in return, receives a stipend from an NGO of around R800 (~£36) per month and as such, is trading. However, as a maid in South Africa, she could earn around R1,200 (~£54) per month for the same hours, so NoCounter does not seem to be receiving the full monetary value of her time. If approximate role equivalence can be assumed, compared to a CHW in the US, NoCounter’s time is undervalued by a factor of around 8.5: a US CHW working for an hour could buy 3.3 McDonald’s Big Macs; NoCounter could buy 0.4.[4] [5] NoCounter is also using her skills and experience to provide care, but economics would describe these as “non-rivalrous” and thus not directly tradable.

Is the CHW doing so for the public good or her own self-interest?
Adam Smith might be confused by NoCounter, because her aim doesn’t seem to be wealth maximisation. However, a “utility maximising” economist would argue that NoCounter is making up for not being paid the full monetary value of her time by obtaining utility either from substitutes for money or from directly helping her community.[6] Even if NoCounter obtains utility from the latter, her motivation would still be to do public good. With regards to money substitutes, CHWs may also receive non-monetary incentives such as community respect, housing and access to health care and/or be motivated in their roles via the support of their families.[6] [7] Furthermore, the CHW role is particularly desirable in areas where residents have a high marginal rate of substitution for leisure over consumption, since CHWs do not have to commute to their place of work. Finally, a by-product of NoCounter’s work as a CHW from which she benefits directly is that she lives in a healthier community: by encouraging vaccination of new-borns, for example, she is lowering her own risk of TB.

On this last question, the relative importance of the different reasons why CHWs undertake their role for a wage lower than they appear to be worth, we cannot be certain about the answer. Research in this area is critical given the push to eliminate the under-supply of CHWs.[8] There are also additional pre-conditions – the organisational structure required to implement a successful CHW programme [9] – that also must be met before the demand for CHWs can be realised (made “effective”) in practice. Nevertheless, it is critical to determine whether all of the additional CHWs required to meet demand would also offer their labour at a low relative price. This was assumed in a costing exercise of a CHW roll-out programme,[10] but which prima facie contradicts basic economic theory of demand and supply.

Fortunately for me, economics provides one approach to studying the interaction between monetary and non-monetary incentives with respect to the supply of labour, for example using discrete choice experiments, where CHWs would be asked to make a choice between a series of pairs of packages of stipend/salary, level of health produced, and non-monetary incentives (see [11] for an example). Such experiments would need to be repeated in (and possibly also within) different countries, since the relative value of “doing good” by volunteering may well differ according to a country’s stage in economic development. Such work would help to provide evidence regarding the sustainability of CHWs as a cadre of health care providers. Here, we hypothesise a U-shaped curve if propensity to volunteer is plotted against GDP per capita

— Celia Taylor, Senior Lecturer

References:

1. Smith A. An Inquiry into the Nature and Causes of the Wealth of Nations. London: Strahan and Cadell, 1776.
2. Perry H, Zulliger R. How Effective are Community Health Workers? An Overview of Current Evidence with Recommendations for Strengthening Community Health Worker Programs to Accelerate Progress in Achieving the Health-related Millennium Development Goals. Baltimore, MD: John Hopkins Bloomberg School of Public Health, 2012.
3. World Health Organization and Global Health Workforce Alliance. Global Consultation on Community Health Workers. Geneva, Switzerland: World Health Organization, 2010.
4. Payscale Homepage. 2015.
5. The Economist. The Big Mac Index. 2015.
6. Greenspan JA, McMahon SA, Chebet JJ, Mpunga M, Urassa DP, Winch PJ. Sources of community health worker motivation: a qualitative study in Morogoro Region, Tanzania. Hum Resour Health. 2013; 11: 52.
7. Dambisya YM. A review of non-financial incentives for health worker retention in east and southern Africa. In: EQUINET Discussion Paper Number 44 with ESCA-HC. Loewenson R (Editor). Harare, Zimbabwe: EQUINET, 2007.
8. One Million Community Health Workers Campaign. One Million Community Health Workers Campaign. 2015.
9. World Health Organization, Policy Brief. Community health workers: What do we know about them? Geneva, Switzerland: World Health Organization, 2007
10. McCord GC, Liu A, Singh P. Deployment of community health workers across rural sub-Saharan Africa: financial considerations and operational assumptions. Bull World Health Organ. 2012; 91(4):244-53B.
11. Kasteng F, Settumba S, Källander K, Vassall, A, inSCALE Study Group. Valuing the work of unpaid community health workers and exploring the incentives to volunteering in rural Africa. Health Policy Plan. 2016: 31(2): 205-16.

Sugar Taxes in Mexico

Consumption of sugar dropped in Mexico after implementation of a sugar tax.[1] It was falling already, but there was a step down, albeit a small one, compared to a counterfactual created by extrapolating previous trends. Demand was most elastic in the lowest income group. Sugar taxes are a tad illiberal, but maybe they can be accepted on the basis that both consumers and the industry (as a whole) would like sugar levels in merchandise to drop. But each individual company is terrified that they will lose market share to competitors if they make the first move. Taxes apply to all products and so keep the playing field level. Some have suggested that taxes have to be quite high (about 20% of the purchase price) to have any material effect, but the effect in Mexico was achieved at levels of about half of this. This week the Chancellor of the Exchequer brought in a sugar tax in the UK. We should track the effects on sugar consumption. Pure, white and deadly, we have done numerous posts on the danger of free sucrose (for example, [2] [3]).

— Richard Lilford, CLAHRC WM Director

Reference:

1. Colchero MA, Popkin BM, Rivera JA, Ng SW. Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. BMJ. 2016; 352: h6704.
2. Lilford R. How Much Sugar is too Much? CLAHRC WM News Blog. 25 September 2015.
3. Lilford R. More, Yet More, On Pure, White and Deadly. CLAHRC WM News Blog. 31 July 2015.

Experimental Study of Income Inequality

Haushofer and colleagues report on a randomised trial of cash transfers to poor people in Kenyan villages.[1] They find that when some people receive a material cash transfer this adversely affects those who do not, on the cognitive, but not affective components of psychological wellbeing. However, the effect is short-lived, dissipating over the 15-month follow-up period in the study. The authors are careful to point out that there is no reason to avoid making the transfers, which, among other things, empower women and reduce violence. In any case, how can society function if people are not allowed to escape from poverty for fear of upsetting their neighbours? All the same, conspicuous consumption is distasteful because it does adversely affect those around you, and should thus be avoided.

— Richard Lilford, CLAHRC WM Director

Reference:

1. Haushofer J, Reisinger J, Shapiro J. Your Gain Is My Pain: Negative Psychological Externalities of Cash Transfers. 2015.

Return on Investment from Vaccines

CLAHRC Africa has previously carried out health economic assessments in Low- and Middle-Income Countries (LMICs) concerned with devices,[1] [2] and is now doing so with respect to milk banking and breastfeeding in collaboration with the African Population and Health Research Centre (APHRC). We were therefore interested to read a Return on Investment analysis on vaccines in LMICs.[3] Ten vaccines were considered, singly and in combination. The costs of the programmes were obtained largely from Gavi, the Vaccine Alliance. The costs saved were calculated on the basis of costs of treating cases at home (including days off work for carers), costs of admission by hospital day, transport costs to care facilities, costs of care for disabilities, and lost production costs based on discounted per capita GDP for people who died or could not work. Herd immunity was not taken into account, neither were effects on demographic structures of countries, thereby under-estimating return. The return on investment ([monetised benefit – programme cost] / programme cost) was a whopping $16 per dollar expended. There are few other such studies in LMICs, but the return was even higher than deployment of Community Health Workers at $9 per dollar expended, but lower than improving road safety at $19 per dollar expended. The ratios were positive for all the ten vaccine studied, but the most favourable ratio was for measles, followed by yellow fever (a surprise to the CLAHRC WM Director) and Meningococcal meningitis.

— Richard Lilford, CLAHRC WM Director

References:

1. Burn SL, Chilton PJ, Gawande AA, Lilford RJ. Peri-operative pulse oximetry in low-income countries: a cost-effectiveness analysis. Bull World Health Organ. 2014; 92(12): 858-67.
2. Lilford RJ, Burn SL, Diaconu KD, et al. An approach to prioritization of medical devices in low-income countries: an example based on the Republic of South Sudan. Cost Eff Resour Alloc. 2015; 13(1): 2.
3. Ozawa S, Clark S, Portnoy A, et al. Return on Investment from Childhood Immunization in Low- and Middle-Income Countries, 2011-20. Health Aff. 2016; 35(2): 199-207.

How Many Doctors Do We Really Need?

In a previous post we blogged about the changing nature of medical practice: the influences of regulation, guidelines, sub-specialisation, and patient expectations. We mentioned skills substitution, whereby less experienced staff take on tasks previously carried out by doctors. We also mentioned the role of Information Technology, but shied away from discussing the implications for medical manpower. However, it seems important to ask whether Information Technology could reduce the need for medical input by increasing the scope for skill substitution. Some patients have complex needs or vague symptoms, and such patients we assume will need to be seen by someone with deep medical knowledge to underpin professional judgements, and to provide patients with such an informed account of the probable causes of their illness and the risks and benefits of viable options. But much of medicine is rather algorithmic. A patient presents with back pain – follow the guidelines and refer the patient if any ‘red flags’ appear, for example. Many of the criteria for referral and treatment are specified in guidelines. Meanwhile, computers increasingly find abnormal patterns in a patient’s data that the doctor has overlooked. Work in CLAHRC WM shows that many patients do not receive indicated medicines.[1] Health promotion can be delivered by nurse and routine follow-up cases triaged by Physician Assistants. A technician can be trained to perform many surgical operations, such as hernia repair and varicose vein removals, and Physician Assistants already administer anaesthetics safely in many parts of the world.[2] Surely we should re-define medicine to cover the cognitively demanding aspect of care and those where judgements must be made under considerable uncertainty.

In the USA they talk about “people working up to their license”. What they mean is that it is inefficient for people to work for extended periods at cognitive or skill levels well below those they have attained by virtue of their intellect and education. Working way below the level is not only inefficient, but deeply frustrating for the clinician involved, predisposing them to burn out. Use doctors to doctor, not to fill in forms and perform routine surgical operations.

We conclude by suggesting that there is a case for re-engineering medical care or at least articulating a forward vision. The next step is some careful modelling, informed by experts, to map patterns of practice, assign tasks to cognitive categories, and calculate manpower configurations that are both safe and economical. Such a process would likely identify a more specific, cognitively elite role for expensive personnel who have trained for 15 years to obtain their license. In turn, this may suggest that less people of this type will be needed in the future.

While high-income countries should address the question “how much should we reduce the medical workforce, if at all?”, low-income countries face the reciprocal question, “by how much should we increase the medical work-force?” Countries such as Kenya have only two doctors per 10,000 population, compared to 28 in the UK, and 25 in the United States.[3] Much of the shortfall is covered by other cadres, especially medical officers (who work independently), and nurses. Health personnel are strongly buttressed by community health workers, a type of health worker that we have discussed in previous posts.[4] [5] Information Technology is unsurprisingly very under-developed in low-income countries, although telemedicine is increasingly used. It is particularly difficult to attract doctors to work in rural areas, and there is the perennial issue of the medical brain drain. The time is thus propitious to consider carefully the human resource needs not just of high-, but also of low- and middle-income countries, and consider how these may be affected by improving Information Technology infrastructure.

— Richard Lilford, CLAHRC WM Director

Reference:

1. Wu J, Yao GL, Zhu S, Mohammed MA. Marshall T. Patient factors influencing the prescribing of lipid lowering drugs for primary prevention of cardiovascular disease in UK general practice: a national retrospective cohort study. PLoS One. 2013; 8(7): e67611.
2. Mullan F & Frehywot S. Non-Physician Clinicians in 47 Sub-Saharan African Countries. Lancet. 2007; 370: 2158-63.
3. World Health Organization. Health Workforce: Density of Physicians (total number per 1000 population): Latest available year. 2015.
4. Lilford RJ. Lay Community Health Workers. NIHR CLAHRC West Midlands News Blog. 10 April 2015.
5. Lilford RJ. An Intervention So Big You Can see it From Space. NIHR CLAHRC West Midlands News Blog. 4 December 2015.