Year : 2015 | Volume
: 8 | Issue : 1 | Page : 1--3
Partnership in healthcare: What can the west learn from the delivery of pediatric cardiac care in low- and middle-income countries
Seshadri Balaji1, Raman Krishna Kumar2,
1 Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA
2 Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Center, Cochin, Kerala, India
Raman Krishna Kumar
Clinical Professor and Head of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Center, Cochin - 682 041, Kerala
|How to cite this article:|
Balaji S, Kumar RK. Partnership in healthcare: What can the west learn from the delivery of pediatric cardiac care in low- and middle-income countries.Ann Pediatr Card 2015;8:1-3
|How to cite this URL:|
Balaji S, Kumar RK. Partnership in healthcare: What can the west learn from the delivery of pediatric cardiac care in low- and middle-income countries. Ann Pediatr Card [serial online] 2015 [cited 2020 Aug 15 ];8:1-3
Available from: http://www.annalspc.com/text.asp?2015/8/1/1/149509
Pediatric heart care has evolved rapidly in the last 50 years and has reached an advanced level in most high-income countries where the average child with congenital heart disease has access to comprehensive pediatric cardiac care and can look forward to a vastly improved life expectancy. The situation is quite different in low- and middle-income countries (LMICs; also referred to as the developing world) where the overwhelming majority of the planet's children reside. There is practically no pediatric heart care among countries classified by World Bank as low income (http://data.worldbank.org/news/new-country-classifications; viewed on Dec 8. 2014). Among the middle-income category, there is substantial variability in quality of care and access for the average child with heart disease. However, this is rapidly changing and most countries are seeking to improve the situation often through partnerships and collaborations with centers from high-income nations.
It is a commonly held truism that in the field of healthcare, LMICs have much to learn from practices in high-income countries (advanced economies or developed nations). In this editorial, we explore the question of what the developed world can learn from healthcare in LMICs that have significant resource limitations. Specifically, we will address issues pertinent to pediatric cardiac care. Since pediatric cardiac care is one example of highly specialized, multi-disciplinary, resource, and capital intensive care, lessons pertinent to pediatric cardiology are probably germane to many other similar super-specialized fields. Because of the practice locations of the authors, this essay will use specific examples using the US as the model for a high-income country and India as the model for a LMIC.
In a prior editorial, one of us explored issues pertinent to delivering pediatric cardiac care in a situation with limited resources.  However, it is becoming clear that resources are not limitless even in the developed world. Current estimates are that in the US, 17% of gross domestic product (GDP) spending is on healthcare (World Bank Data, http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS), viewed December 10, 2014). It was the notion that the trend of increasing healthcare cost was unsustainable that led to the passage of the Affordable Care Act (ACA). In our own field, a single infant with Hypoplastic Left Heart Syndrome (HLHS) being treated through the Norwood-Glenn-Fontan pathway incurs an in-patient cost of around 375,000/-$.  A single heart transplant for a child with Hypoplastic left heart incurs in-hospital costs of around 580,000/-$. 
In the US, it is now recognized by experts that not only is the price tag for healthcare too high but also that the quality of healthcare delivered is often low. The elimination of waste and attempts to deliver higher quality of care at lower cost (deliver "value") has become the mantra of the current era. Furthermore, it is clear that there are wide geographic variations within the US with respect to the cost and the quality of care, with no correlation between the two.  Experts in healthcare analysis regularly mine data from such variations to expose areas for potential improvement. While such lessons learnt have much value, there are further lessons to be learnt from LMICs since they represent an even greater degree of variation from the high-cost-low-quality care in the US.
LMICs represent an extreme situation when it comes to delivering highly specialized care. A useful analogy would be research conducted by a clothing manufacturer to develop clothing able to withstand extremely cold weather. While research tests conducted by placing the fabric or the piece of apparel in cold temperatures in artificial conditions may give some useful information, they are likely to be much less beneficial than asking an Everest expedition to use the clothes and report back on their real-life ability to function at extreme conditions.
In a LMIC like India, day-to-day realities of the cost of expertise, capital, and supplies necessitate innovation.  Choices have to be made and waste ruthlessly eliminated. While some of the lower cost of a heart surgery in India can be attributed to lower salaries for the entire team, most supplies such as heart lung machines, medications, vital monitoring equipment, etc. are all imported from the west and are equivalent in cost to the price paid by institutions in the US. How then do select institutions in India manage to survive and even deliver high-quality care at a much lower cost?
The reality is that the salaries of employees, at all levels, but more so for nursing, technical, secretarial, and housekeeping staff, is significantly lower in most LMICs like India. The lower cost of living (except for housing which has risen in price to near western levels in urban parts of India) allows institutions to pay a lower salary. However, this is rapidly changing. The thresholds for minimum wages are being constantly revised upwards with increasing costs of living.
Materials and supplies
It is in the field of materials that most of the day-to-day savings are realized in LMICs. In the west, little thought is given to the disposability of supplies. Disposable needles, scalpels, catheters, intravenous (IV) equipment, chest tubes, etc. form part and parcel of the culture of care. In most instances, it is assumed that disposability lowers the risk of infection. While this is clearly true in some instances (needles), it is not true in all. Especially, highly engineered pieces of equipment (such as electrophysiology catheters and intracardiac echocardiography catheters) need to be scrutinized carefully to see if there are ways they can be re-used by appropriate cleaning and sterilization techniques. The cost of labor to clean such devices may be prohibitive in the west but are reasonable in many LMICs. For instance, catheters used in catheterization procedures are regularly cleaned with water and sterilized, followed by re-use. There is no indication that this form of reuse represents a risk for infection transmission or loss of catheter functionality as long as prescribed safety standards are adhered to. 
As with salaries, administrative costs are minimal in India. Few patients have health insurance and even for those who do, the cost of administering such insurance is low. Most patients either have to pay out of pocket or depend on the largesse of charity or governmental institutions. Currently, in the US, hospital administrative costs are said to be around 25 cents for every dollar spent on healthcare.  This is an important area for cost-cutting as there is no direct patient benefit from this activity.
One clear way to make things affordable is to have a higher volume. Low-volume centers utilize the same personnel and facilities to care for fewer patients, which limits their ability to be economically viable. At present, the sheer volume to patients in India with the paucity of highly specialized care centers makes this a no-lose proposition, especially in urban India. Whether this will remain so in the years ahead will need to be seen. It will be a challenge for a dynamic healthcare market such as India to maintain profitability as patient volume falls due to the availability of more centers. While volume cannot be artificially increased in the west (attempts to do so in the UK by consolidating centers were successfully challenged), the market itself may achieve such consolidation. Data from the Society of Thoracic surgeons in the US clearly shows that higher volume centers are able to achieve better results overall. While the reason for this may be disputed, the fact remains that it is so. In days to come, as insurance companies (and patients + their families) seek value in terms of better outcomes and lower cost (lower length of stay for instance), this could lead to a movement of patients away from centers that perform low numbers of heart surgeries leading to natural consolidation.
It may be true to say that in India, and many LMICs, facilities looking to deliver affordable tertiary care are built with only one aim: Lower cost without compromising cleanliness and infection control. This is unlike the US, where esthetics are a major additional consideration and consume substantial investment costs. Lowering the cost of facilities and focusing less on expensive investments to enhance esthetics may be trend for the future. Additionally, it may be possible to explore low-cost facilities that also retain esthetic appeal.
While the above factors may be important in terms of lessons the west can learn from LMICs, there are other important areas for learning and collaboration.
Pediatric heart programs in LMICs may be able to contribute significantly in the training of physicians in the west. For a long time now, it is an accepted fact that doctors from LMICs come to the US to train in highly specialized fields of medicine. They are exposed to the newest technology and the latest techniques and bring these ideas and techniques to their own country to help care for patients. However, it is also a fact that tertiary care specialty clinics and hospitals in the developed world deal with lower patient volumes overall than centers in LMICs. This is a resource and an opportunity that could be used by trainees from the US going to India to learn. They could observe and learn to do things (particularly procedures for instance) in a shorter time frame because of the volume of patients they would be exposed to. Furthermore, they are likely to see conditions at much different stages of their natural history. For instance, it has become rare to see patients with Eisenmenger's syndrome in the developed world; however, such patients are still commonplace in India. There is tremendous value to seeing patients with conditions one can only read about in textbooks. No amount of reading can replace the direct impact of witnessing such patients and the ways they are cared for. Another important benefit from spending part of their training in a country like India would be to develop the mindset of value and to imbue the importance of avoiding waste from direct experience.
Collaboration in research can be a major area of partnership for the two sides. While ideas can come from either side, specific research expertise is unevenly distributed. Research funding is harder to obtain while personnel costs for data gathering and analysis is cheaper in LMICs. Collaboration would be a major win-win proposition for both sides. It goes without saying that for the results of such research to be accepted worldwide, the same level of scrutiny to maintain ethical standards would have to be adopted by LMICs.
Twinning and mutual consultancy
Twinning of institutions with regular interactions between participants from both sides can be a powerful way to build trust and mutual respect. It has the potential to use the other side's expertise to refine one's processes. We can visualize a time when experts in pediatric cardiology from India could visit an institution in the US and help identify areas were unnecessary tests, treatments of processes are raising the cost of care for no appreciable patient benefit.
Recognizing the painful consequences of rapidly escalating health care costs globally, there are perhaps valuable lessons that can be learnt from the practice of pediatric cardiac care in the resource poor environments of LMICs. Additionally, these programs offer unique opportunities for clinical training and research in pediatric cardiac specialties, given the declining patients volumes in many centers of high-income countries. National and international societies should now work on a framework for facilitating the exchange of ideas and personnel between leading programs in high-income counties and those in LMICs.
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