|Year : 2013 | Volume
| Issue : 4 | Page : 212-218
Aren't technological choices central to designing health systems?
Professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
|Date of Web Publication||18-Dec-2013|
Professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi - 110 067
Source of Support: None, Conflict of Interest: None
| Abstract|| |
This paper argues that delivery of technology-based preventive, promotive and curative care is one of the central tasks of any health-care system and therefore it forms one of the central pivots for rational structuring/re-structuring of a health-care system. The development of our public health system has, historically, adopted health technologies (HT) uncritically and thereby not explicitly developed institutional mechanisms to assess them for rational choice. Determinants of HT policy choices and structuring of a service delivery system based on that are discussed with examples of modern low cost HT, technologies of codified health knowledge systems other than the modern and local health traditions. Various forms of institutional structures for HT assessment and R and D using a comprehensive primary health-care approach are suggested.
Keywords: Health systems design, Health technologies, Health technology assessment, Local health traditions, Low cost health technologies, Traditional medicine
|How to cite this article:|
Priya R. Aren't technological choices central to designing health systems?. Indian J Public Health 2013;57:212-8
| Introduction|| |
Universal access to health-care (UAHC) is about getting rational health-care to all regardless of the ability to pay, geographical location and social position. The primary, secondary and tertiary level services are demarcated by the level of technology to be delivered. The technology is linked to the kind of infrastructure and health-care providers needed at various levels, all which translate into costs of health-care.
Conversely, the nature of technology developed is also influenced by the prevailing nature of health services; for instance, are they more specialist or generalist based, how much emphasis is given to self-care. Other factors, of course determine the development of technologies, such as the dominant perspective on knowledge and scientific research, the institutional architecture for health research and development and the patent and knowledge management regimes, among others. Interests of the health industry and its financiers, international and national health policy makers as well as professional interests of health-care providers and researchers are its other important determinants. Therefore, it is essential to envision the nature of health technology (HT) and consider its various dimensions when creating a system for universal access.
| The Range of HT|| |
HTs include wide range that are meant for prevention, diagnosis, treatment or palliation of suffering and finally rehabilitation. These also include those used for environmental interventions such as for anti-mosquito activities, water purification systems and sanitation systems.
Besides these technologies based predominantly in modern medical science, there are the traditional practices that require natural raw materials that are processed and used in specific ways to become of therapeutic or preventive value. Taking local herbs for specific health benefits is use of HT as much as buying medicines off a chemist's counter is. There are alternatives with different levels of technology, e.g., boiling of water or using a water filter; boiling glass syringes or using auto-disable syringes.
| Historical Review of HT in Health Systems Design|| |
The Bhore Committee report, that had in 1946 provided the blueprint for the development of a system for UAHC, did not explicitly discuss HT as the basis for its long and short term plans for the health service system. However, it is implicit in the three tier structure of the service delivery system, as set out in the principle that, "The closer the health service can be brought into contact with the people whom it serves the fuller will be the benefit it can confer on the community. The scheme must therefore provide for the creation of a large number of units each including within itself only such proportion of the population as can be catered to adequately by the staff that will be employed. These units will of course be able to offer services of only a limited nature. They must, therefore, be supported by a series of appropriate organizations in an ascending scale of technical efficiency in order to secure for the people all the benefits of modern health practice."  Most significant in shaping of the health services was the unquestioned assumption that they were meant to take the benefits of modern medical science and technology to the masses. The report reflects the excitement with modern medical technologies of those times, the newly discovered antibiotics, anti-malarials and insecticides. Although it repeatedly emphasises what are today widely referred to as social determinants of health, the plans ignored the politics of knowledge and technologies within health-care.  Dissenting notes of members do, however, reveal that related issues were debated and some recommendations were made without consensus.  The same debates are also reflected in other committee reports of the time.
The Bhore, Sokhey and Chopra Committees reflected three different approaches to HT. State-of-the-art medical technologies with the "best" doctor as the only acceptable provider of the technologies was the Bhore Committee approach. Starting with the delivery of basic modern technologies by a trained layperson for equitable coverage, meanwhile building systemic capacities for more sophisticated technologies, was the Sokhey Committee approach.  Use of other than modern medical technologies and knowledge for preventive and curative action as available in the local context was the Chopra Committee's integrative approach.  In the following decades, the Mudaliar Committee promoted the first approach,  Shrivastava Committee the second  and Udupa Committee the third.  Internationally, the Alma-Ata declaration's primary health-care (PHC) approach espoused the second and third in the late 1970s.  Since the late 1990s, complementary and alternative medicine (CAM), traditional medicine (TM) and self-care have been increasingly recognized as saviours from the biological, social and cultural iatrogenesis that modern medicine's technologies bring with them. They have been promoted by World Health Organization (WHO) as components of the strategy to revive the PHC approach.  However, the parallel process of discussing universal health coverage (UHC) does not even mention CAM or TM.  In India, the Community Health Workers (CHW) scheme as well as the more recent Accredited Social Health Activists (ASHA) follows the PHC perspective. The National Rural Health Mission (NRHM) adopted the strategy of "mainstreaming Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) and revitalising local health traditions" (LHT), however its implementation involves the mainstreaming of AYUSH providers rather than their knowledge systems.  This is contrary to the increasing use of AYUSH technologies for their holistic approach-such as herbal products, Panchakarma procedures and Yoga, or their commercial value recognized by the pharmaceutical and health tourism industries. 
| Shaping of the Health Service System in the 21 st Century: Overcoming Iatrogenesis and Exclusion|| |
Now, over six decades after the Bhore Committee, as we design systems for UAHC, with much experience of use of HTs and recognition of their benefits, limitations and negative effects, we need to give HT assessment and choices more explicit thought. Iatrogenesis-biological and also social and cultural-was highlighted by Illich's well-known work. 
"Iatrogenesis can be direct, when pain, sickness and death result from medical care, or it can be indirect when health policies reinforce an industrial organization, which generates ill- health; it can be structured when medically sponsored behavior and delusion restrict the vital autonomy of people by undermining their competence in growing up, caring and ageing; or when it nullifies the personal challenge arising from their pain, disability and anguish." 
Studies in the USA, using data from its medical "adverse events reporting system," find that prevalence of iatrogenic causes of morbidity and mortality are excessively high. Estimates suggest that it is the third highest cause of death after cardiovascular disease and cancers. Of these deaths, about half are attributed to effects of prescription medication and the other half to "medical errors" , Patient's misery is compounded by medical costs as the number one cause of bankruptcy in the USA, with 90% of those thus affected being middle class and 75% of them having medical insurance!  In India, where reporting of adverse reactions is non-existent and medical practice is pervaded by unethical practices and negligence, the rate of iatrogenesis per medical intervention is likely to be much higher than in the USA.  With increase in access to medical services, the prevalence can be expected to rise.
| Harnessing Existing Resources to Overcome Over - Medicalized Mindsets|| |
Without a general policy for assessment and selection of HTs, we have specific policies being formulated for specific HTs. For instance, we have a pharmaceutical policy that is formulated by the chemical and fertilizers ministry from the industrial angle. The draft vaccine policy also seems to override the precautionary principle and instead safeguards interests of the industry by assuring public funds to vaccines that are still to be discovered let alone be tested for efficacy and safety.  There is a separate injection practices policy, a blood banking policy, etc. but no overall policy or institutional structure to assess rational use of HTs in the light of evidence of efficacy and safety.
Therefore now, as we attempt UAHC, is the time to examine the issue and design services that will minimise iatrogenesis and unnecessary expenditures. However, there are several positives within the Indian situation that can be harnessed if there is the will.
In the continuum of care from primary to tertiary, the primary level of care can be further divided into the home, community based and institutional services. In TM, there are similarly three levels. The home remedies, folk practitioners, and practitioners of codified systems who have learnt through the guru-shishya parampara - all three constitute the LHT that work within home and community. The college graduates of the codified knowledge systems of (the official acronym being AYUSH) form the secondary level and then their specialists a tertiary level. For all "pathies," each level implies a set of services with infra-structure, human resources, diagnostic facilities etc. in consonance with it. What is obvious is that each higher institutional level can provide the services of the lower level. Each institutional level progressively reduces the layperson's control and places it in the hands of the expert, introduces much greater costs for the service system as well as the patient and often only minimally contributes to improved indicators of health and well-being at a societal level.  This is not to say that secondary and tertiary care can be ignored, but that their perceived benefits and use must be restricted to an optimal level. The criteria for technological choices that have been adopted by the PHC approach are efficacy, safety, affordability, accessibility and acceptability. Hailing of oral rehydration solution (ORS) for diarrhoeal diseases in the 1970-80s as the discovery of the century was based on the fact of it being in people's hands and therefore universally accessible.  Indicating the shifts since the mid-1990s, United Nations Children's Fund has been promoting commercial packets of ORS, raising debates about their cost-effectiveness in real life settings versus home-made rehydration fluids. , The second approach was of improving water supplies in terms of quantity and quality to create enabling conditions for prevention. Now we are looking to rota virus vaccination. 
Similarly, text books of medicine place diet control and exercise as the first line of treatment for those diagnosed with diabetes in early stages, as do various forms of TM. Several herbal remedies have been traditionally used across the world for it. However, systematic reviews of studies on effectiveness of life-style changes and herbal therapies conclude showing "possible beneficial effect, but the study methodology was not strong enough."  On the other hand, chemotherapy for diabetes type-2 has grown rapidly in the past decade with a plethora of clinical trials  and a general practice among diabetologists that at least one drug should be started at first diagnosis, along with diet control and exercise. 
Each technology may have its rational use and place within a health-care system. We need to engage in a holistic assessment to decipher that role in each context. Existing practices and perceptions of the communities regarding the various technological options are important if "people's access," "people's empowerment," "participation" and "ownership" are to be more than mere rhetoric. The high utilization of private sector services and the large number of doctors being in the private sector is the basis of designing their "contracting in" as PPPs.  However, that as many people use TM and self-care and TM providers cover populations most underserved by the formal system is not factored in while making technological choices and designing systems. 
A recent multi-method 18-state survey of AYUSH services in the public system found that demand for AYUSH services was high wherever they were available with reasonable quality (e.g., in Tamil Nadu an average daily PHC out-patient department was of 120-150 for Allopathy and 50-70 for AYUSH). Even 77% of allopathic doctors perceived some value in TM and 55% practiced cross-referral to other "pathies." Home remedies and folk practitioners were much in use, with 75% of the related lay knowledge being found valid by AYUSH texts/principles.  This resource needs to be given due consideration. Instead, large surveys on treatment seeking behaviours obliterate this information, e.g., the National Sample Survey Organization classifies resort to TM as "untreated!"  Or the AYUSH doctors are viewed as substitutes for non-available allopathic doctors rather than for the knowledge and technology they can offer.
| Technology Assessment and Choices: The Conflict of Interests|| |
The conflict of perspectives and interests are manifest in any assessment and choice of technologies and so multi-stakeholder assessments have been adopted. There is the need for an "objective" statement of all the "evidence" and views and then a logical decision for the given context based on a set of explicitly laid out social values. The randomized controlled trials (RCTs) and quality adjusted life year assessments are some methodologies developed for technology assessment.  Building on these, an approach adopted in the 1990s is to bring all stakeholders to the negotiating table to thrash out a consensus. The National Institute for Clinical Excellence, has used such procedures to decide what technologies the National Health Service (NHS)-UK will provide.  They do result in some transparency and multi-interest involvement in decision-making and need to be examined for suitability in our context.
A moot issue is, who undertakes the review and who acts as referee for the negotiations? A professional clinical expert on the problem, an ethicist, a non-expert administrator or a health systems analyst?
The gate-keeper role
What level and type of technology and care will be provided by the UHC system is a question yet to be answered. Who will be left out through the process of triage for prioritisation of patients, problems and technologies? How do we ensure optimal level of care will be used appropriately? In the Thai model and the NHS-UK, the primary level care provider is the gatekeeper for people to be able to go to a specialist. With the clinical specialists being in the leadership role, there is only further entrenching of unnecessary use of HT and ever escalating costs. 
| A Comprehensive PHC Approach|| |
Demystification of modern science and technology for the layperson was a goal of the people's science movement and the people's health movement in the 1970s and 80s, along with promotion of rational use of medicines. However, now it seems to have been reduced to training a local person as a CHW. In fact, the high level expert group (HLEG) and 12 th plan steering committee, do place AYUSH as a cross-cutting component, but leave the "essential package of services" to be "decided later"! The inclusion of AYUSH too reflects confusion about its role and the operational steps for its integration. , This ignoring of the technological content at the stage of designing the structure, with only pious hopes about rational drug use, will leave the situation to continue as it is.
An attempt was made, based on evidence from the multi-method 18-state survey cited above, to design a health service system for UAHC.  The design therefore started with self-care and home remedies and the requirement of paramedics and AYUSH doctors to validate and strengthen this end of health-care. Then, using some examples of communicable and non-communicable diseases, it projects that, once a certain percentage of illness is dealt with at the home level, a reduced proportion would require moving to the PHC with Allopathic and AYUSH doctors and further to the specialists. This very rough exercise brings down the costs, compared with estimates by the National Commission on Macro-economics and Health that were based only on institutional allopathic services, by over 20%. If costs to the patient are added to system costs, the reduction would be even greater.
The essential drug lists (EDL) and standard treatment guidelines (STGs) facilitate rational use of medical technologies. Therefore, evolving integrated EDLs and rational STGs starting from home remedies and going on to use of local TMs, to primary, secondary and tertiary level allopathic and AYUSH care may be the way forward. A parallel guide for lay people could rationalize the existing pluralism in resort to health-care; when to do self-care, go to a health worker, an AYUSH practitioner, an allopath and when to specialists and hospitals.
However, professional market competition, compulsions of making high-end facilities and infrastructure viable and profitable, act as barriers to rational practice. That is why all studies find a difference between prescribing practices of doctors in the public and private sectors, the latter practicing more irrationally.
Priorities for research and development of HTs
R and D, production, trade, generation of demand, all these are dependent on the perspective adopted. There is enough documentation to show that unethical practices thrive when the agenda is set by commercial interests of industry and research laboratories; unnecessary uses are aggressively marketed, efficacy over-claimed, and evidence of iatrogenesis suppressed.  Transparent research by researcher networks is an option that seems worth supporting, like the open source drug discovery initiative of the CSIR,  as against corporate initiatives.
Innovative high quality low cost solutions
Several instances of developing low cost HTs for common problems faced under local conditions exist in laboratories, hospitals and community health programs across India.  Yet, these do not get promoted within the system or get the recognition they deserve. However, we have an Indo-US joint initiative on "low cost diagnostic and therapeutic medical technologies" to feed the industry of both countries. 
Questioning the evidence of efficacy and safety of AYUSH medicines and procedures is necessary, but we must also seek answers. Studies of efficacy exist and more are needed,  but this blind spot for public health can be opened up to scientific gaze only by examining the evidence for both efficacy and people's knowledge and utilisation patterns. Then arises the question of whether RCTs alone provide meaningful evidence or the multi-method designs are more useful. 
| Conclusion|| |
Thus, this paper argues that rational use of HT is the most vital issue before any health system today if we are to move toward UAHC with optimal increase of the infrastructure and human resources. It is essential for creating affordable and sustainable health-care systems and for minimising iatrogenesis.
HT and knowledge closest to the people can be people-empowering and can take some pressure off from the hard-pressed health-care facilities that strive to provide quality services. Although the HLEG and 12 th plan Steering committee report have highlighted AYUSH, the "package of services" to be delivered is left for later. Neither of them even mention LHT that really comprises of "people's knowledge." Although organically linked to the AYUSH knowledge systems, they represent an entirely different ownership of knowledge and technology. LHTs are even more location specific than AYUSH and dynamic in terms of modifications with changing context and people's experience. These need to be factored into any system of UAHC and made the starting point of all STGs. Institutional structures for technology assessment are urgently needed for optimal use of all available HTs.
Innovative futuristic research in HT requires inter-disciplinary work across the health sciences and social sciences with a public health perspective. Some work is already on in this direction and much more can be facilitated institutionally, for instance by setting up a University of Integrated Health Sciences and Technology that has one college each of the eight recognized systems including modern medicine, an Institute of Local Health Traditions/Folk Medicine and an Institute of Integrated Health Sciences and Technology that can bring different disciplines together on a common platform. India's diversity and pluralism could then be allowed to flower to its fullest to create resources for a world that is looking for affordable and sustainable health care. Without developing a more explicit and pragmatic approach to health technologies, we can only expect ever-escalating financial and iatrogenic costs of health care.
| References|| |
|1.||GOI. Report of the Health Survey and Development Committee. Vol. II. (Bhore Committee). Chapter III Health Services for the People; New Delhi: Manager of Publications; 1946. p. 18. |
|2.||Priya R. Public health services in India: A historical perspective. In: Gangoli L, Duggal R, Shukla A, editors. Review of Healthcare in India. Mumbai: Cehat; 2005. p. 41-74. |
|3.||GOI. Report of the Health Survey and Development Committee. Vol. II. (Bhore Committee). Chapter XVIII on Professional Education, Minutes of dissent; New Delhi: Manager of Publications; 1946. p. 349-55. |
|4.||Report of the Sub-committee on National Health (Sokhey Committee). National Planning Committee Series, Indian National Congress. Bombay: Vora & Co. Pub. Ltd.; 1948. |
|5.||Govt. of India. Report of the Committee on Indigenous Systems of Medicine (Chopra Committee). Ministry of Health, Govt. of India;1948. |
|6.||GOI. Report of the Health Survey and Planning Committee (Mudaliar Committee). New Delhi: Ministry of Health, Government of India; 1962. |
|7.||GOI. Health Services and Medical Education: A Programme for Immediate Action, Group on Medical Education and Support Manpower (Shrivastava Committee). New Delhi: Ministry of Health and Family Planning, Government of India; 1975. |
|8.||GOI. Ayurvedic Research Evaluation Committee (Udupa Committee). New Delhi: Ministry of Health & Family Welfare, GOI; 1959. |
|9.||WHO. Primary Health Care - Report of the International Conference on Primary Health Care, Alma Ata, USSR, September 6-12. Geneva: World Health Organisation; 1978. |
|10.||WHO. Traditional Medicine Strategy 2002-2005. Geneva: World Health Organisation; 2002. |
|11.||First Global Symposium on Health Systems Research: Science to Accelerate Universal Coverage, Montreux, Switzerland. Available from: http://www.hsr-symposium.org/. [Accessed on 2011 Jan 01]. |
|12.||GOI. Second Common Review Mission Report, NRHM. New Delhi: Ministry of Health and Family Welfare; 2008. |
|13.||Harilal MS. Commercialising traditional medicine: Ayurvedic manufacturing in Kerala. Econ Polit Wkly 2009;XLIV:44-51. |
|14.||Illich I. Limits to Medicine - Medical Nemesis: The Expropriation of Health. Harmondsworth: Penguin; 1977. |
|15.||Illich I. Medical nemesis. 1974. J Epidemiol Community Health 2003;57:919-22. |
|16.||Kohn LT, Corrigan JM, Donaldson MS, editors. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; National Academic Press; 2000. |
|17.||Starfield B. Is US health really the best in the world? JAMA 2000;284:483-5. |
|18.||Himmelstein DU, Thorne D, Warren E, Woolhandler S. Medical bankruptcy in the United States, 2007: Results of a national study. Am J Med 2009;122:741-6. |
|19.||Dhikar V, Singh S, Anand KS. Adverse drug reaction monitoring in India. J Indian Acad Clin Med 2004;5:27-33. |
|20.||Puliyel J. Vaccine policy and advance market commitments. Econ Polit Wkly 2011;XLVI:18-9. |
|21.||Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83:457-502. |
|22.||Agency for International Development. Oral Rehydration Therapy: A Revolution in Child Survival. Weston, MA, USA: Oelgeschlager, Gunn & Hain; 1988. |
|23.||WHO & UNICEF. Oral Rehydration Salts: A Joint UNICEF/WHO Update. Geneva: WHO & UNICEF: July 1996, revised March 2002. |
|24.||Werner D, Sanders D. The Oral Rehydration Debate: ORS Packets or Home Fluids. In: Questioning the Solution: The Politics of Primary Health Care and Child Survival. Ch. 7. Palo Alto, CA, USA: Health Wrights; 1997. p. 42-53. Available from: http://www.healthwrights.org/hw/content/books/QTS/qts_ch07.pdf. [Last accessed on 2011 Jan 1]. |
|25.||WHO, GAVI Alliance, PATH. Global use of rotavirus vaccines recommended. News release. Geneva/Seattle, [2009 Jun 5]. |
|26.||Yeh GY, Eisenberg DM, Kaptchuk TJ, Phillips RS. Systematic review of herbs and dietary supplements for glycemic control in diabetes. Diabetes Care 2003;26:1277-94. |
|27.||Gillies CL, Abrams KR, Lambert PC, Cooper NJ, Sutton AJ, Hsu RT, et al. Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: Systematic review and meta-analysis. BMJ 2007;334:299. |
|28.||Nathan DM, Buse JB, Davidson MB, Heine RJ, Holman RR, Sherwin R, et al. Management of hyperglycemia in type 2 diabetes: A consensus algorithm for the initiation and adjustment of therapy: A consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2006;29:1963-72. |
|29.||Peters DH, Yazbeck AS, Sharma RR, Ramana GN. Raising the sights for India's health system-Part-I. In: Better Health Systems for India's Poor: Findings, Analysis, and Options, Health Development Network, Health, Nutrition, and Population Series. Washington DC: World Bank; 2002. |
|30.||Priya R, Shweta AS. Status and Role of AYUSH and Local Health Traditions: Under the National Rural Health Mission, Report of a Study. New Delhi: National Health Systems Resource Centre, NRHM, MoHFW; 2010. |
|31.||NSSO. Morbidity and Treatment of Ailments, 52 nd Round (1995-96), Report No. 441. National Sample Survey Organisation, GOI; 1998. |
|32.||Goodman CS. HTA 101: Introduction to health technology assessment. The Lewin Group, NIH, 2004, updated 2008. Available from: http://www.nlm.nih.gov/nichsr/hta101/ta101_c1.html. [Accessed on 2012 July 05]. |
|33.||NICE. Developing NICE Clinical Guidelines. National Institute for Health and Clinical Excellence, 2012. Available from: http://www.nice.org.uk/guidance/index.jsp?action=folder&r=true&o=37223. [Accessed on 2012 July 05]. |
|34.||GOI Planning Commission. High Level Expert Group Report on Universal Health Coverage for India, 2011. Available from: http://www.planningcommission.nic.in/reports/genrep/rep_uhc0812.pdf. [Accessed on 2012 July 05]. |
|35.||GOI Planning Commission. Report to the Steering Committee on Health for the 12 th Five Year Plan. New Delhi: Health Division, Planning Commission; 2012. |
|36.||Priya R. Conceptualising UAHC 'Bottom Up': Implications for Provisioning and Financing. Background paper for MFC Annual Meet, Jan. 2010. Nagpur: MFC Bulletin; 2011. p. 15-25. Nos. 345-7. Available from: http://www.mfcindia.org. Accessed 30 Apr 2012. |
|37.||Brody H, Light DW. The inverse benefit law: How drug marketing undermines patient safety and public health. Am J Public Health 2011;101:399-404. |
|38.||CSIR. Open source drug discovery. Available from: http://www.osdd.net. [Last accessed on 2012 Jul 05]. |
|39.||Priya R. UAHC with 'Community Participation' OR 'People Centre-stage'? Implications for Governance, Provisioning and Financing. Background Paper for MFC Annual Meet, Jan. 2010. Nagpur: MFC Bulletin; 2011. p. 9-15. Nos. 345-7. Available from: http://www.mfcindia.org. [Accessed 2012 Apr 30]. |
|40.||Department of Biotechnology (India) and National Institute of Biomedical Imaging and Bioengineering (United States) Report of the Indo-US Workshop on Low-cost Diagnostic and Therapeutic Medical Technologies. Hyderabad: DBT & NIBIB; 2009. |
|41.||WHO. Guidelines on Developing Consumer Information on Proper Use of Traditional, Complementary and Alternative Medicine. Geneva: Traditional Medicine (TRM), Dept. of Essential Drugs and Medicines Policy, WHO; 2004. |