There are large deviations in the standard of health care across developing countries, particularly between the private and public sector. A significant number of people living in India and Indonesia, for example, live on or below the poverty line and the superior practice of private health care may not be available to them. Hence, the optimum delivery of public health care is critical to all.
While rising income in India has benefited many, allowing access to private health care facilities is still a problem. About 41 percent of India’s estimated population of 1.2 billion people live below the poverty line and lack access to private health care. This puts enormous pressure on the government’s limited resources (as the main source of public health care delivery) because nearly three-quarters of India’s people still live in rural areas.
Hospital treatment is generally free in India, and frequently subsidized. But these hospitals are often understaffed, underfunded and overcrowded. Furthermore, most hospitals tend to be confined to major cities and are not easily accessible to the rural poor. Therefore, the key to improving health services lies in optimizing existing services by bringing them closer to patients while maximizing the efficient use of current public-sector resources.
An unlikely source of valuable insight in this regard may be at hand, known as battlefield medicine. Army statisticians noted that mortality rates for a wounded soldier remained around 25 percent for most of the 20th century. The military looked at methods of decreasing this rate, investing heavily in developing new technologies, but nothing seemed to work.
A breakthrough came when an audit discovered that the lag time between injury and surgery proved to be the principal factor. Reducing this time significantly reduced the mortality rate. The operating theater was moved closer to the front line, but only for immediate life-saving procedures. Patients were later transferred to another hospital, where more definitive surgical treatment could be undertaken, and then finally into a tertiary hospital in the patient’s home state for rehabilitation. This approach dropped the mortality rates to 10 percent, as measured by the battlefields of Afghanistan and Iraq.
This significant reduction has taken place despite improvements in military technologies and weaponry aimed at more efficient killing of combatants and without the aid of other medical breakthroughs. The improved figures, therefore, can only be attributed to these optimized systems. The major lesson learned here was obvious: Bringing treatment closer to the patient saves lives.
If the primary constraint on public health service provision is fiscal, it may not be possible to have the best facilities in every village, so concentrating facilities within a defined area could reduce travel time to more sophisticated facilities while making better use of financial resources.
In India and Indonesia, satellite clinics linked to a nearby town could offer these sophisticated elective services. Additionally, the government could subsidize these clinics to incentivise their existence. If patients need further specialized treatment or more tests, they can be done at a tertiary hospital within the nearest city, which is linked through the satellite hospital near the surrounding villages.
While this may sound like a replication of the three-tiered approach already existing in these two countries, the reality is that a seamless transition of patient care between tiers does not often occur. There is little scope for transition from rural care to more specialized urban care. This is especially true in an emergency setting.
Most rural areas will have a medical practitioner available to perform simple life-saving measures and initiate basic first-line management, but concentration may make it possible that most emergencies can be managed locally, thus saving even more lives. Of course where problems are more complex, the patient can be transferred to a linked tertiary hospital.
Not only would this save lives, but this concentration of resources could facilitate the significant economies of scale with the procurement of supplies and utilization of fixed equipment like CT scanners and X-ray equipment, which can produce more accurate diagnoses. A recent report by the Healthcare Commission in India found that the average cost of scans was 26 percent lower in larger departments, reducing overall costs.
But these issues are not just developing-country related. Britain and the United States have equivalent stories to tell. In Britain, where certain cancer and trauma services are being centralized, only high-volume centers can perform certain operations. Britain has its share of budgetary implications but also potential improvements in patient outcome. Centralized approach to trauma resulted in reductions of 15 to 20 percent in in-hospital mortality, equating to 450 to 600 saved lives annually.
The “trauma-center” approach to emergency care in the United States has led to an emergency-care system that has lowered the death rate from assaults by 70 percent. These figures illustrate the scale of potential gains for developing countries from implementing an appropriate concentration of health care in rural and urban environments.
Since more people live in urban areas than in cites nowadays, urbanization around the world is increasing. Indonesia is one of the most rapidly urbanizing countries in the world. Despite its large rural population, India is increasingly becoming an urbanized country too. Both should welcome means to improve health outcomes, while minimizing expenditures.
Improvements in battlefield medicine have shown how service-delivery efficiency can lower mortality. Appropriate concentration of health care services has led to improved patient outcomes. A combination of such approaches could offer similar benefits for health care delivery in developing countries.
