The demand for effective care for cardiovascular diseases will exert major economic pressure on health systems in developing countries in the years ahead and will further threaten social order and structures in these countries, unless innovative and ingenious approaches are identified to sustainably mitigate the circumstances.
In 2005, we embarked upon our mission to improve access and quality of cardiovascular care to the people of the Caribbean with the perspective that the current global imbalance in the availability of modern cardiovascular care has created an exploitative system which is morally unacceptable. Citizens from low resource nations expend considerable financial and emotional capital to access high quality cardiac care in high resource nations, further depleting limited reserves from the lower resource nations.
We entered the local market to become the leader in cardiac care in the region, assuring patient satisfaction and improving operational efficiency in the delivery of sustainable world class cardiovascular care. Since we began our journey in of healthcare Jamaica we have encountered and have learned to negotiate a myriad of structural, institutional and behavioral barriers that impede the development of sustainable, high-quality health service programs locally. Our experience of healthcare in Jamaica provides a useful roadmap that could be beneficial to others that may seek to develop similar programs in a developing country.
A DIFFERENT ENVIRONMENT
We encountered an environment where most of the services we proposed were not offered anywhere in the English speaking Caribbean. Residents of these countries have long depended on facilities in Florida to access these services at exorbitant rates. More significantly, only the few elites with means and the access to the USA had any opportunity to do so. The majority had no options. Interestingly, that existing order was widely accepted as the natural order of things.
Our plan, therefore, meant that the order of things would have to change. The old paradigm was not consistent with development. We had to change things to grant access to high quality cardiac care to all. Of course, change as a concept is always a controversial proposition anywhere. Entrenched interests that benefited from the existing status quo were predictably uncomfortable with the change we were bringing and resisted any change because of the uncertainties that change tends to bring.
We encountered a completely different culture and mode of thinking. The paternalistic nature of the local healthcare landscape had created an exaggerated asymmetry of general health-related information. Patients depended solely on their doctors as the source of information for all their health-related concerns and few exhibited the seemingly natural curiosity to seek alternative opinions or more advanced diagnosis and treatment options that have become widely available as medicine and technology advances.
Second opinions generated significant discomfort and covertly discouraged and so were not standard for most patients. The few patients that expressed interest in second or alternative opinions met with displeasure from the medical establishment.
We also encountered significant bureaucratic hurdles in securing the necessary resources to establish our operations. We encountered disjointed and unwieldy approvals processes which added significantly to our risk exposure and general cost of doing business. These hurdles arose partly because of the high dose of skepticism, and partly because of the complexity of the operations we proposed.
Also, unfortunately, the one dimensional approach of multilateral and international agencies to health development in developing nations have made people in many developing countries comfortable with the erroneous and misinformed thinking that CVD and other related non communicable illnesses are not a threat to the population. This thinking of course is illogical, particularly as developing countries continue to adopt western lifestyles and habits.
The rising prevalence of cardiovascular diseases in developing countries is evidently linked to changes in lifestyle and diet, rapid urbanization and increase in the prevalence of traditional cardiac risk factors like obesity, hypertension, diabetes and smoking in these countries. Generally ignored was the fact that the prevalence of Hypertension in many Jamaican communities exceeds 40 per cent or 2 in 5 adults.
Similarly, Diabetes, another independent risk factor for CVD, affects an estimated 20% of the local adult population. To reverse this trend therefore, it is imperative that we reshape or rethink our assessment of the scope of cardiovascular diseases in developing countries like Jamaica. There must be a paradigm shift.
The economic impact of cardiovascular diseases in developing economies is devastating, largely because working-age adults account for a high proportion of the CVD burden. In the Caribbean and South America, diabetes and cardiovascular disease will be responsible for three times more deaths and disability by 2025, affecting mainly individuals in their mid-life years, disrupting the future of families, undermining social structures and depriving nations of workers in their most productive years, thus precipitating economic decline and underdevelopment.
The epidemiologic transition taking place in developing countries with the rising tide of cardiovascular diseases presents a unique opportunity for innovative thinking to create affordable and sustainable solutions to meet the demand in these countries. This requires rethinking of our current mode of operation and smart use of technology, leveraging technological advances to take advantage of new market opportunities.
Accessing financing and favorable terms of trade was yet another significant hurdle that we encountered in our quest for sustainable healthcare development. Most multilateral agencies seemed willing to provide basic aid to support short term “medical missions” to developing countries but uninterested in financing sustainable healthcare development. This is an issue of mental state and narrative. For some reason, the idiocy that all developing countries need is “dependency aid” has taken deep roots and is difficult to shake from the collective consciousness.
Some of this thinking derives from deep-seated attitudes that devalue low resource nations and assume that certain levels of excellence are beyond the reach of these nations. The thinking has become so dominant and entrenched that well-meaning individuals with laudable and good intentions have unfortunately developed a mindset that encourages them to look at development in low resource economies through a dependency and subservient framework, and discourages them from thinking in the broader context of meaningful and sustainable development.
CHANGING THE PARADIGM
We were determined to change that paradigm because we recognized that essential ingredients of sustainable development must include relevant education and appropriate use of technology. We designed our program to make maximum use of the advances in technology focusing on multi-modality systems that are readily adaptable to low resource settings, easily serviceable and durable enough to withstand the stresses of the local environment.
We focused on skills acquisition and training of local talents to improve internal capacity and minimize the need for dependency on foreign entities. We trained our local staff in a way to empower them to believe in their abilities and to be change agents rather than to absorb foreign concepts without local content or relevance.
We believed and still believe that in order to bridge the accessibility gap between the rich and poor nations of the world, the poorer nations must be granted access to modern technology through provision of affordable and sustainable technology solutions that are appropriate and adaptable to their environment. Technology application must have defined objectives that support national development priorities and goals.
Policy direction should aim to encourage students who undertake learning technologies that improve outcomes and quality of life. This is one way to retain talent within countries and encourage brain gain rather than brain drain. This will build internal capacity and put nations on a progressive path to development and out of poverty and dependency. We remain resolute that developing nations can only rise through sustainable investment and development which includes relevant education, appropriate technology and infrastructural development, private sector investment and good governance.
Through the successful execution of our business model in healthcare, we have shown that structural and behavioral barriers to development can be overcome with careful planning, smart design, and appropriate use of technology — while concurrently boosting internal capacity through training and skills transfer — sustainable and affordable high-quality cardiovascular care, anchored on aggressive prevention and treatment strategies, can indeed become a reality in low-resource economies.
About the Author
Ernest Madu, MD, FACC – Dr. Madu is the founder of the Heart Institute of the Caribbean (HIC) which started operations in Jamaica in 2005 and the Heart Institute of West Africa (HIWA) which is currently in development in Nigeria. HIC is the regional center of excellence for cardiovascular care in the English speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region.