Healthcare in Emerging Countries


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Healthcare in Emerging Countries

  1. 1. OR/MS TODAY22 April 2013InternationalO.R.The healthcare sectors in many emerging countries are poised for growth, leveraging economic expansion and a focus on broader welfare policies.Healthcare inemerging countriesByRajib Ghosh, Dr. Amlan Dattaand Kausik LahiriChallenges and opportunities for operations research.Emerging countries are often considered as hot destina-tions for private investments owing to their history ofrapid growth. For example, while most of the developedeconomies experienced anemic growth and in some casesshrinkage during 2008 to 2011, the Chinese economy grew at anaverage rate of 9 percent [1]. During the same time the Indianeconomy grew at near a 7 percent rate and Brazil at close to 4percent. In 2010 China’s GDP of $5.88 trillion surpassed that ofJapan’s $5.47 trillion to become the world’s second largesteconomy after the United States. Brazil’s GDP surpassed theUnited Kingdom to become the sixth largest economy of theworld [2].©Mattmcinnis|Dreamstime.comORMS4002_FTRs_ORMS-FTR 4/5/13 10:00 AM Page 22
  2. 2. The healthcare sectors in those countries are also poised forongoing growth, leveraging the trend of economic expansionand leaderships’focus on broader welfare policies for the peo-ple.However,much needs to be done,especially in ramping uphealthcare delivery infrastructure, access to preventive andcurative care and providing health insurance coverage for abroader population.The latter is particularly lacking in emerg-ing countries,causing over reliance on out-of-pocket paymentfor healthcare services.No country can sustainably grow on a long-term basis with-out ensuring adequate and equitable healthcare delivery to itsmasses. Some emerging countries such as China have madepromising progress in that direction,while many are strugglingto keep up with the rising population burden. This articleexploresthekey issues facing the healthcare systemsof emergingcountries. It also discusses the advent of technology-enabledcare delivery to address healthcare inequities and how the prin-ciples of operations research,if embraced,can help.Population distributionTHE ECONOMIC GROWTH in emerging countries likethe BRICS nations (Brazil, India, China, Russia and SouthAfrica) have created wealth and health divide among the urbanand rural communities. Most of the economic activities beingconcentrated in the tier 1 or tier 2 cities of those countries leftvery few opportunities for the poor in the rural areas to takeadvantage of the economic growth. The high-income middleclass population in these countries are concentrated around afew very large cities, thus creating demand for Western-stylehealthcare in comfortable upscale facilities.Intheabsenceof modernandwell-equippedstaterunhealth-care facilities, private enterprises are stepping in to cater to thisfledgling segment.Luxury hospitals are being built with state-of-the-art diagnostic and therapeutic equipment, imported fromNorthAmericaandEurope,toaddressthisgrowingdemand[3].Disease burdenCOMMUNICABLE DISEASES like AIDS, tuberculosis,malaria, etc. are major contributors to the disease burden inAfrica – mostly sub-Saharan and low-income countries such asBangladesh.In SouthAsia,SoutheastAsia and South America,however, non-communicable lifestyle-related diseases are onthe rise (Figure 1). In India, for example, lifestyle-related dis-eases have overtaken communicable diseases in causing deaths(Figure 2). This is not an anomaly. Rather, it is a reflection ofsocio-economic changes that emerging countries such as Indiaare experiencing as their economy is growing faster than theirWestern counterparts.Most emerging nations have increased their per capitaexpenditure on healthcare, albeit it is still quite low com-pared to the developed countries such as the United Statesor Germany (Figure 3).Many countries provide state-run rudimentary healthcare sys-tems that are free for all,but a substantial percentage of health-care expenses are still out-of-pocket (Figure 5). The share ofprivate sector spending on healthcare is higher than the publicsector counterpart in most of the emerging countries (Figure4).With the uneven wealth distribution in those countries suchpatterns exert enormous pressure on the poverty level of thecountries and overall wellbeing of the population in general.Rural poor sometimes sell their assets to obtain curative health-care in the private centers. Broader principles of 23Figure 1: Burden of disease by cause group and region.Source: WHO 2004Figure 3: Compiled from World Health Statistics 2012.Source: WHOFigure 2: Causes of death in India.Source: Ministry of Health and Family Welfare, GOI, Annual Reportto the People on Health, December 2011.ORMS4002_FTRs_ORMS-FTR 4/5/13 10:00 AM Page 23
  3. 3. health management are mostly lacking among the healthcareproviders of these countries.Key issues in emerging countriesTHE FOLLOWING are key issues impacting healthcaredelivery in emerging countries:Growing disparities in health and wealth: Vast geographi-cal area and huge population with growing disparities inhealthcare access and delivery between the rural and the urbanareas characterize emerging nations, including the BRICScountries. Population pressure is high, and sparse economicactivity zones lead to rapid growth of middle class populationaround a few but huge“megapolises”like Mumbai or Rio deJaneiro.With the increase in affordability among the growingmiddle-class population, sedentary lifestyles and unhealthyfood habits are proliferating,leading to increased prevalence oflifestyle-related diseases such as pulmonary diseases, obesity,cardiovascular diseases,diabetes mellitus,neuropsychiatric dis-orders and cancer around the urban centers.Demand dichotomy: Upwardly mobile emerging countriesare currently facing a dichotomy in healthcare demand – on oneside the countries are trying to provide adequate care to cure andprevent communicable diseases while addressing the demand ofstate-of-the-arthealthcaredeliveryfortheaffluentclasstoaddressthegrowingprevalenceof chronicillnessesontheother.Indiahasclose to 62 million diabetics and 77 million pre-diabetics [4].Those numbers are 92 million and 150 million in China [5].Affluent patients are choosing institutions higher up the valuechain, from nursing homes to big hospitals to“Super Specialty”and tertiary care hospitals. At the same time some emergingcountries like India or Thailand are seeing increased demand forluxury healthcare services from medical tourists visiting fromhigh-cost western countries such as the United States and UnitedKingdom.Withlimitedresourcesattheirdisposal,thisdichotomyis polarizing healthcare systems in the emerging countries wherethe bulk of resources are being diverted toward the private sector,increasingitsshareof healthcareexpenses.Antiquated and sparse infrastructure: Another key issuefacing the emerging countries is the need to upgrade antiquat-ed infrastructure across vast areas,which is both time consum-ing and capital-intensive.Infrastructure-wise,China has madesignificant progress during the last decade.In China,90 percentof the hospitals are currently owned by the state [6]. Theremaining 10 percent that are privately owned mostly cater tothe affluent Chinese and foreigners in the urban areas likeShanghai.But China is very close to the global average in termsof beds and physicians per 1,000 people. The Chinese govern-ment is now focused on upgrading their“mid tier”hospitals tobolster effective healthcare delivery among the masses.Brazil and India are lagging behind the global average ofbeds and physicians with deficient public infrastructure andfunding. Brazil faces overcrowded healthcare facilities andbelow par healthcare delivery even in urban areas.Insufficient capacity of the public healthcare system is drivinggrowth of private healthcare providers in India.India’s globaliza-tion efforts during the last two decades have seen a decline in thegovernment share of expenditure in healthcare,reduction of tar-iff barriers for technology import and attractive tax incentives tosetupoperationsforprivateproviders,bothnationalandinterna-tional. To trounce competition, private healthcare providers inIndiaarerushingintobecominga“bestserviceprovider”byoffer-ing“thebestandthelatest”medicaltechnologies[7].Thisisanal-ogoustowhatweseeinotherBRICScountriesaswell.Lack of health insurance coverage: In most of the emergingcountries the percentage of people with healthcare insurancecoverage is very low with the exception of China. By 2010China successfully brought close to 90 percent of its populationfrom less than 25 percent in 2004 under the purview of threestate-run health insurance schemes. This has helped China’srural population have better access to healthcare. In Brazil 25percent of the population is covered by private insurance.Pub-lic and private health insurance covers about 25 percent of thepopulation in India as well [8].Emergence of new healthcare delivery modelsINFORMATION AND COMMUNICATION technol-ogy-based services are revolutionizing healthcare deliveryOR/MS TODAY24 April 2013Global healthcareISSUESFigure 4: Compiled from World Health Statistics 2012Source: WHOFigure 5: Compiled from World Health Statistics 2012.Source: WHOORMS4002_FTRs_ORMS-FTR 4/5/13 10:00 AM Page 24
  4. 4. The anatomy of a decision.Today, with computation times compressed from days to seconds,Operations Research is becoming accessibleto not only scientists and engineers, but business leaders as well — fundamentally redefining how real-worldcompanies meet their performance goals. What’s more? We’re helping companies leverage customer, supplier,and partner data to enable integrated, adaptive planning and execution strategies that allow them to anticipate,control, and react to disruptions and volatility at the business point of impact.Together with the advanced analytics and consulting expertise of IBM Research and Global BusinessServices®, IBM’s industry-leading ILOG® Optimization and Supply Chain Management technology is allowingbusinesses to take the guesswork out of decision making.Already, over 1,300 corporations and government organizations are using IBM ILOG CPLEX OptimizationStudio, featuring a complete toolkit for mathematical and constraint programming, a powerful IDE, modelinglanguage, APIs and 3rd party connectors. And now with a connector to IBM SPSS Modeler, IBM offers anintegrated toolkit bringing together predictive and prescriptive analytics capabilities.IBM,theIBMlogo,,SmarterPlanetandtheplaneticonaretrademarksofInternationalBusinessMachinesCorp.,©InternationalBusinessMachinesCorporation2010.Smarter technology for a Smarter Planet:A smarter business needs smarter software, systems and services.Let’s build a smarter planet. 4/5/13 10:00 AM Page 25
  5. 5. Global healthcareISSUESin the emerging countries. While we see many adoptionbarriers of those services in the Western world, emergingcountries are more open to utilize modern technologiesto alleviate their pain. By digitizing patient informationand utilizing remote services via telemedicine, healthcareproviders are improving patient-provider interaction aswell as speed of information dissemination. Mobilehealthcare through satellite services connected to urbansuper specialty hospitals and ambulatory centers arebreaking down access barriers for the masses.In India, the government and private healthcareproviders like Apollo and Narayan Hrudayalaya havetaken major steps toward scaling up both informationdigitization and the spread of telemedicine across thecountry. In fact, telemedicine is now being utilized forremote consultations between India-based physicians andmedical tourists in the developed nations prior and aftertheir visits for medical procedures. Electronic medicalrecords are being used to capture episodic interactions toshare across various general and specialty care centers ofthe same provider network. This is a huge step forward.However, data liquidity among different providers, whichrequire collaboration among competing organizations, isstill not possible.We anticipate that absence of strict data privacy legislationsand public sensitivity around that topic in the emerging coun-tries will lead to quicker adoption of data interchange amongdifferent providers compared to what we witness in the devel-oped countries. Acquisition of digitized data is the first steptoward improving efficiency of healthcare delivery,responsive-ness and effective resource management practices. Once databecomes available, analytic tools can be deployed for generat-ing such insights.Application of O.R. in healthcare projectsOPERATIONS RESEARCH (O.R.) helps organizationsmake decisions based on models of reality constructed withquantitative and qualitative data.Data needs to be acquired byemploying systemic and scientific techniques that if necessarycan be replicated. In healthcare, O.R. can help provider orga-nizations and policy-makers improve outcomes of care pro-grams that are designed to preventillness in specific settings and/orpopulation cohorts. O.R. can alsohelp decision-makers assess feasi-bility and optimization of certainclinical intervention strategies oradvocate policy changes. Toachieve the best results, O.R. prin-ciples should be prioritized,designed, implemented and repli-cated within national health pro-grams and institutionalized as anessential component of monitor-ing and evaluation efforts.Unfortunately, the application of O.R. is not common inhealthcare delivery settings of emerging countries. For exam-ple, the Global Fund to Fight AIDS, TB and Malaria allows 5percent to 10 percent of each grant for monitoring,evaluationand O.R. However, based on recent estimates, projects budgetan average of 3 percent for O.R. and actually spend consider-ably less [9]. Except for AIDS programs where a good deal ofO.R. modeling is utilized, the disparity between O.R. budgetand actual spending remains an issue. Interviews, question-naires and observations are used but little to nothing is done onmodeling or application of analytics. This can be attributed toa lack of O.R.knowledge and skills in emerging countries.For-tunately global organizations such as the World Health Orga-nization (WHO), International Union Against Tuberculosisand Lung Diseases (IUATLD) and Medicins Sans Frontiers(MSF) are taking notice of this shortfall and instituting train-ing and capacity-building initiatives. In countries like Indiapolicy-makers and national organizations such as the Instituteof Health Management Research (IIHMR),International Insti-tute for Population Sciences (IIPS) and Public Health Founda-tion of India (PHFI) are also working to fill this knowledge gap.In Bangladesh similar work is ongoing, led by organizationssuch as BRAC University.Following are a few examples where principles of O.R.havebeen applied in healthcare delivery projects in low-incomecountries:1. The Indian Institute of Health Management Research(IHMR) led a project named “Monitoring andEvaluation of Technical Assistance for StrengtheningHealth of the Rural Poor (METASHARP)” [10] inAfghanistan in collaboration with the Johns HopkinsSchool of Public Health. The project was designed toconduct performance assessment of all health centersin Afghanistan and create a balanced scorecard basedon extensive data analysis utilizing principles of O.R.The project used various scientific investigations andmodeling techniques based on quantitative andqualitative data. A balanced scorecard for 2009-2010was completed, and in 2010 a major exercise wasundertaken to revise the scorecard based on thechanging healthcare situation in Afghanistan.OR/MS TODAY26 April 2013Fig 6: Compiled from World Health Statistics 2010.Source: WHOORMS4002_FTRs_ORMS-FTR 4/5/13 10:00 AM Page 26
  6. 6. 2. The Department for International Development(DFID) ran a five-year project in Bangladesh toaddress “health and killer diseases” and “improvingaccess to healthcare” using O.R. [11].3. The Bangladesh Rural Advancement Committee(BRAC) ran the “Saving Newborn Lives” (SNL)initiative in rural Bangladesh communities using anO.R. approach to strengthen safe delivery and essentialnewborn care at the community level [12].Roadmap for O.R. in healthcare deliveryHEALTHCARE DELIVERY in emerging and low-incomecountries can benefit significantly by the application of O.R.andanalytics. The latter can only be applied if systemic data collec-tion and storage are ensured. Application of broad-based ana-lytical frameworks might take many years, and different coun-tries are at different levels of maturity at this time. However,following are six key areas in healthcare delivery that are mostcommonly applicable to the emerging countries and where thebiggest impact of O.R.can be realized:Improve access to medical products: O.R. principles canstrengthen health systems to overcome barriers to accessaffordable, good quality, efficacious and safe medicines, vac-cines and other medical technologies for communicable andnon-communicable diseases.Improve hospital or clinic efficiency: Every hospital orclinic in emerging countries needs to do more with less. O.R.can help them to improve quality assurance,to design an effec-tive medical informatics system, to schedule scarce and high-demand resources like emergency room or critical equipment,to model resource availability and utilization and, in somecases, to diagnose diseases more efficiently.Improve emergency service efficiency:Emergency ambu-latory services such as air ambulances wherever available canrely on O.R. to keep response times quick and determine ade-quate fleet levels.Increase effectiveness of clinical interventions:Millennium development goals for health, nutrition andpoverty reduction can be accelerated by application ofO.R. principles [13].Prevent, control and eliminate communicable diseases:Adoption of O.R.principles can help low- and middle-incomecountries progress toward universal healthcare by 2020,as wellas prevent,control and subsequently eliminate communicablediseases like tuberculosis and malaria by 2040 and make theworld AIDS free by 2060 [14].Build equitable and effective healthcare systems: Aboveall O.R. can help build a global health research culture andfacilitate development of equitable and effective health systemsenabled by evidence-based policy-making,knowledge transla-tion and practice [15].SORMSRajib Ghosh ( is an independentconsultant and business advisor with 20 years of technologyexperience in various industry verticals where he had seniorlevel management roles in software engineering, 27R E F E R E N C E S1. Gougen, F. et al, “Global Wealth Creation: The impact on EmergingMarket’s Health Care,” 2012.7. Winnie Yip and Ajay Mahal, “The Healthcare Systems of China and India:Performance and Future Challenges,” Health Affairs, Vol. 27, No. 4, July2008, pp. 921-932.8. “A Critical Assessment of the Existing Health Insurance Models in India,”PHFI Report, 2011.9. “Saving Newborn Lives in Rural Communities – Learning from the BRACExperience,” BRAC Research Report, 2005.13. DFID, 2007, “DFID Research strategy 2008-13,” working paper series:Better Health, DFID and R4D.14. Pardee Center, 2011, “Improving Global Health: Forecasting the next 50years – Patterns of Potential Human Progress,” Vol. 3, Chapter 8, OxfordUniversity Press, 2011, New Delhi, pp. 142-145.15. Theobald, S. et al, “Towards building equitable health systems in Sub-Saharan Africa: lessons from case studies on operational research,”Health Research Policy and Systems, Vol. 7. No., product management and business andstrategy development. Ghosh spent a decade in the industry as part of a global ecosystem of medicaldevice manufacturers, medical software companies andtelehealth and telemedicine solution providers. He’s heldsenior positions at Hill-Rom, Solta Medical and BoschHealthcare. His recent work interest includes public healthand the field of IT-enabled sustainable healthcare delivery inthe United States as well as emerging nations.Dr. Amlan Datta ( is a physician, publichealth specialist and an associate professor at the Institute ofHealth Management Research (IIHMR), Kolkata, India. He hasa Ph.D. in public health from Jawaharlal Nehru University(JNU), New Delhi, India. Prior to joining IIHMR, Dr. Dattaworked with the government of India and WHO first in theNational Polio Surveillance Project and later with the RevisedNational Tuberculosis Control Programme for more than adecade. His research areas include operations and healthsystems research, health and hospital management, primaryhealth care, quality issues in health care, health regulations,health financing and health informatics.Kausik Lahiri ( is an associate professorof economics at Surendranath College, University of Calcutta,India. Lahiri has a master’s degree in economics from theUniversity of Calcutta. His current research interests includetrade in health services with a special focus on developingcountries such as India. He has been awarded a teacherfellowship by the University Grants Commission (India) tocomplete his doctoral studies at the Department ofEconomics, University of Calcutta.ORMS4002_FTRs_ORMS-FTR 4/5/13 10:26 AM Page 27