Course 1: The Complexities and Realities of Global Health

Complex issues are involved with implementing effective global health programs.  These issues arise from the unique barriers that exist in poverty-stricken communities as well as from the inherent complexity of the health care field.  

For example, the provision of health care requires trained health workers and physicians who can appropriately treat and educate patients.  Effective health care cannot merely be delivered without providing the follow-up needed to assure high rates of adherence and resolve potential complications. Furthermore, the developing world presents obstacles to the delivery of health care such as structural barriers to accessing care. In order to improve access to health care in the developing world, we must remember that “delivery” is only part of the solution.  This article outlines the various issues that may arise in global health work and suggests best practices to overcome them.

Patient Barriers to Care

A primary complexity in global health involves barriers to accessing care in the developing world.  For example, although blindness is usually curable, most patients do not receive medical attention. One recent study found that over two thirds of adults in a rural Indian population with low vision, cataracts, glaucoma, and refractive error had never sought eye care,(1) while another showed that 90 % of the people seeking eye care in poverty-stricken areas in Sri Lanka had no previous eye care.(2)

Why is it that visually impaired people do not seek eye care services even when care is available?  The answer to this question is multifold, and it is important to note that lack of awareness about treatment availability and benefits is not the primary problem.(3)  Rather, patients face a variety of barriers that combine to prevent them from seeking proper medical attention. Cost, fear, cultural beliefs, and distance are a few barriers that prevent patients from accessing available health care.

Financial barriers are commonly cited as reasons patients do not follow through with ophthalmic surgery.  In fact, cost has been identified as the most important barrier to the uptake of cataract surgery.(4) In addition to cost, the fear of poor outcomes can be enough to cause patients to forego treatment. This fear is oftentimes exacerbated by a poor understanding of the procedure, or by hearsay of surgeries gone awry, especially by visiting doctors involved with short-term interventions.  Thirdly, cultural beliefs about medicine may influence a patient’s willingness to seek or accept medical care. In cultures where diseases are believed to have non-medical causes, patients do not consider treatment by surgery.  Patients who believe blindness is an inevitable consequence of aging also fail to seek medical care.

Lastly, distance from clinics and hospitals creates a physical barrier to obtaining care, which is not easily overcome due to a lack of transportation services. This is particularly true for those living in the rural areas.Surgical services are much more available in urban areas, while the majority of cataract patients needing care are located in rural locations.  In rural Africa, distance to the hospital was cited by one third of patients as the most important barrier to surgery. (5)

In order for a health care delivery program to be successful, these barriers must be addressed.  This can be accomplished by the provision of transportation via rural outreaches, providing subsidized or free medical care, and utilizing community health workers to educate local people about treatment options.

Culturally Appropriate Education

Complex health care challenges call for a holistic response.  In order to catalyze behavioral changes at a societal scale, health education programs must address the cultural and social dimensions of health care.(6)  This means that healthcare necessities will not be used unless accompanied by effective and culturally appropriate education.  When working in a different cultural and social context, it is necessary to engage with a community “from within” in order to build an environment of trust.  Culturally appropriate education efforts are tailored and framed from the perspective of the target community.  Thus, to develop a culturally relevant education program, one must engage strategically with local culture to look at the way in which culture influences lifestyle and behavior.(7)

Implementing a healthcare education initiative without an adequate understanding of the local culture can be counter-productive, giving rise to more problems than solutions. For example, when working in a new cultural environment, health workers cannot assume that other cultures readily share, or are ready to submit to, their philosophies and belief systems. There are implicit power relations at work in many cultures that can hinder effective health care delivery if they are not taken into account during program planning.

One way to ensure that education efforts are culturally appropriate is to develop programs that are locally led and managed by local healthcare professionals, supported and assisted by community health workers. The Community Health Workers may be family members, friends, or even patients who provide health education, refer people who are ill to a clinic, or deliver social support to patients in their homes.  While they do not supplant the work of doctors or nurses, they are a vital interface between the clinic and the community.  Above all, community health workers are crucial to the success of global health efforts because of their unique understanding of local problems.  Their close community ties allow them to identify areas of need and to effectively navigate potential barriers that others may not be positioned to understand.  By leading education campaigns in their communities and raising awareness regarding health issues, community health workers are more trusted and better able to encourage community members to take charge of their own health.

Local Management

Partnering with local doctors is essential for efficient and effective healthcare delivery.  The needs of the local community are best known by those who have an understanding of the local situation.  Local providers are familiar with the etiologies and distributions of diseases in their communities. They are also aware of regional aspects of public health such as hospital patterns, who has access to care, and how to best distribute resources. Additionally, many Western physicians are unfamiliar with local disease and must rely on the expertise of local doctors to make correct diagnoses and dispense effective treatments.

Integrating local doctors into global health programs is essential for sustainability. A global health program that does not seek to support local healthcare providers can only yield temporary improvements, if any.  Long-term improvements in community health require follow-up care, ongoing care, and broadening the reach of local doctors’ practices so that more patients have access to care year-round.

Failure to involve local doctors in global health programs can yield deleterious results.  For instance, medical treatment without follow-up care can be more harmful than helpful, and foreign medical providers unfamiliar with cultural norms often struggle to communicate with patients.  More importantly, excluding local doctors subverts community trust in local healthcare programs. Dr. Edward O’Neil, Jr. notes that in spite of their expertise, there exists a widespread belief among locals and foreigners alike that local doctors are “inferior clinicians.”(8)  This belief is reinforced when Western physicians refuse or neglect to collaborate with their local counterparts.  Undermining the legitimacy of local doctors can only harm community health.

Medication Management

Other complexities of global health work stem from the nature of health and disease.  Such complexities can be seen in issues of medication management and treatment follow-up.  Years of poor compliance rates for drugs targeted at tuberculosis, malaria, and HIV have led to the emergence of wide-spread drug resistance.  For example, while the prevalence of malaria infections has declined in the developed world, incidences have been increasing in already endemic regions.  In fact, forty-one % of the world's population now lives in areas where malaria is transmitted.(9)  These alarming figures continue despite over a century of malaria control efforts and the current unprecedented amount of funds spent toward such efforts. Ensuring that patients are adhering to drug regimens can prevent the further emergence of drug-resistant parasites.

In addition to stopping the spread of resistance, high adherence rates can prevent the transmission of disease. When patients fail to take appropriate doses at regular time intervals, they increase the chance that they will remain infectious and thus spread the disease to their family and friends. “For individuals living in extreme poverty, adhering to antiretroviral medicine regimens helps them protect the relationships they rely upon to survive”.(10)  Furthermore, non-adherence has detrimental effects to patient outcomes. Research data supports the importance of adherence in post-operative eye-health.(11) Patients who faithfully instilled their non-steroidal anti-inflammatory eye drops after surgery were more comfortable than those who did not use their drops. In addition, those who used eye drops were far less likely to develop Cystoid Macular Edema, a common cause of vision loss after cataract surgery.(12)

In order to address the issue of medication compliance, research is needed to uncover the underlying reasons for adherence failures.  Qualitative studies may uncover the nature of adherence and non-adherence in particular locations.  Proper educational materials may help to increase patient understanding of their drug regimens and members of the community may be helpful in providing follow-up care.  When implementing global health efforts, it important to remember that adherence is a complex issue that should be treated and researched as such.  

Program Evaluation Metrics

Resource limitations often complicate the desired goals of global health initiatives. Thus, it is important to maximize resources by spending funds wisely on programs that work.(13)  Without knowledge of best practices, global health programs may end up spending resources on the quantity of an intervention over its quality and potential impact.  In order to avoid this pitfall, organizations must strive to maximize their resources by measuring the outcomes of their work.

“Sound information on financial and human resources invested in health, health interventions delivered to people in need, and the impact of these efforts on people's health is critical for planning health systems, implementing programs, epidemic response, allocating budgets for research and development, monitoring progress, and evaluating what works and what does not.”(14)

The availability of health information to inform decisions can ensure funding and further the efficacy of global health interventions.  For example, metrics such as output and outcome indicators can enable decision makers and donors to assess progress toward intended goals and best practices. Outputs are defined as the goods or services produced by programs or agencies, while outcomes are defined as the impact on social, economic, or other indicators arising from the delivery of outputs.(15)  Typically, outputs are used to document the amount, quality, or volume of use of the project's products or services.  While outputs are important to track, evaluation approaches need to focus on measuring outcomes that reveal the extent and kinds of impact the project has on its participants.  Impact could be reported in the amount of change in behavior, attitude, skills, knowledge or condition of the target population.

For example, an output would be the number of microfinance loans distributed or the number of loans repaid, whereas the outcome would be the number of microfinance participants who have significantly increased their income or risen out of poverty.  Similarly, job-training programs have an output of the number of people enrolled in the program.  The outcome would be the number of people who were able to get a job due to the training program.  

The dichotomy between outcomes and outputs can be seen in the case of mosquito net distribution.  A Kenyan newspaper, The Daily Nation, reported that many people are using mosquito nets for alternate activities such as making wedding dresses and fishing, especially in the Nyanza Province.  In response, mosquito net manufactures are collaborating with the local government to prosecute people who use the products for purposes other than covering beds.  Dr. Juma, head of malaria control under the Ministry of Public Health and Sanitation remarks:

“This is wrong and totally unacceptable. Bed-nets are supposed to play a noble role of preventing deaths that would be caused by malaria. I think there is need for further sensitization and education for the entire public to understand the importance of sleeping under insecticide treated mosquito nets.”(16)

In this case, the output value was the number of mosquito nets distributed to villagers.  If evaluation metrics merely looked at this number, the program may have been seen as a success.  However, the real success metric is the outcome: whether people used the net in the proper way and whether this led to decreased rates of malaria.  Programs that give out mosquito nets, condoms, and other supplies are common.  While these interventions are popular because they can “help” a lot of people, there is often a discrepancy between their outputs and outcomes as it takes far more than just handing out nets to change behavior.

Conclusion

Global health work is complicated by a variety of factors.  First, the local environment of each target community varies widely, each presenting unique challenges to the delivery of health care.  This means that education efforts must be locally conceived, tailored, and implemented.  Secondly, barriers to accessing care are widespread in developing countries and require innovative strategies to overcome them.  Third, the healthcare field is complex in nature, requiring trained professionals and follow-up care to ensure adherence to drug regimens.  Lastly, resource limitations make it essential to assess the impact of programs via metrics.  In order for global health programs to be effective, these complexities must be recognized, understood and addressed.

Footnotes

(1) Chang, M.A., Condon, N.G., Baker, S.K., Bloem, M.W., Savage, H. and Sommer, A. “The surgical management of cataract: barriers, best practices, and outcomes.” International Ophthalmology. 28.4 (2008): 247-260.

(2) Holden, B.A. “Blindness and Poverty: A Tragic Combination.” Clinical and Experimental Optometry. 90.6 (2007): 401-403.

(3) Donoghue, M. “People Who Don’t Use Eye Services: ‘Making the Invisible Visible.’” Journal of Community Eye Health. 12.31 (1999): 36-38.

(4) Gyasi, M.E., Amoaku, W.M.K., and Asamany, D.K. “Barriers to Cataract Surgical Uptake in the Upper East Region of Ghana.” Ghana Medical Journal. 41.4 (2007): 167-170.

(5) Chang, M.A., Condon, N.G., Baker, S.K., Bloem, M.W., Savage, H. and Sommer, A. “The surgical management of cataract: barriers, best practices, and outcomes.” International Ophthalmology. 28.4 (2008): 247-260.

(6) Ibid.

(7) Thomas, Stephen B., Michael J. Fine, and Said A. Ibrahim. "Health Disparities: The Importance of Culture and Health Communication." Am J Public Health

(8) Edward O’Neil Jr., A Practical Guide to Global Health Service (American Medical Association, 2006), 24.

(9) Burattini, M. N., E. Massad, and F. A. B. Coutinho. 1993. Malaria transmission rates estimated from serological data. Epidemiology and Infection 111, (3) (Dec.): 503-23.

(10) Ware et al. Explaining Adherence Success in Sub-Saharan Africa: An Ethnographic Study. PLoS Medicine, 2009; 6 (1): e11.

(11) Henderson, B.A., Kim, J.Y., Ament, C.S., Ferrufino-Ponce, Z.K., Grabowska, A., and Cremers, S.L. “Clinical pseydophakic cystoids macular edema: Risk factors for development and duration after treatment.” Journal of Cataract & Refractive Surgery. 33.9 (2007): 1550-1558.

(12) Lloyd, B. “The Power of Postoperative Eye drops.” September 2007. Eye On Vision.

(13) Kahan & Goodstadt, IDM Manual. Accessed 15 December 2009.

(14) Ibid.

(15) McAllister, K. 1999. Understanding participation: monitoring and evaluating process, outputs and outcomes. Ottawa: IDRC.

(16) Esipisu, Isiah. "Villagers using bed-nets for wedding gowns." (Apr. 22, 2009). Daily Nation. https://www.nation.co.ke/kenya/life-and-style/horizon/villagers-using-bed-nets-for-wedding-gowns--589592.