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The Obstacle Source
The most critical roadblock to delivering care in the developing world is not money, but an implementation bottleneck.
by Jim Yong Kim

Each year at least ten million preventable deaths occur around the world. Most of these deaths take place in developing countries, usually among children, young mothers, and people with HIV. While more money is always needed, funding isn’t the biggest challenge we face in preventing these tragedies. The biggest challenge is the delivery gap that prevents existing, often simple health interventions from reliably reaching those who need them.

The situation in Africa is especially dire. In southern Africa, millions have already died from AIDS. In South Africa, more than one-quarter of adults are infected with the virus. The HIV epidemic has also created a resurgence of tuberculosis, which kills more than a million people a year. Again, the toll is highest in Africa. A child dies of malaria every 30 seconds, and most of those deaths occur in Africa as well. Every year, we bear witness to millions of deaths, all from conditions that are routinely treated in the developed world.

Meanwhile, health spending in Africa—both public and private—though much improved over the past decade, falls far below levels found almost anywhere else. The number of physicians working in Africa is just as skewed. We often hear that more Malawian physicians live in Manchester, England, than in Malawi, and that more Ethiopian doctors can be found in Chicago than in Ethiopia.

What’s especially tragic is that we know how to prevent or treat the most prevalent and deadly diseases. Take, for example, the risk of an HIV-positive mother transmitting the virus to her unborn child. Currently, the best way to prevent transmission is to provide the mother with prenatal services and, if appropriate, a combination of antiretroviral therapies to reduce viral load to undetectable levels. In an emergency, a single dose of nevirapine will also prevent transmission. Yet only an estimated 30 percent of pregnant women who need prevention-of-mother-to-child-transmission services actually receive them. And only half of pregnant women infected with HIV have access to nevirapine.

Statistics on the use of insecticide-treated bed nets to prevent malaria infection are just as troubling. These nets can reduce infant mortality from malaria by 20 to 30 percent. Every African child living in areas where disease-carrying mosquitoes are endemic should be sleeping under a bed net, but less than 10 percent do.

In neither of these cases is the problem the lack of a proven solution. The fundamental problem is one of consistently and effectively delivering interventions that are known to save lives.

Bridging the Gap

African nations and other resource-poor countries are not alone in this delivery gap, of course. The U.S. health care system has its own share of delivery problems. As of several years ago, we were still only 69 percent successful at meeting the standard for administering beta blockers within 24 hours to people admitted to hospitals for chest pain. The United States spends up to 17 percent of its gross domestic product on health care, and yet our health outcomes aren’t as good as those in countries that spend far less.

Admittedly, few African countries can rely solely on their own national budgets to fund the kind of health care systems they need. But the estimated cost of providing decent primary care—and even more complicated care—in developing countries is much lower than one might expect. A recent analysis of a project in Rwanda suggests that it is possible to build a system that—when linked to primary care services—can treat such diseases as AIDS, tuberculosis, and malaria for $25 to $50 per person each year. Compare that to the United States, where we spend about $7,500 per person on health care annually.

As funding for health in developing countries grows, it is conceivable that there will soon be enough resources to build functioning health care systems in even the poorest settings. To achieve such a lofty aim, though, we will need to dramatically improve our capacity to deliver health care interventions, both simple and complex, in resource-poor settings. For, despite the existence of proven treatments and much more money available now to pay for them, an implementation bottleneck prevents care from reaching patients.

Meanwhile, the Bill & Melinda Gates Foundation and other funders are investing billions of dollars to develop new tools to treat the deadliest diseases. This investment is absolutely critical. Any physician who has confronted drug-resistant tuberculosis will tell you how desperate the need is for new treatments. But when these new tools hit the market, I fear the bottleneck will just become more clogged.

One key to clearing the bottleneck is, I believe, to work toward developing what might be called the science of health care delivery—to systematically capture global health successes and failures, study them, and then widely disseminate the lessons learned to practitioners and policy makers. Moreover, we must create robust programs that will train a new generation of implementers and link those implementers together in communities of practice to allow the process of generating—and spreading—new insights to continue.

The Discovery Channel

At the press conference to announce the eradication of smallpox in 1979, physician and epidemiologist D. A. Henderson was asked, “Now that you’ve eradicated smallpox, what’s the next major disease you want to take on?” His answer: “Bad management in public health.”

Indeed, if you asked anyone who was involved in smallpox eradication what it was like to be part of a vaccination campaign of that magnitude, they would tell you it wasn’t a vaccination campaign. It was an epidemiological and management campaign—and those strategies were the key to the campaign’s success. That kind of intense focus on management and implementation is lacking in today’s efforts to stamp out other diseases, which just might help explain why we’re falling short.

Health care delivery is complex, but it’s not a black box. We can and must develop better ways to capture this complexity and then teach what we learn about effective care delivery to our students here and—most important—in the developing world. We can lay claim to being the best in the world at teaching basic science. We’ve made huge contributions to clinical research and clinical science. But one piece is missing—the science of health care delivery. To overcome the challenges we face today in global health, we need a new cadre of leaders—ones who are trained in the best and most effective ways to deliver interventions.

Of course we need to keep investing in health care systems in poor countries. We need better infrastructure; we need more money for medications, equipment, and supplies; we need new therapies. All of these things are critical, but this type of investment won’t unstop the implementation bottleneck.

In fact, if we don’t unclog the bottleneck, we run the risk that much of what we invest will be wasted. Today, we have literally billions of dollars in new spending—all of it sorely needed—to treat disease in the developing world. But we don’t have support—or even a plan—for the creation of leaders who will ensure the money is well spent.

Stopping needless deaths in the developing world—from AIDS, from tuberculosis, from malaria—is within our reach. Let me tell you about a recent patient of ours in Rwanda. Jean presented at our clinic with both tuberculosis and HIV. He literally looked like a skeleton. Yet his CD4 count was over 500, so we didn’t need to start him on antiretrovirals. With just food and medications for his tuberculosis, he began to recover. In a short time, he had his health back and, soon, had grown downright chubby.

This case illustrates what is possible, not just for Jean, but for millions of others. The challenge and the opportunity are before us—to significantly increase our understanding of effective care delivery, to teach what we learn to implementers worldwide, and to make good on the promise of dramatically improving the health of poor nations.

Jim Yong Kim ’86 is chairman of Harvard Medical School’s Department of Global Health and Social Medicine, director of the François-Xavier Bagnoud Center for Health and Human Rights at the Harvard School of Public Health, and chief of the Division of Global Health Equity at Brigham and Women’s Hospital.

Photo caption: A 15-year-old schoolgirl, burdened by AIDS, awaits antiretroviral treatment at a clinic in South Africa. The care came too late; she died two weeks after this photograph was taken.

Photo: Gideon Mendel/Corbis