Healthcare in the Remote Developing World: Why healthcare is inaccessible and strategies towards improving current healthcare models

Sadia Ali

Abstract

In 2008, the World Health Organization (WHO) celebrated the 30th anniversary of the Alma-Ata Declaration. The declaration called for the “the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life.” In other words, the WHO aimed to provide “health for all,” by increasing primary care investments at the turn of the millennium. Fifteen years post target year, we still find the majority of the developing world without access to basic healthcare. Despite foreign investments from institutions such as the World Bank, the Bill and Melinda Gates Foundation, and the WHO along with a myriad of nonprofits and local government, the disparities still exist among poor enclaves of developing nations.³

This paper explores where current strategies fall short and what strategies can be implemented to propel us to the promised Alma-Ata goal. In addition, it addresses continuing accessibility challenges faced by remote communities specifically the Hmong villages in Laos. In addressing these issues, this paper investigates an example of an effective health policy strategy, which shows the potential countries have in increasing healthcare accessibility when the right strategies are employed.

Background

In the summer of 2014, National Geographic tasked the author to conduct research on healthcare conditions among the Hmong in Laos with a particular focus on Laos’ integration of alternative medicine with modern medicinal practices. This paper draws from this research to present the author’s viewpoints.

The Hmong are a minority ethnic group in South East Asia. Since the 18th century, due to political unrest and the Laotian Civil War (1953 -1975), the Hmong were in state of frequent migration. Under the UN’s resettlement program following the end of the Vietnam War, many resettled in Laos while others settled in Western nations and Thailand.⁴ Today in Laos, this minority is often referred to as Lao Soung (“Lao of the mountain tops”) because they have traditionally lived at high elevations in remote communities. These communities are largely poor and depend on cash crops and crafts sold at night markets to eke out a living. Largely animistic, this ethnic group believes all beings and natural objects have multiple souls. These principles lay the foundation on the Hmong’s way of life and how they interact with modern society.

Healthcare Accessibility

Accessibility to basic healthcare in remote communities is rooted in four dimensions: geographic accessibility, financial accessibility, availability, and acceptability. These four dimensions, discussed further, contribute to the low demand and low supply of healthcare options in these communities.

Geographic Accessibility

In the last century, most of the public health resources have traditionally been allocated among large hospitals concentrated in cities. However, for rural communities, access to these facilities is difficult at best because of distance and the lack of transportation and roads.

Poor infrastructure hinders the transfer of patients, medicine, and human resources between rural and urban areas. The problem is exacerbated during poor weather conditions when communications between rural communities and urban institutions are truncated, further isolating remote areas from essential services. Such uneven distribution of medical resources is a critical barrier to healthcare access for rural populations.⁶

As a result of this physical barrier to health resources, individuals in these rural communities suffer. Researchers have found an inverse relationship in low-income countries between the standard of healthcare and travel time to health facilities. Studies have shown that when the distance between health facilities and rural communities in Ghana was halved, thereby reducing travel time, the utilization of medical services had doubled.⁵

Increasing the quantity of health clinics to serve rural communities, however, will not comprehensively solve the geographic accessibility issue. Although governments commonly employ it, proliferation of rural clinics has not resolved intrinsic problems of properly staffing, financing, equipping, and integrating these facilities into remote communities. These problems remain significant hurdles for a long-term solution. Infrastructural improvements in roads and transportation that increase access to urban facilities are other options, but they require extensive planning, financial investment, and resources that many low-income countries are ill equipped to supply.⁵

For the Hmong tribe, which primarily resides in mountainous regions in Laos, utilization of Western forms of healthcare (i.e. pharmaceuticals, hospitals) is limited. Instead, traditional medicine, the knowledge of which has been passed down from generation to generation, is used as a localized form of healthcare. The World Health Organization (WHO) defines traditional medicine as “the sum total of the knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness.”¹⁰ In Laos, traditional medicine comprises of herbal remedies and shamanism in particular sub-populations.

Traditional medicine is used for both chronic and acute diseases. Many collect herbal plants in nearby jungles and concentrate them in teas. The effectiveness of these remedies is a point of contention for many medical professionals, but studies have shown that some traditional medicines do have remedial effects.⁷

For example, researchers found that some traditional plants have positive effects in treating Tuberculosis. For example, Justicia adhatoda (Acanthaceae) commonly found in Laos, Nepal, and India contains the anti-TB compound, vasicine, in its leaves, which has been extracted to develop bromhexine and ambroxol, derivatives often found in cough syrup.

Although there is a lack of regulation and research to measure the effectiveness of all herbal remedies, traditional medicine practices have made healthcare more accessible and affordable to remote communities and can serve as remedial substitutes to allopathic care. Since knowledge and access of such remedies are generationally known, rural communities are less dependent on human resources and health clinics found in urban regions.²

Financial Accessibility

The financial burden of modern medicine is considered as one of the strongest determinants of healthcare access for the poor.

In response to this public health issue, Laos passed the Law on Health Care (2005), which gave provincial and district health authorities the right to implement user fees and fee exemptions for the poor into their health financing. User fees involve transferring partial or complete burden of payment for health services as an option to generate funding for health care services. With the addition of Prime Ministerial Decree No. 52, fee-exemptions were established for the poor.

The funding received from user fees, however, is relatively low considering the poor are exempt from paying medical fees. This has reduced utilization of health care services because there are limited resources available to improve and provide health care to the poor. Furthermore, direct costs of medical services are a fraction of total medical expenditures. Indirect costs, which include opportunity cost of time for the patient, transportation costs, and food and lodging expenses, also significantly contribute to the financial burden.⁹

The majority of the Hmong lives in poor communities. Catastrophic medical emergencies can pull families further into financial burden. They not only bear the costs of services, but also lose a provider of income. Typically affect families take out a high proportion of household finances, borrow money, or sell their assets in response to these medical emergencies.

Availability

The majority of the rural population relies on local medicinal shopkeepers and informally trained health workers the shops support. These third-party providers are commonly used because they are an available alternative at a significantly reduced cost compared to treatment at urban centers. Despite reducing costs, these facilities are poorly regulated. Often, rural shopkeepers sell incomplete or expired doses of drugs of off-patent, generic or unknown origins, sometimes even repackaged as branded medicine.⁶

The lack of regulated health clinics in these regions has left consumers misinformed or not informed at all about dosage, health risks, and complications associated with taking the drug. At a rural dispensary in the Hmong settlement, National Geographic researchers found an eleven-year-old boy distributing addictive drugs such as Valium over the counter with little concern of the appropriateness of the drug for the malady or its side effects. The consumer was not informed about dosage and potential complications, but rather left with instructions offered in the package.¹

Acceptability

Patients have different perspectives of what constitutes quality care and varying expectations from different providers. Western models of healthcare with physician-based care are foreign to communities who view illness and treatment differently. In the Hmong belief system, a misbalance of souls in an individual’s body causes illness. Treatment for illnesses transcends the physical ailments, but rather intends to restore spiritual balance of the patient’s souls. As a result, many Hmong consult village doctors or shamans to retrieve souls or fight off bad spirits.¹⁰ Shamans are readily accessible and are usually part of the extended family. There are fewer social barriers since relationships are longstanding and customs are known and respected.

Researchers found that shamans are often the first point-of-contact when a family member experiences a medical ailment. A shaman can refer a patient to a hospital if herbal remedies and shaman rituals have little effect. However, the integration of localized customs within Western models of healthcare poses challenges to the achievement of the Alma Ata goals.6 The patients’ perceptions of illness and treatment remains one of the strongest determinants of utilization of health care services.

The Traditional Medicine Research Center: A Micro-Solution

There is no clear-cut solution that can be applied universally to populations with severe disparities in health care accessibility. Solutions that were invested by the government have an increased likeliness to succeed in reforming healthcare.⁶ In addition, successful strategies are adapted to local customs and monitor the results for further refinements.

Realizing the importance of local customs, Laos’ Ministry of Health established the Traditional Medicine Research Center (TMRC) in 1976. The TMRC is the only institution of its kind committed to researching the effectiveness of traditional medicines and preserving their use in rural forms of healthcare.

TMRC works with pharmacy students to integrate western knowledge of pharmaceuticals to the use of traditional medicine. Since its establishment, TMRC has expanded to 5 districts in Laos and are well positioned in rural communities. Traditional healers working in these communities have passed down the knowledge of herbal remedies to district centers. The institution has been sponsored not only by the Ministry of Health, but also by pharmaceutical companies, which use findings for large-scale production.

Since herbal remedies are widely used throughout the country and are often exported to other neighboring countries, rural communities that collect herbal remedies have a financial incentive to sell products to TMRC reserves and markets. In addition, because TMRC acts as a liaison between rural communities and large pharmaceutical companies, there is an incentive for pharmaceutical companies to invest in systems that promote drug discovery. Focusing on mainstreaming herbal remedies through big pharma involvement can offer a more cost effective means of providing healthcare since it removes the need for expensive hospitals and clinics. In addition, because the TMRC dedicates research into measuring the effectiveness of herbal remedies, it shares its findings with traditional healers.²

These remedial plants are already being accessed in remote communities. Herbal therapeutics is often found in the mountainous jungles near Hmong tribes. The Hmong have the knowledge to find certain herbs around their terrain and can grow essential plants in households.¹

Despite TMRC’s overall success, there are still improvements that can be made in the TMRC model. While TMRC has the potential to reduce the cost of basic medications, it does not safeguard poor remote families from expenses resulting from catastrophic incidents. Risk pooling through an insurance model can mitigate financial burdens. The challenge for developing countries, however, is to shift high levels of out-of-pocket expenses into public or private pooling arrangements to protect individuals from poverty and debt. The current user fee model does not protect individuals from expensive procedures, but will remain until the government can find additional financial resources.

These challenges demonstrate that difficulties in creating an effective healthcare model that promotes equity of care. Healthcare accessibility or lack there of is an overarching problem that stems from a multitude of issues that commonly define the developing world. Lack of infrastructure further isolate these communities from critical care centers. The lack of financial resources makes it difficult to incentivize people to invest in health clinics in remote areas. It contributes to a poor availability of human and medical resources to provide quality care. Long held traditional beliefs of health often conflict with investments in Western models of healthcare, which are typically sponsored by international organizations. Organizations use of “blanket policy” methods often neglect subtleties in cultural norms.

Although the TMRC model is not necessarily a sure solution to a universal problem in the developing world, it is an innovative approach to leverage tangible resources for the betterment of isolated communities. Its sensitivity to cultural norms and the government’s investment to the integration of Western practices applied to Eastern methodologies have arguably created a unique system that provides accessible primary and preventative care.

Therefore to work towards sustainable healthcare models, international agencies and nonprofits should not implement blanket-policies that apply Western models of healthcare to rural Eastern communities. The issues behind health care access in remote regions are too complex to allow these models to be sustainable. Instead of using top-down policies, agencies should invest more in researching how communities currently utilize healthcare, analyze cultural norms and values, and create areas of collaboration where health systems are created based on community input. Accessibility of services and resources will be an issue unless there is a massive investment in improving infrastructure. But by gaining insight from community players, researchers and investors may find strategies that are low costing, readily accessible, and easily accepted by remote communities. The TMRC is successful in integrating the community in creating healthcare models and drawing resources from the government and international agencies in financially sustaining it. Therefore it is key that we approach rural healthcare with sensitivity to the customs of these remote regions and also build on current informal systems to create a better-integrated and sustainable model of healthcare.

About the Author

Sadia Ali is a graduate student at Columbia University Mailman School of Public Health. She graduated from, University of Southern California studying Global Health with a minor in Film Production. Prior to her research and film engagement with National Geographic Society, Sadia distinguished herself by founding the Roots Homeless Health Clinic in Los Angeles, conducting research at the International Center for Diarrheal Disease Research, Bangladesh (ICCDR, B), developing and executing a Clean Air Campaign for the Los Angeles Department of Public Health, and raising funds and managing a bridge building project at a remote village in Mali.

Sadia may be reached at sa3232@columbia.edu

References

1. Ali, Sadia. “A Healer’s Meridian.” Voices. National Geographic, 2014. Web. 20 Jan. 2015.
2. Elkington, Bethany G., et al. “Biological evaluation of plants of Laos used in the treatment of tuberculosis in Lao traditional medicine.” Pharmaceutical biology 47.1 (2009): 26-33.
3. Hall, John J, Taylor, Richard “Health for all beyond 2000: the demise of the Alma-Ata Declaration and primary health care in developing countries.” The Medical Journal of Australia 178.1 (2003): 17-20.
4. Hamilton-Merritt, Jane. Tragic mountains: The Hmong, the Americans, and the secret wars for Laos, 1942-1992. Indiana University Press, 1993.
5. O’Donnell, Owen. “Access to Health Care in Developing Countries: Breaking down Demand Side Barriers.” Cadernos De Saúde Pública 23.12 (2007): 2820-834.
6. Peters, David H., Anu Garg, Gerry Bloom, Damian G. Walker, William R. Brieger, and M. Hafizur Rahman. “Poverty and Access to Health Care in Developing Countries.” Annals of the New York Academy of Sciences 1136.1 (2008): 161-71.
7. Sydara, K., S. Gneunphonsavath, R. Wahlström, S. Freudenthal, K. Houamboun, G. Tomson, and T. Falkenberg. “Use of Traditional Medicine in Lao PDR.” Complementary Therapies in Medicine 13.3 (2005): 199-205.
8. “Traditional Medicine: Definitions”. World Health Organization. 2008-12-01. Retrieved 2014-04-20.
9. WHO and Ministry of Health, Lao PDR. “Health Service Delivery Profile Lao PDR 2012.” Health Service Delivery Profile (2012): 1-11.
10. Westermeyer, Joseph. “Folk Medicine in Laos: A Comparison between Two Ethnic Groups.” Social Science & Medicine 27.8 (1988): 769-78.