Demand for healthcare in the developing world: what you want and what you get

When it came time to explore the concept of healthcare demand in the developing world, I was interested in hearing some tales of firsthand experience.  Luckily, the director of the global health NGO that I work for is very experienced in his field and often quite chatty about his time spent implementing health projects throughout the poorest communities in the world.

My boss began his public health career at the age of 22 with his very first job of picking up Los Angeles-area drug users and prostitutes from street corners or crack houses and driving them to local clinics for syphilis treatment before dropping them back off where he found them.  He has since lived and worked all over the world from Switzerland to Guatemala to Zimbabwe eventually switching his focus from strictly STDs to TB and HIV.  He is one of the people in the field who has seemingly seen it all.  With his experience, he seemed to be the perfect person to explain to me the intricacies of healthcare and supplies demanded in the developing world.

One of his favorite stories, one that I have heard him tell several times, involves our work with a partnering regional TB management organization located in Brazil.  About a year ago, he travelled out to Rio de Janeiro on a site visit prior to implementing a diagnostic tools research project.  The director of the hospital he visited greeted him excitedly.  They had acquired the newest and trendiest diagnostic equipment being recommended by WHO.  He brought my boss to the lab section of the building and proudly presented the device.  Sitting in the corner, covered in dust and coffee rings, sat a clearly unused machine for processing TB diagnostics.  The doctor continued to beam proudly, and my boss congratulated him, and they continued on their site visit.

When I first heard this story, I couldn’t understand what had happened.  Why would such a hard-sought and high-tech machine sit idly when it could be used to diagnose the hordes of patients clogging the reception area?

His answer to this query begins with, “It’s important to remember that WHO doesn’t necessarily think through to implementation.”  WHO often recommends treatments, tools, and similar for the management of disease, but often these recommendations are made assuming the best of conditions.  Diagnostic tools that work within the confines of a sterile lab environment with access to electricity, clean water, and trained clinicians are often not optimal in the developing world for obvious reasons.

Additionally, WHO does not necessarily consider the cost of the inputs needed when recommending a moderately priced tool or piece of equipment.  The initial device that my boss found in the Brazilian lab may have been a onetime cost of only a few hundred dollars – well worth the investment.  However, if the slides or chemicals needed to run the machine are hugely expensive (and these costs are incurred after only minimal or moderate use) then the device is, in essence, useless due to lack of funding.

So why would the expensive equipment remain in demand knowing full well that it may not be useable in the long run?  Even in the developing world, doctors often want the newest, shiniest, and most sought after equipment.  They want their lab to be the best.  They want to proudly display their equipment to visiting health professionals.  Similarly, ministers of health want to order the best their budget will allow so they can tell their country that they are offering the best tools and care that are available.   Often healthcare demand seems to become a matter of principle instead of practicality.

I’m not sure where it goes from here, but it seems like the global health community isn’t really sure either.  I assume that the best answer is to continue funding operational research activities where recommendations from WHO can be tested and trialed in low-resource settings, and new and existing equipment can continually be developed and tweaked.  An idealist would hope that the demands will eventually meet the supply, but only time can tell.

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