Today’s class was by far the best of the semester in terms of sparking debate surrounding the role of companies, NGO’s, and individuals at the Bottom of the Pyramid. In particular, we were discussing the provision of healthcare, which is particularly meaningful to many of the students in the class who are in the Medical School or getting a Healthcare MBA. So instead of going into a recap of the discussion, I’ll throw out some of the types of questions that were being asked throughout the class and see if we can get people discussing the topic online.
Does providing free healthcare put the business model for healthcare out of business?
What is the best model, and when is it appropriate to use? Free care supported by donations? A sliding-scale fee-based system?
How does this type of debate relate to the proverb: ‘Give a man a fish, feed him for a day; teach a man to fish, feed him for a lifetime?” It could go both ways- perhaps providing the free care is enabling the population to teach themselves to fish?
What are the tangential benefits to society of providing free healthcare? What is the role of healthcare in society, and is it fundamentally different than the role of other businesses?
Do businesses have any obligation to provide services for free or below cost to help develop the population/customer base’s ability to pay for the services in the long run? Is it in their best interest to do so even if they are not obligated to do so?
Let the debate begin…
by: Ann Magruder
Since 2005, I’ve been volunteering with a group building a children’s hospital in Rwanda. The numbers alone in Rwanda support the need for free healthcare: 43% Rwandans are under age 14: 400,000 orphans, and approx 80,000 homes are headed by children (no adults). In this case- free health care is absolutely necessary when there are just not enough adults around. As for the benefits- if the kids are healthy, they can be in school which will hopefully allow them to pull themselves out of poverty.
Please check out the link. I’ll be glad to talk more about it!
http://www.onehundreddays.org/
by: Kelley Brewer
Health care is an issue that needs serious attention both in the United States and abroad. I think it is easy for some people in the United States not to realize that this problem is right under their noses. Many people here do not have access to health care. I was thinking about this in stats class this morning when we were talking about charging different prices for health insurance based on the person’s risk to the insurance company in filing claims. I understand that this is how insurance works. It is numbers in, numbers out, you may or may not get insurance, and you pay more if you are a risk. Furthermore, your pre-existing conditions won’t be treated. Basically, if you need health care, you can’t get it. If we stop and think about this, it is unethical and immoral. We, as a nation, should calculate the costs of health care for everyone, then find a way to provide it. Health care is a problem for everyone, not just those who don’t have it. Because of our system, many Americans who “have done everything right” file bankruptcy because of health disasters. We have to change this system, stop denying people health care, and start treating the sick. I think it would be cheaper in the end to treat people as needed, provide preventative care, rather than pay for the repercussions. This is possible. I would encourage anyone to watch Michael Moore’s Sicko.
by: Lori Singleton
I understand the concern that free healthcare could put the business model of healthcare out of business. However, we must examine the reasons behind why the free clinic was established. In Nashville, Shade Tree Family Clinic was started to try and reduced the number of unneccessary visits to the ER. If it was intended to be a source of permanent primary care, then it would be best to begin as a free clinic and later transition to a sliding scale clinic. Abroad, many free clinics are established because there is no accessible healthcare in many of the rural areas. In most of these areas it is not best to transition into a sliding fee clinic. However, there are ways to offer these clinics assistance, besides uing financial donations. Remedy at Vanderbilt Medical School addresses the issue of providing surgical supplies, etc. to clinics overseas. In the United States, we open sterilized packages and sometimes only use one of the tools included. The remaining tools are not allowed to be used in the U.S. since the package has already been opened. Remedy collects these. Instead of the equipment being thrown away, it is donated to clinics in underdeveloped countries. The remedy model can be applied to free clinics abroad to reduce the amount of funding required for operation.
by: Kristy Kummerow
Health is important to productivity at the level of the individual, business, and society. Generally, a person who is physically or mentally ill is less capable of doing work, be it tasks requiring physical strength or mental concentration. A recent study published in the Journal of Occupational and Environmental Medicine that reviewed a database of medical/pharmaceutical claims and employees’ productivity and health information found that health-related productivity costs were more than four times greater than medical and pharmacy costs (2007 July, 49 (7) 712-21). In addition, people who die prematurely represent lost potential to improve themselves and society. A productive society will safeguard the health of each individual for the betterment of all. In this way, healthcare can be seen as a social good.
Healthcare as a social good makes it unique among consumer services. In the current system in the United States, in which healthcare is provided through a free market of providers, suppliers, and insurers, there is often maldistribution of goods and services, the consequences of which are sickness, lost productivity, and death. Surely this is not good for the individual, for businesses, or for society.
Health care can be likened to another social good, public education, which is accessible to all members of society. Public education has positively impacted individual and social survival, productivity, and fulfillment of desires. According to economist Willis Peterson, “…education of individuals makes the community a better place to live for all….An increase in the educational level of people … reduces the amount of fear and suspicion that people have of one another … it helps us become more tolerant of persons who are different than ourselves.” Furthermore, education enables individuals to make improvements and to understand and develop novel solutions to problems. Arguably, increasing the education level of the least educated members of society makes society better as a while. Americans have seen the value of accessible public education, continuing to finance public education measures with their tax dollars and allowing the establishment and enforcement of laws for the creation and maintenance of schools, established standards for educators, and compulsory school attendance for children.
Policymakers ought to consider providing health care to all people in a way that is comparable to public education.
by: Meena Putatunda
I don’t exactly agree with the statement, “perhaps providing the free care is enabling the population to teach themselves to fish.” I believe providing free care is like feeding the man for just one day; they can become sick (or hungry) the next day. However, if we help educate people on how to stay healthy and even perhaps help them improve their environment along with giving free care, then we are helping people get healthy and empowering them to stay healthy and thus “feeding them for a lifetime.”
by: Jonathan Pressley
The healthcare dilemma is one that almost everyone has an opinion about. I feel that while free healthcare may be necessary in some instances, additional alternatives should be explored to help subsidize the cost associated with providing free care. I feel America’s healthcare systems, while one of the better ones in the world is inefficient and is becoming less accessible to everyday citizens each day because of the rising cost. In reading a recent article discussing how healthcare costs are increasing at a rate above inflation, I asked myself a couple of question. At what point will healthcare be unaffordable for me? What can be done to reverse or slow the trend? I challenge everyone to think about each of these questions and at the least come up with a few suggestions to help solve the problem.
by: Brie Robinson
Unfortunately I was unable to attend this last class, and I am sorry to have missed the debate. In another class of mine we are studying a case about the Pharmaceutical Industry and AIDS in Africa. I have been circling around very similar questions to those that were posed in this blog: should Pharma firms be required to lower their prices in order to make AIDS medications accessible to the African poor? Is it the responsibility of the large Pharma firms to help create infrastructure and medical services in Africa? What is the role of the Pharma companies in the poor’s battle against AIDS? It’s all very tricky stuff.
While I think that the war on HIV & AIDS is easier to approach, in that it is much more specific, I think the question of free Health Care is just as important. Only by facilitating these discussions and making ourselves face these questions to we have a chance of making real change.
by: Lindsey Lawrence
While I do whole-heartedly believe that everyone deserves access to healthcare, I also believe that many problems arise from the free clinic model. First, free clinics are not sustainable. Funding to the clinic can vary from year to year. Donations may lessen, grants may not come through, etc. Some years more money goes toward children’s health, while the next year AIDS may be a bigger issue in the public’s eye. With unpredictable outside funding, clinics that utilize a pay-scale are better equipped to serve the community for longer periods of time. They are also often able to see more patients. With a pay-scale, those who validly need free care will still receive it. Yet, patients who can afford slightly more can pay a minimal fee. Lastly, free clinics are beginning to provide chronic care. While this is a good idea in theory, chronic care and continuously supplying these patients with medication can quickly utilizes the clinic’s funds on only a few patients. Meanwhile, patients attempting to utilize the clinic one time, instead of making a visit to the ER, are not seen.
by: Indriati Hood
In considering the complex issue of healthcare both here in the United States and overseas, it is critical to keep in mind that there is not a single model that will work in all situations. While the business model may work well and may the most promising model in terms of longterm sustainability in many situations, there clearly circumstances in which this may not be feasible, at least as a starting point. It is similarly important to recognize that systems can (and should) adapt and change as populations and needs change. This latter point becomes particularly difficult in (arguably) highly developed health systems like that of the US in which the players, and likewise the interests, are many.
While the provision of free healthcare may risk putting “the business model of healthcare out of business” in a context in which there is no model of health care, free health care may be the only logical place to start. Several people have already pointed out some of the societal benefits to improved health care access/delivery in terms of productivity gained and I would echo the overall sentiment. I might also add that there are certain health care investments that while still perhaps ultimately being distributed at no cost to the patient, promote a certain level of sustainability, or at least possibility for growth and development, over others. In other words, there may be models of free care that are “better” than others in terms of long-term reduction in overall health care expenditure as well as reduction in morbidity and mortality. Investment in preventive medicine – education in risk reduction, vaccination programs, HAART medications, antenatal care, etc. – as well as in training of health care workers may have higher return on investment and in the long run free up resources (and develop human resources) for the future development and improvement of the system.
by: Thomas Spain
This issue relates back to an earlier discussion over the terms “alleviate” vs. “eliminate” with respect to poverty. Under a broad definition of poverty, illness is one integral component. It is also, I think, one of the most striking examples of the reality that poverty is alleviated, not eliminated. Illness is an excellent reminder of the limitations an individual has on charting his or her own destiny.
In a very real sense, illness is “no respecter of persons”. A balanced lifestyle, safe environment, and quality healthcare only increase the likeliness of a long, healthy life. In no way do they ensure one. Regardless of this reality, we all strive after these things for ourselves and others whom we value. They are our best efforts to prolong the interval between two life-events that are shared by all of humanity: birth and death. In our striving, it is nearly universally agreed that we do not “eliminate” death. Instead, our efforts seek to “alleviate” both the mechanisms that are killing us and the signs that we are dying, prolonging the time between birth and death. From an individual perspective, this alleviation is a very crucial task—one that consumes much of our time and energy. It is critically important to remember this perspective when discussing the economics of healthcare. It is this weighty issue—quite literally the personal implication of life vs. death—that resists so strongly the attempts to fit healthcare into the pure, free-market framework that so well accommodates many other pursuits of life.
In medical parlance, there is a heavy usage of the terms “acute” and “chronic”. The word “acute” evokes the characteristics of rapid onset, short duration, and, often, severe quality. In contrast, “chronic” suggests a more gradual progression, lengthy duration, and, occasionally, lower intensity. The treatment of an acute illness often differs significantly from that of a chronic illness. Regardless, both methods of treatment are of great importance—especially to the patient receiving them. When many healthcare providers observe the global need to address illness, they see solutions at many levels. Some solutions address needs that are more acute, and others address needs that are more chronic. Some are very large, structural interventions at the level of policy and society. Some are at the level of an individual patient or family. Some involve years or decades of time. Some are only implemented for an hour or less. Most are important. None is a panacea.
I would submit that free, charity-supported care, and sustainable non-profit and for-profit care are all important, and that each methodology is well suited to meet specific types of needs over specific timeframes. One of the most widely applicable ideas we have considered in this class is the reality that “cookie-cutter” or “one-size-fits-all” approaches routinely fail. I would disagree with anyone who suggests that either model of healthcare—“business” or “charity”—renders the other unnecessary or less ideal. Ultimately, we aren’t talking about goods, products, or services…We are talking about living and dying. The problem of effectively alleviating illness is too broad and too deep for either business or charity alone. As we become increasingly aware of how great the need is for this alleviation, it emphasizes the importance of honest, open collaboration among disciplines in an attempt to identify the most appropriate approach for a given situation and set of resources.
by: Shana Levy
In terms of the health care dilemma, I agree that everyone has a fairly strong opinion. In my opinion, there are two necessary steps that should be taken. The first step is to provide free health care. After care is provided, the second step is to educate people on ways to keep themselves and their families healthy. Providing people with the knowledge to maintain a healthier lifestyle enables them and makes them feel like they have the power to change their current way of life even if it just a small change.
by: Rachel Barnhard
One of the most fascinating jobs I’ve had was working as an intern in the development and communications department of a non-profit called Project HOPE near Washington D.C. HOPE stands for Health Opportunties for People Everywhere and the organization’s programs operate in a variety of developing countries.
Aside from providing general emergency healthcare and preventative services around the globe, one of the NGO’s largest projects involves their network of Village Health Banks. As of 2004, there were approximately 950 VHBs in operation, reaching more than 50,000 women.
This innovative program combines what seems to be the essence of a Project Pyramid company. Although Project HOPE itself is a non-profit, and many of its services are free, the Village Health Banks operate through a different model.
A VHB is basically a micro loan program designed to help women in groups of 18-25 generate income through agriculture, sales of goods and services, and other activities. In exchange for the loans, the women are required to elect a management committe to handle the bank’s operation, which is then trained by Project HOPE. They are required to set aside a portion of their earnings from the loan as savings that are then consolidated by the bank and deposited into a commercial account. In addition, during bi-weekly meetings, a one hour health education session is presented by the local HOPE staff. The sessions are on topics including childhood illness and sexual health. Women are encouraged to request sessions on a specific topic that may be of interest to them.
Because of the interest on the loans, the VHB runs a small profit that goes towards two goals: giving out larger loans to members who stay involved and to establish more VHBs.
The results of this program have been solid, with recorded improvements in household income ranging from 22%-64% and savings improvements from 20% to 42%. By targeting women who are active in their communities, small but significant gains were made in the health knowledge of the respective villages.
Through programs like these, both healthcare and economies of small communities can be enhanced through small loans in an ultimately self sufficient manner.
Project HOPE has recently been tweaking this program to help communities afflicted with AIDS, which have special challenges considering the longevity of such a debilitating disease.
Through programs like this, non-profits can have a lasting and sustainable impact on the worlds healthcare, creating ownership and responsibility of the women involved in the program and improving the financial standing for entire communities through one comprehensive effort.
by: Ryan Igleheart
Rachel’s post brings up a great point- it is not essential to separate the non-profit and for-profit models entirely. They can coexist simultaneously without detracting from the goals and/or success of either one. The idea of a for-profit side of an organization providing the financial support for the organization’s larger, more non-profit oriented goals is certainly a good model, one that was enacted by Wil and Henry at Enjuba. While their model is founded in the for-profit business realm, their goals of helping educate children to break the cycle of poverty in Ugandan communities are more alligned with what we would typically think of as the non-profit realm. These goals would be untainable without the profits. I would argue that the altruistic goals of Enjuba actually motivate the artisans to succeed and achieve more than if profits was their only goal.
Thanks for the insight, Rachel!
by: Chris Baxley
Thanks for posing the questions Ryan.
What follows is only intended to apply to the idea of “free” healthcare in poor and developing countries. For various reasons, some of them inextricably linked to political views that tend to entrench debaters into an unproductive “you’ll never change my mind on this point…” attitude; I do not offer this as commentary on offering “free” healthcare in the US.
Free or significantly-discounted healthcare is essential to launching successful, sustainable ventures in the un/under-developed world.
Any business that meets the Project Pyramid framework is going to involve the poor in its operations and many of those people we will seek to employ and partner with will be exposed to serious health issues. If those health issues are not addressed, then our ventures will lose valuable assets (our people) to sickness and death. This consideration should be extended to the family members of our employees and partners…a seriously ill or dying child at home will inhibit the productivity of a worker in the office.
Companies who seek to do business “…at the bottom of the pyramid…” should factor in the costs of providing basic healthcare to their employees and partners when conducting any pre-launch profitability analysis. While not part of a sustainable framework, they might also consider partnering with a charitable organization to provide that care.
The question, which deserves separate consideration, of how to approach healthcare for those same employees and partners once they have achieved the financial means to provide healthcare for themselves, will likely place this debate right back where we are in the US… and we’ll have a lot of people politicizing the issue and taking on the “you’ll never change my mind on this point…” mentality.
by: Rachel Gore
During this week’s class, guest speaker Alfredo Vergara (from Vanderbilt’s Institute for Global Health) spoke to us about health issues facing developing countries. He described the effect their conditions have on population life expectancy, and on a nation’s livelihood and prospects for development. Professors Bart and Vergara posed a question to the class about how to stop the spread of HIV/AIDS in a small village in Mozambique, where the US government has allocated money for a clinic through the President’s Emergency Plan for AIDS Relief (PEPFAR) program. They suggested that a group of doctors, business experts and public health experts would be going down for a short period of time to analyze the needs of the community where only one doctor is available to several thousands of community members. They then asked what they should do during their time down there.
I was surprised that most of the comments in class focused around obtaining affordable treatment programs and less about prevention and education. My immediate thought went to condom distribution programs and sexual education. Many people have commended the Bush administration for its generous allocation of funds to the PEPFAR program as a real contribution to decreasing the spread of HIV/AIDS in the world. Yet, if you take a more critical look, one can observe that some of this money is contingent on furthering Bush administration policies, such as abstinence. When international health policies and aid are contingent upon promoting policies such as abstinence, then there is less money for programs with higher success rates on prevention, such as condom distribution. In fact, The Center for Reproductive Rights, a global legal advocacy group based in New York, has documented the effect of the US Mexico City Policy (also known as the “Global Gag Rule”, which effectively cuts off U.S. family planning assistance and funding to foreign Non-governmental Organizations (NGOs) that perform abortions (some exceptions for rape, incest and maternal health are allowed); provide counseling/referrals for abortions; or lobby to make abortion legal or more available in their country (for more information, visit http://www.globalgagrule.org/). The policy created during the Reagan administration, and reinstated by the Bush administration, is called the “gag” rule because it stifles debate about abortion-related issues, prevents the dissemination of information concerning essential health services, and may jeopardize the health of many women who turn to foreign NGOs which are dependent on US-based aid for contraceptive supplies. Furthermore, the Center works to challenge laws in other countries that try to promote this policy– Croatia has sponsored an extracurricular sex-education program Teen STAR (Sexuality Teaching in the context of Adult Responsibility) for a decade now promoting abstinence at the expense of other programs providing contraception (for more information, visit http://www.reproductiverights.org/pr_07_1010CroatiaSexEd.html). This is a classic example of the abuse of US governmental aid allocations because this group has now been awarded a U.S. government PEPFAR grant. The tie between the Bush administration’s coercion tactics to promote abstinence and the selection of NGOs for PEPFAR funds seems like a shotgun marriage. Its important to think about the complexity of the issue before commending Bush for taking a step in favor of global health because, in fact, it’s a step back for women worldwide.