Blogs posted for Asian Development Bank (ADB)

Without incentives, health data sharing systems don’t work for patients

Published July 1 2016

In the multi-payer systems that characterize primary health care in Asia and the Pacific, both developed and developing countries suffer a way of delivering care that works against data sharing.

Even in Hong Kong, China—which has one of the highest standards of health care in the region—services are rendered without a sharable electronic medical records system, as I witnessed in a recent encounter with the medical profession that gave me first-hand insight into the matter.

Like 70% of Hong Kong’s population, I get my primary health care in the private sector. After a recent well-woman check-up with my family doctor, she sent me to a specialist, with a printed letter and photocopies of my test results. The specialist subsequently typed up and posted back his reply, explaining his diagnosis and course of action. Now both doctors had the same sheets of paper in my medical records. Meanwhile, the specialist my doctor recommended was not the same one who had provided my obstetric care, as well as periodic check-ups, over the past 17 years.

Now there were three doctors, with consulting rooms within walking distance of each other, all of who know me, and had important information about my reproductive health (and illness)… and no formal way to share the data with each other.

So I shared the data myself – I delivered the referral specialist’s handwritten notes to my longstanding gynecological care provider so he could put them in his paper records. This is what happens in Hong Kong’s private medical sector, which delivers the most expensive—and arguably the most patient-centric—primary care in the territory. The only reason all three of these doctors are now up to speed on my health is because I took it upon myself to make that happen. This is not a typical way that patients in Hong Kong deal with their health records, if they even see them at all. Usually this data is simply not shared with them or anyone else because there is no mechanism for that to happen.

Had I been part of the minority who access primary care at a Hospital Authority (HA) outpatient facility, every encounter with any health worker would have been logged in the HA’s excellent electronic medical records system. My health data would be available for easy retrieval at any point in the future. What the HA’s system can’t do, though, is tap into private sector medical records, where the vast majority of primary care happens in Hong Kong.

In March 2016 the Hong Kong, China government launched its Electronic Health Record Sharing System. It didn’t seem to create much of a splash, so I was intrigued. There is a system for data sharing after all. But leaving aside the baffling instructions for patient registration, there is another major constraint – I can register as a patient, but there is no mechanism for me to check whether or not any of my private providers have signed up, and even participating providers may not be able to share all the data they have due to “technical constraints and readiness.”

When I asked my providers, one specialist supported the idea of patient data sharing and praised the HA system, but complained the registration process was onerous and the perceived benefit to him and his patients was minimal.

Hong Kong, China is a multi-provider, multi-payer health care environment where public hospitals compete with private primary and specialist care providers. There is thus a strong disincentive for the sectors to share patient data they consider to be their proprietary information. This lack of data sharing is one key reason why Hong Kong’s primary care financing model is poor value for money.

Patients are not in a position to drive the creation of a central medical records database. Public trust in the Hong Kong government, currently at its lowest level since the 2003 SARS outbreak, also undermines efforts to reassure patients that their data will be kept safe and confidential. Moreover, the government’s data sharing system only offers a (somewhat clunky) mechanism for sharing data, but does nothing to address the disincentives to sharing it.

A robust, genuinely population-wide medical data sharing system with strong and transparent governance helps identify patients uniquely and confidentially whenever and wherever they access health care. Providers can access the information they need–and only that information–to provide continuity of care. This has enormous positive implications for public health, and other Asian countries should be aware of this.

The problem can only be effectively addressed by government intervention that compels all public and private health service providers to share their data, promote continuity of care, and put their patients’ wellbeing first.

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Blogs posted for Asian Development Bank (ADB)

Malaria elimination – a public health best buy

 

Published on ADB website on Monday, 12 October 2015

Written by Susann Roth and Jane Parry

Despite the many successes across Asia and the Pacific in reducing the incidence of malaria, the disease continues to be a heavy burden for many countries, with an estimated 2.2 billion people at risk in the region. Growing resistance to simple-to-use, effective malaria drugs and sub-optimal delivery of malaria treatment, in particular for mobile and migrant populations, are both widespread throughout the Greater Mekong Subregion (GMS). Lack of timely and comprehensive disease surveillance and inadequate cross-border and multi-sectoral cooperation are also serious obstacles to malaria elimination. Together, they threaten to undo all the progress to date toward elimination of this public health menace. Any serious effort to tackle malaria and other communicable diseases must thus start from this understanding: these diseases thrive in the face of weak health systems, and they do not respect national boundaries. Malaria has long been on ADB’s radar as a threat to regional prosperity and security, and our efforts to support countries striving to eliminate malaria received a significant boost when the Regional Malaria and Other Communicable Diseases Threats Trust Fund (RMTF) was set up in December 2013 to support developing member countries create multi-country, cross-border and multi-sector responses. To date, the RMTF has pooled over $28 million in resources from multiple donors, among them Australia, Canada, and the United Kingdom. Over $19.5 million in technical assistance has already been approved, including support to countries to reduce the risk of drug-resistant malaria and work toward elimination of the disease; malaria and dengue risk mapping in the GMS; and support for the Asia-Pacific Leaders Malaria Alliance. Expectations of solid results by the end of 2017—when the first round of financing expires—are high, with ambitious targets set for each of its six components: strengthened regional leadership; increased financing for malaria; better access to drugs and commodities; better use of surveillance technologies; improved capacity to detect drug resistant malaria and other disease threats; and inclusion of malaria and communicable disease prevention in large commercial and development projects. The focus of the RMTF tells us that five changes to the business-as-usual approach are needed if we are to get serious about malaria control and elimination:

  1. More sustainable financing.
  2. Cooperation to ensure supplies of affordable and effective malaria drugs and commodities.
  3. Improved data for evidence-based decision-making.
  4. Stronger national malaria programs.
  5. Expansion of leadership that looks beyond the health sector.

Under the RMTF, ADB is busy leveraging financing by mobilizing co-financing from other donors, and linking with ADB’s ongoing and planned loan and grant portfolio on communicable diseases control in the GMS. We are acting as both a catalyst and financing body for innovation, bringing together centers of excellence such as the the Harvard School of Public Health, Oxford University, the Mahidol Oxford Tropical Medicine Research Unit and the University of Tokyo to help GMS countries better manage their malaria and dengue surveillance and response planning through call data record and geographical information systems. The benefits of the RMTF stretch beyond malaria and will feed into broader health systems strengthening,  so we are working with the World Health Organization and the Asia eHealth Information Network to improve the regional evidence base for elimination of malaria and control of other communicable disease threats through better data collection, and analysis including accurate data on the costs involved. And since accurate surveillance of malaria relies on being able to identify, track and treat people with the disease, ADB and UNICEF are supporting national efforts on civil registration and vital statistics systems, based on unique identifiers for every member of the population. Finally, we are also teaming up with Singapore’s Center of Regulatory Excellence and other partners to improve regulatory convergence of pharmaceuticals to improve availability of high-quality communicable disease and anti-malaria pharmaceuticals and commodities. For ADB, malaria elimination is an obvious public-health best buy, not just because of the reduction in human suffering that it offers, but also because it can bring substantial economic gains: annual per capita GDP growth in malaria-affected countries is 0.25–1.3% lower than in countries without the disease. Investments in malaria now will yield savings in the longer term through reduced health care costs, more robust and sustainable health systems, increased worker productivity, improved educational outcomes, and a more vibrant tourism sector. Success depends on countries, agencies and sectors working together, being as innovative as possible, and putting our developing member countries in the driving seat.

 

 

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Blogs posted for Asian Development Bank (ADB)

ICT helping countries move toward universal health coverage

 

Published on ADB website on Friday, 12 December 2014

Written by Susann Roth and Jane Parry

When the Conference on Measuring and Achieving Universal Health Coverage with ICT in Asia Pacific wrapped up earlier this month, the 290 participants could head home knowing that it had been time well spent. Not only did they share their experiences as health systems administrators and managers, they also left with a bigger network, and a commitment to taking concrete steps to use information and communications technology (ICT) to help their countries move closer to universal health coverage

It was gratifying, as one of the co-organizers together with colleagues from World Health Organization and the Asian e-Health Information Network to see this process unfold. The conference was designed to get people talking in small groups, actively learning from each other, consulting together to hammer out what needs to happen for health systems to fully harness the benefits of ICT, and it culminated in a vote on what the 10 most important next steps are.

ADB is committed to increasing health investments in the coming five years and those investments have to go where the organization can have the biggest impact. One of ADB’s key strengths is its ability to convene disparate organizations and foster partnerships.

This conference was a prime example of effective collaboration among partners to capitalize on each other’s strengths. The knowledge that was gained in the conference room will not just travel back home with the participants. ADB’s health team learns from this process too.

The 10 next steps agreed to at the meeting will also inform a forthcoming joint ADB/WHO policy brief on using ICT to promote and measure progress towards universal health coverage.

ICT can bridge the gap between existing health systems and universal health coverage, but it’s a complex process and every country has its own challenges. We need to know from the people who are closest to the respective health systems to ensure that ADB’s commitment to supporting the goal of universal health insurance continues to hit the mark.

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Blogs posted for Asian Development Bank (ADB)

Move away from HIV and AIDS? Not quite yet!

Published on ABD website, Monday, 01 December 2014
By Susann Roth, Patricia Moser and Jane Parry
The AIDS response in our region has undoubtedly made impressive gains in the past 15 years. But as we mark today World AIDS Day, we can reflect that there is so much more that remains to be done.
New infections have fallen since 2001, but in 2013 there were 4.8 million people living with HIV in the region, including 350,000 newly infected that year. Worryingly, the number of new infections has flatlined for 5 years. Treatment access has been massively expanded, and 1.56 million people living with HIV were receiving life-saving antiretroviral therapy by 2013. But at that rate only half of those eligible will be on treatment by 2015.
Resources dedicated to the AIDS response in our region come from both domestic and international sources, and ADB has been supporting HIV prevention projects since the early 1990s. From 2005 onwards, much of ADB’s contribution has been through the ADB Cooperation Fund for Fighting HIV/AIDS in Asia and the Pacific, established with a $19.2 million grant from the Government of Sweden.
HIV specialists from ADB and its partner organizations gathered recently to discuss what the fund had achieved as it draws to a close at the end of this year.
The 120 participants from governments, UN agencies, and civil society organizations had a lot of good news to discuss. The fund has supported 17 projects in 12 countries, and had its most notable successes when it focused on ADB’s unique advantages: its key role in the development of the region’s new transport and economic corridors, its convening power and knowledge broker status, and its established relationships with national decision-makers at the most senior level.
The Cooperation Fund’s success stories included projects that capitalized on ADB-supported infrastructure projects to mitigate HIV risk along economic and transport corridors. Projects in Cambodia, the People’s Republic of China, the Lao People’s Democratic Republic, Mongolia, Myanmar, Papua New Guinea, and Viet Nam all used this route to bring HIV prevention interventions to otherwise hard-to-reach vulnerable groups such as migrant workers, mobile populations and people living in border areas; and key populations at higher risk of HIV including sex workers, and people who inject drugs.
The knowledge base on HIV in Asia and the Pacific has been greatly improved thanks to a grant from the Cooperation Fund to set up and manage the HIV and AIDS Data Hub. The Data Hub’s website is now the go-to resource for data on the epidemic and response in the region. Other projects under the fund contributed more than 20 publications and other knowledge products, many of which are routinely used by ADB staff in HIV prevention work as part of infrastructure projects.
Partnerships with specialist HIV agencies, in particular UNAIDS, and grassroots organizations that have strong connections to marginalized groups and target populations, have greatly extended ADB’s reach. They have also enabled resources from the fund to strengthen civil society and nongovernment organizations and build their capacity, notably in the Greater Mekong Subregion.
HIV prevention is not a static target and as the epidemic in this region has evolved, the Cooperation Fund has been able to target resources to areas where there are newly emerging vulnerabilities, e.g., in cities such as Manila, Bangkok, and Chennai; and in border areas throughout the Greater Mekong Subregion.
And thanks to ADB’s established relationships with governments and the private sector in Asia and the Pacific, the fund has been uniquely positioned to convene key players from the private and public sectors, build on their experiences, and foster cross-border collaboration. Some of the most innovative projects are those that have brought on board the private sector, such as the Asian Football Confederation, which was able to use its massive region-wide reach to disseminate HIV prevention messages through the Protect the Goal campaign.
Hearing about the successes of the Cooperation Fund—as well as the lessons learned from those projects that were less successful—was heartening. Based on all this good news, it might be tempting to think that it’s time for HIV to move over and make way for other health and development priorities. What a wrong move this would be.
One only has to look again at the data, and the newly emerging epidemics in hotspots around the region, to see how much more work remains to be done.
HIV/AIDS continues to be a significant threat to economic prosperity and health security in the region. Slowing down efforts now runs the grave risk of unraveling the gains made so far, and missing the opportunity to stop the epidemic in its tracks, reverse its course and get on target for zero AIDS by 2030.
In his opening remarks at the meeting in Bangkok, Myo Thant, an ADB Principal Economist in the Office of Regional Economic Integration, said that we need more resources, but we also need to understand how best to utilize these resources. Specifically, there is a need to increase the knowledge base, not just about the epidemic landscape in the region, but also about what works, and how best to invest previous resources in future interventions.
HIV does not exist in isolation, nor does it respect national boundaries. The strengthening of health systems is crucial to improve access to HIV/AIDS testing, prevention, treatment, care and support, including harmonization of services across the porous national boundaries in border areas. All sectors must be brought onside including, public, private and nongovernment agencies. Moreover, greater domestic responsibility for HIV/AIDS investments notwithstanding, support from regional and international funding sources is still essential.
For its part, ADB must continue to be innovative in its contribution to the HIV/AIDS response, strengthen its partnerships and tirelessly use its influence to ensure that this region does not drop the ball on HIV/AIDS.

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Blogs posted for BMJ, Public health issues in Asia

Why real-name HIV testing won’t fly in China

Two interesting documents that came across my desk this week got me thinking about how different HIV-related human rights look depending on where you’re standing. The first was a press release from UNAIDS, UNDP and the International Commission of Jurists about the first-ever judicial dialogue about HIV, human rights and the law. The second was a news story from the China Daily about legislation recently passed in Guangxi Zhuang autonomous region requiring real names to be used for HIV tests.

The authorities in Guangxi, including doctors charged with the task of treating people who are living with HIV, and keeping the epidemic under control, have sound reasons for wanting to use real-name testing. They say it will reduce loss to follow-up: it will be easier to track people down and convince them to get treated. It will also contribute to better public health policymaking because the region will have a more accurate picture of its HIV epidemic.

No it won’t, AIDS NGOs say, because people won’t come forward for testing in the first place, never mind being lost to follow-up. Instead they will at best do home self-testing, which is not accurate and could leave them with a positive test result and no clue what to do next.

It’s a typical example of how public health policy often serves the needs of the health system instead of the patients. One of the main reasons patients prefer anonymous testing is that they want to know their status but have no inclination to share that information. Once the information leaks out of the medical system, all too common in a society where individuals’ rights are routinely trampled on by the state, people living with HIV are subject to widespread stigma and discrimination.

A 2009 survey conducted by the China Stigma Index found that over 49% of people living with HIV interviewed had experienced discrimination related to their HIV status. Over three quarters said their family had suffered the same discrimination. Pregnant women living with HIV are routinely advised to terminate their pregnancies: 12% of the respondents reported being pressured into having an abortion. The children of 9% of respondents were forced to leave school regardless of their own HIV status. Discrimination by medical staff, teachers and government officials was rampant.

So I think it’s great that eminent judges from the Asia Pacific region gathered to discuss what they can do to provide a supportive legal environment for people living with HIV and to protect those particularly vulnerable to being infected. The conversation has to start somewhere, and there were Mainland Chinese judges participating in this ground-breaking event.

But for people on the receiving end of public policy about HIV, it will be a long while yet before the target of zero discrimination is reached. And until that time, the Guangxi authorities would do well to turn around in their minds the conundrum of how to combat HIV and look at it from the perspective of their patients. Until they can guarantee that those who test positive won’t feel the chill of stigma from the very same health care workers responsible for testing and treating them, and until their communities are educated out of shunning them, real name testing is still just a good idea in theory.

 

Jane Parry is a Hong Kong-based public health and medical journalist and researcher.

 

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