One Step Closer: Narayana Health

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The “One Step Closer” series features high-impact non-governmental organizations and individuals, and innovative solutions bringing the world one step closer to cardiac surgery for all. Today’s post features the Narayana Hrudayalaya hospitals group in India, known for its low-cost cardiac surgical procedures, available for India’s poorest.

Dr. Devi Shetty, Indian cardiac surgeon (medically schooled in Mangalore, India, and surgically trained in Guy’s Hospital London, United Kingdom) and healthcare entrepreneur, founded Narayana Hrudayalaya/Health (NH) in 2001 in Bommasandra, Bangalore, India.Today, NH is the largest cardiac hospital in the world, with over 1,000 beds and performing over 40 cardiac surgeries per day, including 16 paediatric heart surgeries. As a whole, the so-called NH Health City, the hospital and its campus’ services, intends to treat 15,000 outpatient visits per day. Through an agreement with Ascension Health’s TriMedx in 2012, NH has expanded to create a network of hospitals across India, providing low-cost cardiac care, in addition to expansion to services as neurosurgery, paediatric surgery, haematology, transplant, and nephrology, among others. Accordingly, the NH network has expanded to 26 hospitals with 6,900 beds across India, employing 13,000 people (of which 1,500 doctors) and treating over 2.5 million people every year.

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NH’s success in reducing costs of cardiac surgery builds on the use of economies of scale and innovative solutions (e.g., using reusable scrubs and natural cross-ventilation instead of airconditioning), which has allowed the price per procedure to drop by 50% (coronary artery bypass grafts (CABGs) dropped 50% to 95,000 rupees or US$1,583 in India, compared to US$106,385 in the United States, $27,000 in Mexico, and $14,800 in Colombia). Other interventions include limiting redundant pre-operative testing and training patients’ family members to take over part of the post-operative care. The mass production of surgical interventions and purchasing has given Dr. Shetty the reputation of the Henry Ford for cardiac surgery.

And yet, the low cost does not come at the expense of quality reduction, as mortality rates (1.27%) and infection rates (1%) after CABG parallel those in the United States. Bed sores, normally present in 8 to 40% of post-CABG patients globally, are close to 0. Data registries, integrated on the Cloud rather than in high-cost data hubs, form a critical part of NH’s model, aiming to continuously improve both the quality of care delivered and the efficiency of use of resources to do so.

The wealth of a nation has little to do with quality of health care its citizens can enjoy.
– Dr. Devi Shetty

NH sets itself even more apart by delivering free surgeries for India’s poorest and poor children, also earning Dr. Shetty the nickname of Bypasswale Baba in India, the Saint who Grants Bypasses. In parallel, a model of micro health insurance (yeshasvini) was set up in collaboration with the government of Karnataka, providing an innovative insurance model for 4 million Indians, severely reducing out-of-pocket expenses and financial catastrophy.

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In the future, Dr. Shetty and NH aim to expand to a network of over 30,000 beds across India and bring costs per CABG down to US$500. “I believe we can dissociate the wealth of a nation from the quality of its healthcare”, he says.

National Surgical Planning

As the international community moves away from long-standing volunteerism (fly-in, fly-out missions) to more sustainable, collaborative approaches to advance global surgical care, integrated frameworks are becoming increasingly important to convene all stakeholders and optimize health system interventions. One such approach are National Surgical, Obstetric, and Anaesthesia Plans (NSOAPs), a framework put forward by the Lancet Commission on Global Surgery as a response to the findings that five billion people lack access to safe surgical care when needed. The framework addresses five crucial domains (infrastructure, service delivery, workforce training and education, information management, and financing) to be integrated in national health plans focused on surgical capacity and access in a country.

During the 70th World Health Assembly (WHA) in May 2017 in Geneva, Switzerland, Zambia was the first country in the world to launch an NSOAP, integrated in its National Health Plan 2017-2021. Inspired by Zambia’s work, Papua New Guinea and Tanzania followed in the months that came after, with many other countries in process of starting or completing the creation of their individual NSOAPs.

Screen Shot 2018-08-11 at 13.20.04Figure 1.: National Surgical, Obstetric, and Anaesthesia Plan (NSOAP) Framework (1)

National plans innately build upon what’s in place, and therefore require a baseline assessment of a country’s surgical system, from the pre-hospital chain to post-hospital follow-up and care, assessed through the six LCoGS indicators: two-hour access to a facility providing surgical care, surgical workforce density, surgical volume, perioperative mortality rate, protection against impoverishing expenditure, and protection against catastrophic expenditure. In addition, on the ground collaboration with local stakeholders, including the Ministry of Health, professional societies, healthcare professionals, civil society, and private and non-state sectors, is essential for fruitful progress and implementation of plans, addressed in a contextual and country-specific way, rather than an all-size-fits-all approach. Accordingly, NSOAPs form an inclusive and integrated policy document guiding a country and holding it accountable to scale up surgical care delivery for the entirety of its population in its efforts towards universal health coverage. Over time, NSOAPs are monitored and evaluated to ensure efficient use of resources and the provision of care, and maximize effects to promote the economic prosperity of the population and the nation as a whole.

To fully address health issues in, especially, low- and middle-income countries (LMICs), integration of cardiac surgical care, as many other subspecialties, will prove crucial. Despite the complexity of cardiac procedures, the need is ever so high, underlined by the global burden of cardiac disease. With 17.5 million deaths each year and 80% occurring in LMICs, cardiovascular diseases form the leading disease cause of mortality in the world. Although prevention is crucial to address this, holistic approaches to reduce mortality and morbidity will have to be built on interventional and surgical care. Creating a framework in which cardiac surgical services, from infrastructure to delivery, are optimized, will require increasing recognition across sectors, but impact hospital-wide settings.

Further Reading:
World Health Organization, 2017 – Surgical Care Systems Strengthening: Developing National Surgical, Obstetric, and Anaesthesia Plans: http://apps.who.int/iris/bitstream/handle/10665/255566/9789241512244-eng.pdf?sequence=1&isAllowed=y

Harvard Program in Global Surgery and Social Change (PGSSC) – National Surgical Planning: https://www.pgssc.org/national-surgical-planning

Congenital Heart Defects

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Congenital heart defects (CHD), defined as clinically significant structural heart disease, are the most common birth defect worldwide, and the most common cause of birth defect related deaths worldwide. As a result, every year, 100,000 babies (children under one) will not live to celebrate their first birthday.

Globally, an estimated 1 per 100 babies are born with CHD requiring treatment or being present by a year of age, although incidence does not vary much between countries and regions.(1) These cases do not include other more benign cases, such as small muscular ventricular (VSD) and atrial septal defects (ASD), which generally close spontaneously before a year of age.

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In the past decades, advances in paediatric cardiac surgery have made it possible to repair or palliate most CHDs, which makes that over 85% of operated cases are expected to survive to adult life. However, because of the lack of human and infrastructural resources in most developing countries, less than 1.5% of children with CHD are able to undergo the surgery they need.(2) Covering the wider paediatric cardiac burden, over 15 million children die or become debilitated each year due to suffering from cardiovascular diseases.

Although some babies are diagnosed during pregnancy or at birth, the diagnosis is often not made until later in life. Sometimes, especially in developing countries, CHD is not detected until adolescence or adulthood, during which the condition is often already associated with complications such as heart failure, pulmonary hypertension and severe polycythaemia. Moreover, children with CHD often suffer from associated defects and up to 50% of these patients present with some neurodevelopmental problems.(3) Nevertheless, the earlier CHD is detected and treated, the higher the chances of survival and the less long-term health complications. One important preventable complication is the risk of infective endocarditis, which has a 20-year mortality of over 50% in patients with CHD, underlining the importance of early intervention and careful follow-up.(4)

The burden of supporting CHD patients falls heavier on countries with higher fertility rates, which tend to have the lowest incomes per capita, which only accentuates the disparity. Costs for open heart surgery are high and are accompanied by additional medical (treatment and follow-up) and non-medical (e.g., transport, which is especially difficult in rural areas or developing countries) costs. Moreover, there is a loss of parental working time when taking children to a medical center, which further puts a financial burden on these families.(5)

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With the epidemiological transition from communicable to non-communicable diseases globally, there is an increasing interest in conditions such as CHD. Nevertheless, because of absolute and relative (maldistribution) shortages of the health workforce and diagnostic and therapeutic equipment, urgent measures need to be taken. Children should have the right to live, in full health, and be able to play with other children of their age without being harmed by the misfortune of where they were born.

References:
1. Hoffman JI. The global burden of congenital heart disease. Cardiovascular Journal of Africa. 2013;24(4):141-145. doi:10.5830/CVJA-2013-028.
2. Young JN, Everett J, Simsic JM, et al. A stepwise model for delivering medical humanitarian aid requiring complex interventions. J Thorac Cardiovasc Surg 2014;148:2480–9.e1.
3. Marino BS, Lipkin PH, Newburger JW, et al. Neurodevelopmental outcomes in children with congenital heart disease: evaluation and management: a scientific statement from the American Heart Association. Circulation 2012; 126: 1143–1172.
4. Delahaye F, Ecochard R, de Gevigney G, et al. The long term prognosis of infective endocarditis. Eur Heart J 1995; 16(Suppl B): 48–53.
5. Hewitson J, Zilia P. Children’s heart disease in sub-Saharan Africa: Challenging the burden of disease. S Afr Heart J 2010; 7: 18–29.

Cape Town Declaration on Access to Cardiac Surgery in the Developing World

On August, 3rd 2018, the “Cape Town Declaration on Access to Cardiac Surgery in the Developing World” was published in the Journal of Thoracic and Cardiovascular Surgery, amongst other journals, in order to raise awareness of the increasing global burden of rheumatic heart disease (RHD).

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In 2006, the Drakensberg Declaration on the Control of Rheumatic Fever and Rheumatic Heart Disease in Africa was released, calling for attention for the prevention and treatment of RHD around the world. Today, RHD remains an important condition, with 34 million being affected by RHD worldwide (equalling the prevalence of HIV), the majority of which lives in low- and middle-income countries (LMICs).

Nevertheless, preventive efforts, although important, have been unsuccessful in eliminating RHD. Furthermore, open-heart surgery (OHS) remains the only treatment for RHD, yet is largely inaccessible for the majority of the world’s population. In endemic regions, the need for OHS runs up to 300 surgeries per 1 million population. Nevertheless, only 22 cardiac centers exist for the nearly 1 billion people living in sub-Saharan Africa, with further limited access in high-prevalence countries as India, Pakistan, China, and Indonesia.

The Declaration acknowledges the need for building local capacity to address the burden of RHD in a sustainable manner, rather than short-term solutions as “fly-in fly-out” humanitarian missions. Long-term partnerships with local collaboration and training ought to create a more cost-effective, effective, and sustainable framework, allowing autonomous local services to be created with government buy-in. However, to do so, coordination of efforts by all stakeholders will prove vital in the long run.

CAPE TOWN DECLARATION
To urge all relevant entities within the international cardiac surgery, industry, and government sectors to commit to develop and implement an effective strategy to address the scourge of rheumatic heart disease in the developing world through increased access to lifesaving cardiac surgery.