OBWOGO: Example of First Principles Thinking in Health Care —Universal Health Care [LO3-CRITICAL THINKING]

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In today’s lesson, I’ll use critical thinking and reasoning through First Principles to address the challenge of accessing health care in Africa. To do that, I'll follow five steps: Step 1: Identify the problem; Step 2: List the main obstacles; Step 3: Question assumptions; Step 4: Uncover the first principles; Step 5:?Come up with possible solutions.

Step 1: Identify and clarify the problem

Africa is conspicuously behind the developed world in public health achievements by more than one-and-a half centuries. For example, malaria is a preventable disease that has been virtually eliminated in wealthy countries and, yet, it kills around 400,000 people a year, mostly African children. Tuberculosis, which killed 1.5 million people worldwide last year, is preventable and, in most cases, treatable. HIV is a preventable and treatable disease. Non-communicable diseases such as diabetes and hypertension are also preventable and treatable.

?The last cholera outbreak in England— the 1854 Soho cholera epidemic which killed tens of thousands— was brought to a sudden halt even without a clear understanding of the cause, transmission or cure of the disease. In 1900, 194 out of every 100,000 U.S. residents died from TB but, by 1940, before the introduction of antibiotic therapy/ streptomycin, the crude death rate had decreased to 46 per 100,000 persons. To compare, in 2020, the TB death rate in Kenya was 39 cases per 100,000 people (World Data Atlas) compared to 0.2 cases per 100,000 people in the USA.

Often, when countries think about investing in health care, what comes to mind? Building 10-storey complexes, setting up cancer units, buying diagnostics such as MRI machines, or dialysis units, or starting open heart surgical units. These services are definitely necessary but history tells us that developed countries didn’t get where they are by investing in sophisticated medical technologies and treatments.

In reality, financial resources for public health are scarce, and the situation is only getting worse.

?Step 2: List the main obstacles: The global efforts to improve access to quality and affordable health care services focuses on sustainable financing solutions to achieve universal health coverage for all by 2030 in line with the third goal for sustainable development. In many poor-resourced countries, inadequate financing of health care services and low recurrent to capital expenditure ratio results in minimal resources available for human resources, infrastructure, drugs, equipment and diagnostics, leading to poor quality services and diminished demand.

?Step 3: Question the assumptions: Is insufficient funding the main problem? Do we understand how the allocated resources impact health outcomes such as preventing new cases, reducing deaths or improving well- being? Do we make the most out of the available limited resources? How are decisions between two promising programme options made when we can afford only one? Can we demonstrate whether the benefits of our healthcare programmes such as malaria, tuberculosis or HIV and specific interventions (testing, treatment and patient follow up) are worth the costs? What is the evidence?

Step 4: Uncover the First Principles: In lesson 1 and 2, I said that to understand reality— idea, problem, concept— the assumptions we make must be based on facts/ principles in order to yield the results we want, or else we go on a wild goose chase. In this step, I am going to question assumptions that we often make about investing in health care and provide evidence in order to uncover the First Principles.

First, studies have shown that most improvements in health outcomes and life expectancy in the USA and Europe in the 20th century resulted from public health improvements in living conditions such as nutrition, housing, clean water and sanitation (crude mortality rate fell from 800 to 200 per 100, 0000 between 1900 and 1940) long before modern medical interventions such as antibiotics and intensive care units were available (see Fig. 1).

It means that no country, however rich, can treat or spend itself out of epidemics of infectious and non-infectious diseases and, the only way to realise UHC— and achieve the third sustainable development goal— is by prioritising preventive, promotive and primary health care (this is a First Principle).

?Second, scientific approaches and interventions to prevent and control infectious and non-infectious diseases, and to improve health, have traditionally focused on the health care system as the key driver of health and health outcomes. However, studies have shown that about 80 percent of what impacts a person’s health are non-clinical factors, and that access to healthcare— those moments in a healthcare setting— accounts for only 20 percent (see Fig. below). Although health care (‘medical care’) is essential to health, it is a relatively weak health determinant, and studies have shown that health outcomes are driven by an array of other factors, including genetics, health behaviors, social and environmental factors (this is another First Principle).

Third, there’s evidence to show that improving health and achieving health equity requires broader approaches that address social, economic, and environmental factors that influence health (this is also a First Principle).

?Step 5: Come up with possible solutions. It means that as a resource-limited continent, we can’t treat or spend ourselves out of epidemics and— to realise universal health coverage (UHC) ?and achieve the third sustainable development goal— Africa needs to address root causes of illnesses (see Figure below) and focus on preventive, promotive and primary health care and direct funds to priority populations, high impact interventions and services such as reproductive, maternal and child health, adolescent health, infectious and lifestyle diseases.

In the next lesson, I'll address tuberculosis through the lens of First Principles Thinking.