How can self-care help health systems rebuild better during COVID-19?

Whilst there is now global consensus on the importance of self-care and recently published guidance from the WHO, there remains a need for a seismic shift when it comes to implementation.

Barriers to self care: Access and affordability:

We created Babylon with a single ambition: To make healthcare accessible and affordable for every person on Earth.

Accessible:

To make it more accessible, we can leverage the fact that the majority of the population is connected through mobile networks. We are working to deliver most of the services most people need through the devices most already have. devices they already have that will make it much more accessible than what it used to be in the past when people had to travel from the villages town cities on the buses or cars into the doctor’s surgeries and clinics to be seen.

In Rwanda today we deliver health care to the entire population where the government has made digital first primary care universally available to the most remote villages to the center of the galley to the towns to the cities in one of the financially poorest countries in the world we do the same in UK one of the richest countries in the world in Canada United States

However, there is no accessibility without affordability, and this is a bigger challenge.

To bring costs down, we need to understand the origins. There are two main cost sources in any health delivery system.

Firstly salaries, which account for two-thirds of the global spend in the sector. In every country, healthcare professionals are an expensive resource. At the same time, they’re in short supply. The latest estimates from the WHO state that the world is short of 7.2 million healthcare workers, and this figure rises to 12.9 million by 2035.

Secondly, timing. By the time most patients seek medical attention, a minor problem has grown into a bigger one, requiring relatively expensive treatment. When unaddressed, a $10 problem can become a $100 solution, and management for preventable, predictable diseases end up commanding almost 60% of the overall spend.

So everything we are doing with our technology is to solve for these main cost sources by enabling automation and prediction.

Automation: To make healthcare affordable, we must optimise clinicians’ time and focus. Tasks that can be automated must be, so medical professionals can spend their time doing what machines can’t.

Prediction: To solve this, we must develop monitoring technologies that can identify nascent issues and enable prompt action. Early diagnosis, health assessment and predictive analysis are crucial. In this scenario, healthcare becomes about keeping people at the peak of their health, rather than crisis management for the sick.

We’re combining human expertise with the power of technology to drive solutions forward on these fronts. By doing so, it’s possible to radically rework the system everywhere, for everyone.

We’ve created a digital-first model of healthcare delivery, which starts with AI (self care), and only connects to a clinician virtually when needed, and arranges physical examinations and intervention only when clinically necessary.

We’ve created a digital first, end-to-end healthcare delivery model that aims to meet most people’s needs, in sickness and in health. We offer a continuum of AI, virtual, and physical healthcare to serve each person most appropriately, according to their needs.

So to sum up, as most costs in healthcare are spent on salaries and predictable preventable diseases, fundamental cost reduction will only be possible through, respectively, automation and prediction; and then directing users to the right part of our service for their needs. All three have to come together to enable the service to be affordable. Automation allows us to reduce the high labour costs that other healthcare providers see, prediction allows us to intervene in the medical issue earlier than the patient would previously and direction to the correct service allows members to avoid using expensive parts of our service such as consultations when they could be safely cared for more cost-effectively.

To make this affordable therefore, we need to create a very disciplined funnel that delivers the most appropriate care at the most appropriate cost to each patient according to their needs, while minimising the use of scarce and expensive clinical resources.

The following pyramid illustrates how we need to be constantly innovating to move care from the top of the pyramid downwards, while maintaining or improving that care, to achieve the associated cost saving.

Covid19 forced us to start looking at the way we deliver health care in a fundamentally different way. What the system experienced was that as soon as the pressure on the system grew, almost the entire functionality of the system at the beginning came to a halt forcing everybody to rethink the way they’ve been delivering healthcare. At Babylon we deployed our technology and our capability and everything we had learned in the last five years to be able to deliver this pyramid model.

We have shown how effective this approach was for the management of COVID-19, and now need to deploy it everywhere else, especially for the management of chronic conditions that consume the bulk of the resources in healthcare.

Regulation:

As senior clinicians and scientists at babylon, we take our responsibilities to provide safe and effective care extremely seriously. Creating services that are available anytime, anywhere at the touch of a smartphone button is core to what we do, but even more important is the ongoing testing, quality improvement and external assurance that we undertake to ensure the clinical safety of all elements of our work. Our job is not just to build and provide great services across the world, it is to set the climate and culture across the 2000 people who work for babylon, including 200 GPs, embedding patient safety as a priority in everything we do. We believe in transparency, we welcome the feedback from the global community of clinical colleagues and the general public, and above all we know that no matter how a service performs today, it can always be better tomorrow. By setting out our approach, we hope to bring even greater transparency to our work, to help raise the bar on patient safety, and to dispel a few myths along the way

Babylon provides a suite of digital health services, provided via mobile applications and on the web. One component of these services is the ability for people to use a symptom checker to check their symptoms

Integral to our clinical safety approach is the clinical evaluation of all products, and the clinical safety and risk management processes that are in place across all products and services. To ensure the continued safety and effectiveness of any products in a live environment the above elements are regularly reviewed and updated, overseen by a Clinical Safety team, and documented in the Clinical Safety Management System, as per recognised NHS Digital safety standards.

The triage system described above is regulated under the EU Regulation on Medical Devices 2017/745, overseen by the MHRA in the UK, and is registered as a Class 1 Medical Device. The system is also CE marked, demonstrating compliance with all relevant European standards.

Prior to deployment of the triage system within the NHS service a thorough process of due diligence was undertaken alongside NHS England colleagues

All triage algorithms undergo thorough clinical evaluation both pre- and post-market, with this process being repeated for all major updates since initial release.

This doesn’t entirely answer the question, but MOHs in Uganda, Nigeria and Ethiopia are all developing consolidated national self-care guidelines for sexual and reproductive health which will help place self-care at the forefront of their national health agendas. Ensuring access to vulnerable populations will be included in all guidelines, I’m sure.

Policies should look at new approaches to behavior change when they are determining future investments in health promotion, prevention, and self-care initiatives. Effective educational campaigns centered on promoting the benefits of self-care are few and far between; nor are there many noteworthy programs that encourage people to take greater control of their own and their family’s health. To address this unmet need, authorities should consider instituting health promotion programs that begin at an early age, continuing through school and into the workforce. Governments don’t need to do these programs alone and should consider utilizing multi-stakeholder-initiatives and public-private partnerships.

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Alice - to your question about language - the reality is that access to self-care is particularly challenging for lower income individuals and minority populations. These groups often work multiple jobs and face the decision between putting food on the table or buying essential medicines to manage a single or several chronic conditions. Life’s competing demands – work, school, childcare, and more – are even more exacerbated among these populations, making the ability to engage in self-care even more of a challenge. How do we expand out the definition of self-care to make it resonate with all populations and not just a select few?

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@ AliceAllan, you make a very good point that self care means different things to different people/cultures. Certainly we have to be cognizant of this. My sense is that one of the things we are trying to achieve through this movement is to redefine what self care is and to allow it serve health care more broadly, and not just be the domain of middle-upper class luxury

A good example is the work the government in Indonesia has done with NGOs and other partners to commit to micronutrient access for their people. A few years ago, they recognized that about a quarter of women of reproductive age had nutrient deficiencies and 30% of children were born stunted. Through partnership, they carved out significant resources from their health budget to help educate their communities about the importance of prenatal micronutrient supplementation and distributed interventions. We need to see more countries making an effort to create policies that will make healthcare accessible to all.

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Affordability and access are clearly barriers. In an article for Business Fights Poverty, Gillian and Scott Ratzan highlighted some interesting approaches including product reformulation to reach certain price points.

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There is no easy answer for this as there is in theroy a lot of data we can consider. A simple approach that was used previously was to detemrine if a self-care intervebtion caused a reduction on reliance of resources (& savings were calculated in that way) but again this is only possible if we are able to catpture the right data a- ideally over a long period of time to acount for seasonality and other factors.

The social return on investment approach is very interesting and is gaining momenetum. It looks at things like traditional health/economic cost savigs but also quality life and other less-tangible outcomes that mean so much to people (the self-carers).

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Still on my micronutrients topic, Unicef’s approach to affordability is to continuously work with different producers to stimulate the market, to reduce costs and providing technical support and supply provision to countries that require it leveraging its position as the major worldwide buyer of products such as RUTF or MMS, Unicef Supply division works also with producers to ensure high quality standards are achieved, A simple graph on Unicef’s supply division website can show the historic changes in price of MMS facilitated, in part, by Unicef’s work with suppliers and govt’s.
https://public.tableau.com/profile/supply.division#!/vizhome/UNICEFPricedataoverviewforvaccines/Fulldashboard

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From our perspective benefits of self-care can be expressed around three pillars:

Better choice

Self-care gives people greater availability of effective healthcare. It saves individuals time and effort, by allowing them to manage many health conditions conveniently and successfully by themselves. It lets individuals address basic needs without the complications and added effort of going to see a doctor.

The value of self-care goes beyond its impact on resource constraints. Self-care interventions give users greater choice, access, control, satisfaction and affordable options to manage their healthcare needs. Self-care can recognize the strengths of individuals as active agents in their own health care, and not merely passive recipients of health services.

In the United States alone, primary care physicians estimate that 10 percent of visits to their offices could have been avoided by using OTC medication, and 92 percent of physicians agree that OTC medications are effective and appropriate for first line of treatment (1)

Better care

Self-care empowers people to take their health and wellbeing into their own hands, giving them the incentive to improve their quality of life. It plays a key role in the prevention of certain conditions and improves recovery times where total prevention fails. It’s a critical part of well-being at all stages of life.

Better value

Self-care helps combat rising healthcare costs around the world. Short-term investments in self-care lead to demonstrable long-term savings for governments and healthcare industries across the world. Self-care eases the workload of strained healthcare systems by enabling them to allocate resources more efficiently and effectively.

According to WHO, self-care will ease the burden on overstretched health systems, reduce costs and increase the effectiveness of care.

The cost savings associated with self-care are beneficial to the whole of society – to the patient, the healthcare system, and the broader economy:

  • Europe : moving 5% of prescribed medications to non-prescription status across Europe would result in estimated total annual savings of more than EUR 16 billion (2)
  • United States : Every $1 spent on Over the Counter (OTC) medicines saves the US healthcare system more than $7 dollars. (3)
  • Latin America : $3 billon are used in the treatment of non-serious conditions by Public Health Systems. (4)

(1) http://overthecountervalue.org/white-paper/#findings
(2) Joshua Noone & Christopher M. Blanchette (2017): The value of self-medication: summary of existing evidence, Journal of Medical Economics, DOI
(3) The Value of OTC Medicines to the United States, IRI, Mar. 2019
(4) https://www.infoilar.org/teste/wp-content/uploads/2019/04/BROCHURE-VALOR-AUTOCUIDADO-ILAR.pdf

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We can look at affordability in a few ways:

  1. Policy can help with this. For instance, in the U.S. there are government programs which create tax-free health and flexible savings accounts which help you plan for unplanned medical expenses and also allow for purchases of many OTC products
  2. Companies can better understand their audiences and what they value. At Bayer we do a lot of work to understand what people want in a self-care solution. We know they want a product that’s works well on the first try. Think about the smallholder farmer in Brazil who has a backache and doesn’t get paid if she doesn’t go to work. She needs something that’s going to get rid of the pain quickly (in a non-addictive way) so she can go to work and be able to take care of her family. So, we sell Flanax (Aleve) in a two-count format so that she can just buy what she needs and can afford today without trading off quality.

New data landscapes (that integrate health, social care,community care, mental health & other data) can help us make the absolute case for self-care by illustracting where the avings manifest in the system (whcih ae not usually always in health).

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Anoher impportant barrier is lack of a unified way to ‘measure’ the self-care capability of individuals. There are many proxy masures for self-care and more work is being done in that space.

Totally agree! It also leads us to the big questions around data: transparency, use of data, who owns the data etc

I think one of the biggest barriers is that we are asking people to change their behaviour. Access to self care for self-treatable conditions in the UK is good. 99% of people live within 20 minutes of a pharmacy, there’s a wide range of over-the-counter products available to treat a wide range of conditions… People should find it easier to access advice and treatments from their local pharmacy, but many still continue to visit the GP or A&E.

Agree the micronutrients topic is critical, especially for pregnant women in underserved communities. Ensuring a mother has the vital nutrients necessary is a critical health intervention for both mother and baby. It’s also a key intervention to ensure every baby has the best start in life!

@elise and @austenelosta from a Dr’s perspective how would increased use of self-care change the doctor/patient dynamic? Is there a barrier that people just want to listen to a Doctor and don’t trust their own knowledge?

A2. During COVID-19 self-care has been particularly put under the spotlight and proved its integral role in healthcare systems. Certain flexibilities have occurred in light of the pandemic, including:

  • Pharmacies have been allowed to remain operational for longer , modify prescriptions, produce disinfectant gel and dispense alternative medicines without consulting a doctor to ensure the continuity of treatment among vulnerable persons. Some concrete examples include:
    • In Italy Federfarma, in collaboration with the Italian Red Cross, launched a home delivery service to ensure continued access to medicines and medicinal gases while protecting the safety of vulnerable patients.
    • Pharmacies in Australia now provide medical management consultations to eligible patients via telehealth.
    • In Korea, pharmacies are working with the government to provide an equitable solution to the shortage of face masks.
  • Other regulatory flexibilities have occurred to ensure the continuity of supply amid increased demand for self-care products including nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen.

We need to learn from such flexibilities and to work with all the actors to create further regulatory frameworks that truly enable to harness the power of selfcare for better healthcare systems for all.

It is important that we integrate the lessons from these regulatory flexibilities in the future discussions about regulation of the healthcare sector.

Governments and manufactures need to work hand in hand to manage the supply chain so that medical equipment is available. We also need a global regulatory framework that encourages investment in self-care and encourages its use as a primary component in the delivery of all health care.

if you see my answer to question 2. In delivering our mission of making healthcare accessible and affordable to every person on the planet - it is only possible by using AI to augment our clinicians, in the form of a symptoms checker for example as the first point of self care. Building the AI is the expensive part and is what we do at Babylon so that we can provide that for free for everyone. We’ve designed our AI to empower people with knowledge about their health and help relieve pressure on clinicians.
Our AI mimics the way a doctor operates, performing some of
the cognitive tasks they carry out. Things like interpreting, reasoning, decision-making and learning. Our AI revolves
around three main things: the knowledge graph, the
comprehensive health record and the probabilistic
graphical model. This means that Babylon can develop AI
tools to put patients in control of their health and alleviate
the burden of administrative tasks for GPs.

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I completely agree about the issue related to behavior change - it is so difficult! Programs exist with effectiveness on offering incentives to change behaviors (think of Vitality in the UK or US or their parent company Discovery in South Africa), though how does this tap into the intrinsic motivations that are required to change health behaviors?