The COVID-19 pandemic uncovered underlying inequities in healthcare and likewise solid new partnerships amongst governments, hospitals, and community-based organizations—partnerships that may function fashions for enhancing well being fairness in non-pandemic occasions.
“Investing in communities, I’ve discovered, is an antidote to the plague of distrust in public well being,” says Raj Panjabi, MD, former particular assistant to US President Biden and senior director for international well being safety and biodefense on the White Home Nationwide Safety Council (NSC).
Panjabi, who served in his position with the NSC from February 2022 to August 2023, has additionally taught at Harvard Medical Faculty and cofounded Last Mile Health, a company that companions with governments to coach and empower neighborhood well being employees to offer important major healthcare to the world’s most distant communities.
McKinsey Well being Institute international chief Pooja Kumar sat down with Panjabi as his tenure with the Biden administration was winding down. As a follow-up to half one of many interview on pandemic prevention and preparedness, beneath Panjabi discusses extra about his private background, his work as a social entrepreneur, and his ideas on well being fairness, entry, and healthcare employee capability.
The interview has been edited for readability and size.
Pooja Kumar: Raj, you and I first met as undergraduates heading to medical college. You’ve had a very diversified profession well being. Inform us a bit about your journey to the place you might be as we speak.
Raj Panjabi: I got here to America as a refugee with my household once I was 9 years previous, round 1990, fleeing the conflict in Liberia. My household misplaced an entire lot, however right here within the US we had an opportunity to rebuild our lives and profit from a neighborhood that rallied round us.
My father had this saying rising up: “No situation is everlasting.” We’re not outlined by the circumstances we face however by how we reply. My dad and mom had been extraordinary entrepreneurs; they hustled and began a clothes store, and that helped put me by means of faculty and medical college.
Whereas I used to be in medical college, I went again to Liberia to see if I may very well be a part of serving the individuals we’d left behind. I discovered utter destruction. Fifty medical doctors to serve a rustic of 4 million individuals. If you happen to received sick in a metropolis the place these few medical doctors remained, you would possibly stand an opportunity. However in case you had been dwelling in rural areas the place there was already a scarcity of medical doctors, made even worse by the conflict, you had been out of luck.
The concept that sickness is common and healthcare isn’t grew to become fairly actual to me as a clinician. Seeing individuals die from situations they actually shouldn’t die from within the twenty first century: issues of childbirth, malnutrition, HIV. That set me on a journey to pursue drugs as a path and likewise to turn out to be a social entrepreneur.
I labored with different Liberians and American well being employees to launch Final Mile Well being, which is targeted on attempting to shut that hole in healthcare by hiring, coaching, and equipping area people members as neighborhood well being employees to actually increase the medical crew and convey care out of hospitals and clinics to the individuals themselves. I had the privilege of main that group as CEO for about 15 years.
‘We’ve received to deliver care to individuals’
Pooja Kumar: You’ve sat within the position of a public sector chief. You’ve additionally sat within the position of the social sector chief in your prior position at Final Mile Well being. How do you see that relationship working 5, ten years from now to handle pandemics and different well being points, just like the healthcare employee dearth internationally?
Raj Panjabi: What I’ve seen in my years as CEO of Final Mile Well being and as a social entrepreneur is that more and more, essentially the most intractable social issues require some capacity to form public coverage, to get financing or have a public subsidy to, as an illustration, make a healthcare mannequin work for the poor, or in rural areas, or for the economically marginalized in city areas.
At Final Mile Well being, working with governments all over the world to get issues like HIV or malaria additional beneath management, we discovered that we’ve received to deliver care to individuals, not anticipate individuals to return to care.
If you happen to’re a toddler, and you’ve got a fever in the midst of a rain forest, and also you’re in a malaria endemic place like Liberia the place I grew up, and it’s important to wait days to your mom to take you all the way down to the canoe, paddle throughout, and stroll by means of the forest to get to a clinic to get to a health care provider to get examined and handled, it’s possible you’ll lose your life. In actual fact, many do.
If you happen to can rent a area people well being employee in that forest neighborhood to deliver that take a look at and therapy to you, assess when you have a sophisticated case, join you to an outreach nurse and convey you to the hospital—that’s the imaginative and prescient of healthcare. What we discovered within the social sector is that the very locations the place that mannequin is essentially the most highly effective—rural areas—is the place a lot of healthcare is publicly financed. And we have now needed to work with many governments to determine tips on how to shift their insurance policies to higher pay these employees, higher equip them, higher practice them.
The vast majority of neighborhood well being employees are girls. And in case you take a look at the best way girls are compensated within the healthcare sector, we are able to see that the gaps are broad. In accordance with a latest Girls in World Well being report, six million girls go unpaid or underpaid each single yr in healthcare.
So the flexibility to see an issue within the social sector and reveal options that might work—as an illustration, placing neighborhood well being employees beneath contract and paying them—then working with the general public sector to remodel coverage, that’s simply logical—whether or not it’s between this nation and others, or inside this nation, between federal, state, native, tribal, and territorial well being departments.
Healthcare employee capability
Pooja Kumar: I believe one of many actual issues of our era is healthcare employee capability. It seems like there are a lot of areas within the US and all through the world the place it’s turning into an increasing number of pressing, as people are burned out from COVID-19, discovering different alternatives to have the ability to feed their households, and so forth. If you happen to had a magic wand, what could be the highest two or three belongings you would do to actually improve healthcare employee capability?
Raj Panjabi: To start with, I might work inside the personal sector, public sector, and social sector to make a dedication to have gender fairness in pay. Abolishing the concept girls ought to receives a commission much less, or that caregiving roles—whether or not staffed by girls or males—ought to receives a commission much less. We’ve got to shift from a ideas and values perspective. And that should come from the CEOs of hospitals; it wants to return from the presidents of nations; it wants to return from governors of states.
The second factor is to then shift coverage to allow that, and to hardwire into each a part of the healthcare and public well being system a spotlight not simply on merchandise however on individuals.
A technique we’ve finished that within the Biden–Harris administration, by means of the American Rescue Plan Act of 2021, was to place $3.2 billion of funding into America’s public well being workforce on the native and state degree: 107 jurisdictions, in each state on this nation, have $3 billion over the following 5 years to place towards knowledge scientists, epidemiologists, and veterinarians who work to cease the fowl flu outbreak, and neighborhood well being employees.
The third factor we’ve received to do is to construct the general public’s understanding and the political constituency to maintain that going. I believe all of us perceive how essential our medical doctors, nurses, lab scientists, and neighborhood well being employees are when a pandemic occurs. You noticed murals celebrating medical doctors, nurses, neighborhood well being employees, and others; you heard individuals bang pots and pans when hospitals had been overwhelmed with COVID-19 sufferers.
We want a constituency of people that push their leaders on the native degree to maintain investing in these well being employees in between main pandemics, not simply when we have now a pandemic.
There’s a transparent, commonsense case to make for it. There’s additionally a really robust financial case to make for it. For each greenback you spend money on well being employees—closing that scarcity that we have now right here and all over the world—you get $9 of return. Within the case of neighborhood well being employees, for each greenback in, you get $10 again, one evaluation simply confirmed. And that’s by averting and mitigating outbreaks, by extending more healthy life years, and thru job creation. This shouldn’t be seen as a value; when it’s finished the appropriate approach, it’s an funding. There’s all the time extra to do to ensure the well being sector is contributing to the job creation we want over the long run.
The position of expertise
Pooja Kumar: What concerning the position of expertise? There’s been quite a lot of discuss it, and the way we are able to prolong the attain of healthcare by means of expertise. How do you see that enjoying out?
Raj Panjabi: Ever because the introduction of medicines and diagnostic checks, expertise’s been on the core of drugs. I noticed how highly effective this was in my first job in well being, about 22 years in the past, on the Yukon River Delta in Alaska, the place the state had labored for about 50 years to attempt to prolong the attain of healthcare to rural communities throughout the state.
In 2001, they had been coaching area people well being employees and nurses in each Alaskan Native neighborhood—fishing villages on the Delta, as an illustration—on tips on how to turn out to be a part of a telemedicine system. On the time, that meant, for instance, utilizing digital cameras to take photos of rashes so they may ship them to dermatologists in regional hospitals for assist with a prognosis; or sending video otoscopies of a kid’s eardrums to ear, nostril, and throat specialists to assist diagnose and handle recurrent infections of otitis media. Know-how was used to coach these neighborhood well being aides to triage when an grownup introduced with chest ache. You’ve received to have the ability to inform: Is it due to their coronary heart? Or perhaps they’re anxious? Or perhaps they’ve received a bit heartburn? You possibly can’t try this wherever on the planet except you could have an EKG. A part of my job was to work with these neighborhood well being aides to show them to make use of a quite simple crimson, yellow, and inexperienced color-coded, 12-lead EKG after which transmit the EKG tracings to a heart specialist or a normal doctor to diagnose.
I deliver up that instance as a result of the explanation the Alaskans had been [training community health workers] was, at the start, to enhance high quality of care, to save lots of extra lives, and to cut back struggling. However they discovered it additionally supplied a approach to enhance fairness, to deliver the form of care that wasn’t out there in these rural communities, and to be extra environment friendly economically.
That concept of extending healthcare that’s excessive tech, excessive contact, and neighborhood based mostly with expertise, you see it play out in many various methods, together with throughout the COVID-19 emergency section of the pandemic when stay-at-home orders had been in impact in lots of locations. It grew to become tougher to coach physicians and nurses on the entrance strains in new protocols on the similar time you had a novel pandemic and needed to be taught new issues.
As with my Massachusetts hospital on the time, a few of us volunteering on the entrance strains realized on-line what to do once we went into the COVID-19 testing clinics in April 2020. In Ethiopia, teams like Final Mile Well being helped the Ethiopian authorities practice their 40,000 well being extension employees and their medical doctors and nurses on Ethiopia’s medical protocols for COVID-19 by leveraging smartphones and creating apps that allowed the federal government to see whether or not or not a health care provider or nurse really understood the protocol for administering oxygen, or offering therapy, by transmitting their quiz scores from the app centrally, in actual time, after which adapting and sending out extra coaching as we realized about therapies that labored.
Take into consideration any future pandemic—we’re going to need to develop, normally, novel therapies, or at the least take a look at current ones. And we’ll want that form of functionality once more. We’ll additionally want it between pandemics. The necessity for addressing high quality, fairness, and effectivity goes to wish extra of that merger between high-tech and high-touch care.
Investing in healthcare employees
Pooja Kumar: Listening to you speak, it’s simply so evident that we have now many examples to attract on, whether or not they’re native to the US, or international, and that there’s no scarcity of the way individuals have tried to deal with this drawback of not having sufficient healthcare employees. A few of our analysis suggests there’s going to be between a 20 and 30 p.c scarcity of nurses within the US alone.
How can we transfer from an experimentation mindset to a scaled mindset? Any classes realized, out of your vantage factors in public sector or social sector, that will say, “That is how we have to do it to begin making an even bigger dedication to vary”?
Raj Panjabi: One of many key issues is to see the chance for harnessing, leveraging, and fascinating the elements of the workforce which may be thought of the bottom paid, the least compensated, essentially the most peripheral, the least appreciated, and really acknowledge their contribution, assist their contribution, and have interaction them in medical care and in public well being by elevating their standing.
In rural elements of sub-Saharan Africa the place I’ve labored, that usually means taking a volunteer neighborhood well being employee and professionalizing their work. Meaning giving them a contract to receives a commission; it means making certain they’ve a profession path and a coaching program to continue to grow; it means supervising them with a clinician and a nurse, which additionally means elevating the nurse’s work from usually being underappreciated on the entrance strains, and less-often, turning into the chief within the healthcare system.
A lot of the international locations that make investments locally well being employee usually discover that the nurses are requested, and wanted, to play management roles, which makes the healthcare system stronger and permits us to handle and shut a number of the hole within the scarcity of well being employees.
Some states have labored to shut the physician scarcity in rural areas by sharing extra medical duties with nurse practitioners and doctor assistants and empowering them to do extra—usually with some supervision from a doctor who is perhaps distant, or by means of telehealth.
When care duties get shared, sufferers fare higher as a result of care comes nearer to house: greater entry, higher high quality, decrease prices for the healthcare system. If you happen to speak to those that are main these packages, you’ll discover a better quantity of satisfaction and fewer burnout as a result of medical doctors can play to the highest of their license, nurses can play to the highest of their license, and so they get to share duties with others who in any other case wouldn’t be a part of the crew.
Well being fairness
Pooja Kumar: Raj, the time period “well being fairness” has been thrown round rather a lot just lately, and perhaps much more so popping out of the pandemic. Individuals have very totally different definitions for what meaning, and the way we are able to really get there. What’s your definition of “well being fairness”? And what would you level to as one or two issues that you just suppose we may very well be doing in another way to attain fairness in how we ship healthcare?
Raj Panjabi: Whether or not you’re inequities between city and rural areas; between Black, Brown, and White individuals; between schooling ranges or revenue ranges; the wealthy and the poor—these inequities had been rising in lots of locations earlier than the COVID-19 pandemic. And we had a power inequity that had an acute-on-chronic occasion: we had a pandemic emergency on prime of inequities that already existed.
There’s no one-size-fits-all resolution to inequities. However there are just a few ideas that I believe we are able to use, and that I’ve seen work. At the start is to look past our partitions: as suppliers, as well being methods leaders. Meaning trying past the partitions of your workplace, the partitions of your clinic, the partitions of your hospital. Meaning going to the neighborhood to pay attention and be taught, and assembly with neighborhood organizations. They’ve the lived expertise and experience and belief of their neighborhood.
The second piece is to spend money on the individuals closest to the issue. It means issuing financing grants throughout a pandemic, because the state of Massachusetts did—not simply to the hospital system across the nook to face up the medical doctors, nurses, remedies, clinics that we want but additionally to area people organizations like La Colaborativa, to assist them within the work of offering meals help, of training their neighborhood, of coping with the social/financial wants locally once we didn’t have a vaccine. After which giving them a grant once we did have a vaccine to shut the gaps in vaccine inequity, and to handle the problem of vaccine hesitancy.
Once we’re closing gaps, once we’re attempting to handle inequities, distrust is an enemy. Investing in communities, I’ve discovered, is an antidote to the plague of distrust in public well being.
The story of healthcare, the story of public well being usually will get informed as if communities are the objects of change: some heroic physician or healthcare system saves the day. That’s just one a part of the narrative. Communities are the themes—the brokers—of change. We’ve received to make care extra proximal, public well being extra proximal. And I believe trying past our partitions, investing within the individuals closest to the issue, is a giant a part of that method.