The doctor will see you now (if you turn on the video)

health workforceMark Pearson, Deputy Director, OECD Directorate for Employment, Labour and Social Affairs. Also published by Europe’s World

An elderly man with cardiovascular disease tests his own blood pressure, and sends the results to an online application that his doctor can access. Another patient with depression living in a rural area far from health services tells a psychiatrist how he is feeling via a video connection. All of this occurs without the patients leaving their homes.

These scenarios may sound like something scripted by writers of science fiction, but such ‘telehealth’ has the potential to bring high-quality and specialised care to previously underserved populations. Studies indicate patients respond positively to using the technology, and it increases access to health services. Health professionals report that it reduces the need for patient visits, and assists with clinical decision-making. There is also evidence suggesting that telehealth can improve patients’ ability to manage their own health, not to mention lower the cost of healthcare through fewer hospitalisations.

Despite this clear advantage, health systems have yet to abandon their hospital-centric approach to care. If telehealth is such a good idea, why is not being given wide support? One of the most intractable problems holding the service back is a much-needed rethink of the types of workers we will need in future health systems.

Up until now, much of the discussion on the healthcare workforce has centred on the shortage of doctors or nurses. It’s true that many doctors in particular are approaching retirement and will soon need to be replaced. An OECD report released this month shows that countries have substantially increased their training of doctors and nurses, and the numbers are growing. But this is an expensive approach. A recent report by the UK’s National Audit Office has indicated it takes three years and costs about £79,000 to train a nurse, ten years and £485,000 to train a general practitioner, and 14 years and £727,000 to train a specialist. These huge investments deliver healthcare professionals with astonishing skills, but regrettably we do not always take advantage of these skills wisely.

There is evidence of a considerable skills mismatch in the health sector, with a large proportion of health workers over-qualified for the work they do. The 2011-12 OECD Programme for the International Assessment of Adult Competencies survey showed that between 70-80% of doctors and nurses report being over-qualified for some aspects of their work. This suggests an inefficient use of their time and a waste of human capital. To be blunt, is it really worth ten years of training someone to spend much of their day looking into children’s ears to confirm that they are a little bit red and might require some basic antibiotics? Is there not a way their skills could better serve the population’s health?

At the same time, after all that training, about 50% of doctors and 40% of nurses report being under-qualified for some of the tasks they have to do. Education and training programmes need to transform so as to make health workers ‘fit for practice’. The outlook at present is discouraging, as many health programmes teach little about the skills we know to be needed in future systems such as ICT and people management.

Perhaps the biggest challenge will be to rethink ‘who does what’ – or ‘scopes of practice’ in the health jargon. This means letting appropriately-trained clinicians perform tasks they were previously not permitted to. The most common example of this is the nurse practitioner. In some countries, these more advanced nurses, who usually have a Master’s qualification, can prescribe limited medication and order diagnostic tests under controlled conditions. An OECD review in 2010 showed that advanced-practice nurses are able to deliver the same quality of care as doctors for a range of patients. Most evaluations find high patient satisfaction, mainly because nurses tend to spend more time with patients as well as provide more information and counselling.

Is it so difficult to imagine that diabetes workers, when backed with strong ICT support and clear protocols about what to do when symptoms are not within a prescribed range, can be trained to ensure that treatments are followed correctly, leaving those with more expertise to focus their attention on problematic cases? The barriers to realising this vision remain considerable. There are strong lobbies against change, particularly by professional associations. Policymakers need to engage these groups boldly, so they too can begin to see change as the tremendous opportunity to gain new skills and focus on what they do best, rather than succumbing to the impulse to feel threatened.

Traditional roles and responsibilities need to transform, and alongside them so do the antiquated ways of thinking. The evidence base for change is growing, but it needs to be matched by a growing political will. The question is, are governments bold enough to meet the challenge?

Useful links

OECD health statistics

OECD health workforce project

Health workers with right skills in right places needed

Health policies and data from the OECD

Why technology matters for advancing women’s financial inclusion

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The bank can go to her

In preparation for the 2015 Global Forum on Development, which will focus on how access to financing can contribute to inclusive social and economic development, the OECD Development Centre, the United Nations Capital Development Fund (UNCDF) and the Better than Cash Alliance have developed a series of articles exploring the key issues and dimensions of financial inclusion. Today’s post from Beth Porter and Nancy Widjaja of UNCDF and Keiko Nowacka of the OECD Development Centre highlights gender differences in financial inclusion.

Women play multiple economic roles within society. They are consumers, business owners, farmers, employees and entrepreneurs. Regardless of what they do or where they live, women are dependent on market systems and they need access to finance to manage their livelihoods.

The gap between women and men in access to formal financial services is great. In developing economies, women are 20 percent less likely than men to have a bank account and 17 percent less likely to have borrowed from a formal institution in the past year. This disparity, particularly within the population at the bottom of the socio-economic pyramid, has knock-on effects: women’s inability to access finance also impedes them tapping into market opportunities, thus widening the gender gap.

Legal frameworks and cultural norms condition market dynamics and may limit the space in which women can operate and interact. OECD analysis has shown that in many countries (in the Middle East and North Africa region, for example), legal and customary frameworks insist on male signatures for women to open bank accounts. Moreover, women are typically found to have lower awareness and knowledge than men about financial matters, and have lower confidence than men about their financial skills. This can present significant challenges to women in making decisions about their income or assets.

To close the gender gap in financial inclusion — and to expand women’s overall level of access — policymakers and financial services providers need to understand what women value when it comes to financial products and services. In a variety of settings, the answers given by women are strikingly similar: convenient, reliable, secure, private. When these attributes are taken into consideration, the benefits to women — in terms of greater economic participation and empowerment as well as greater account ownership and asset accumulation — are significant.

There is also great value in drawing lessons from informal financial systems in order for financial service providers to cater to women’s financial needs and preferences, as women are often found within this sphere. Because of collateral and other requirements imposed by formal financial institutions, informal services such as microcredit represent an easier source of revenue for women, who are less likely to own land or assets. In the 2014 edition of the OECD’s Social Institutions and Gender Index (SIGI), two-thirds of the countries surveyed had discriminatory laws or practices that restrict women’s access to land, assets and financial services.

Correspondingly, commercial viability must be part of the business proposition to target women and in order to be able to cope with growing demand and be sustainable. This is particularly important, as financial service providers still perceive women as a higher risk, less profitable client group — despite the fact that women in many contexts have been proven to be reliable clients.

The use of digital financial services has the potential to address women’s preferences in new and exciting ways, as well as to reduce the cost and time of service delivery. In Malawi, for example, with UNCDF support, Women’s World Banking and NBS Bank designed the Papfupi Savings Account to give “mtima myaa” or “peace of mind” to its clients. It does so by using mobile phones in rural areas as a transaction point to make deposits and withdrawals, and with the help of the mobile sales team, clients can even open an account in ten minutes from anywhere. The product conveys information simply and visually so that the customer does not need to be literate.

In Niger, evidence from the social cash transfer programme demonstrates that the greater privacy and control of mobile transfers compared to manual cash transfers shifts intra-household decision-making in favour of women.

In Kenya, the arrival of mobile money transfers increased women’s economic empowerment in rural areas by making it easier to request remittances from their husbands who migrated to urban areas for work.

In India, trust was a particularly important issue for women, especially when dealing with unfamiliar mobile technology. In these settings, agents played an essential role in training and supporting women in their use of the technology.

Digital financial services can be offered in many forms including Automated Teller Machines (ATMs), point of sale terminals, cards (pre-loaded or debit), and, particularly promising for women, mobile phones. However, the “digital divide” between women and men cannot be ignored. In many contexts, women have less access and are less adept in the use of technology. For example, the large gaps in mobile subscriptions (there are some 300 million fewer women subscribers than men worldwide) and ownership (women in developing countries are 21 percent less likely to own a mobile phone than men) means that if digital financial services are going to deliver on their promise to women, these gaps in awareness, access and use of technological devices need to be taken into consideration.

Take, for example, the Benazir Income Support Programme (BISP) in Pakistan. It was thought that mobile phones would be a low-cost and convenient way for women in remote areas to interact with a bank. The reality was that many of the women neither had a phone nor knew how to use it. This experience and others like it point to the importance of ensuring that the product is simple and easy to use, and that adequate customer support or training is provided — particularly for illiterate women who have little experience with technology, financial services or both.

Governments also have an essential role by creating an enabling regulatory environment, establishing an appropriate financial consumer protection framework and catalysing a digital ecosystem. They also have a responsibility to remove discriminatory practices and laws for women’s access to finance.

The links between financial inclusion — particularly for women — and broader development goals is increasingly being recognised on the global stage. Greater inclusion has a strong potential to push the frontiers of markets. Addressing the demand and supply issues of financial inclusion for women could offer pathways to new and additional market opportunities that eventually lead to the growth of economies as a whole, not only for women. Indeed, the latest draft of the post-2015 Sustainable Development Goals features financial inclusion as a key enabler to multiple goals. The links between financial inclusion, digitisation and the global growth agenda are priorities for the Turkish G20 Presidency.

Digital financial services have the potential to close the access and usage gap between men and women. Deliberate efforts on the part of governments and providers can help put the tools in the hands of the women ready to use them.

Useful Links

OECD work on financial education

OECD work on gender

International Gateway for Financial Education (IGFE)

OECD Social Institutions and Gender Index (SIGI)

World Bank Financial Inclusion Data

OECD Science, Technology and Industry Scoreboard: Innovation and Growth in Knowledge Economies

When the Reverend William Whewell invented the term “scientist” in 1834, a natural philosopher could probably have read everything published in his (or very rarely her) field and would have known most if not all of the other researchers. There were only 100 or so scientific journals and even by the turn of the century there were only 10 physics PhDs awarded a year in the US (“physicist” was another of Whewell’s neologisms).

Today, Pubmed alone has 21 million articles, adding an average of one every minute, and as Duncan Hull points out, it concentrates on biomedical literature so a huge number of physics, mathematics, chemistry, engineering and computer science papers are indexed elsewhere, perhaps around 50 million in all.

The latest OECD Science, Technology and Industry Scoreboard uses an index of how this mass of information is cited to explore trends in where research is being done and what impact it has.

Intuition still plays a role in scientific breakthroughs, and the individual who can see a connection nobody spotted is vital to progress, but the most influential science these days is done within networks, not only of individuals but of institutions, and at international level.

The Scoreboard shows that greater scientific specialisation and cross-border collaboration can result in increased innovation and the broader the collaboration, the higher the impact of the research. Top research remains highly concentrated though, with 40 of the world’s top 50 universities in the US when all disciplines are considered.  On a subject-by-subject basis, the picture is more varied, with the UK playing a leading role in social sciences, and China with 6 of the top 50 in pharmacology, toxicology and pharmaceutics.

Patents are another way of tracking the impact of science. However, the best level of protection is subject to debate. If protection is weak, technology that exploits an innovation will spread more quickly, boosting growth. At the same time, weak protection reduces the incentive to spend money on R&D.

The quality of patents themselves can be a problem. The Scoreboard’s data show that quality has fallen by 20% over the past two decades in nearly all the countries studied. “The rush to protect even minor improvements in products or services is overburdening patent offices. This slows the time to market for true innovations and reduces the potential for breakthrough inventions.”

One of the most striking parts of the industry section of the STI Scoreboard is the relative decline of manufacturing in OECD countries. In 1990 the G7 countries accounted for two-thirds of world manufacturing value added but they now account for less than half. By 2009, China had almost caught up with the US (and may have overtaken it by now).

The good news for OECD countries is that investment in the intangible assets expected to be the new sources of growth, such as education and skills or organisation, is growing.

Are all patents being filed true innovations? Who is leading this global race? Find out more in this video

Clean water, cold vaccines, cell phones = a simple way to save lives

This post comes to us from Harvey Rubin MD, PhD. Professor of Medicine and Computer Science, University of Pennsylvania and Alice Conant, Harvey Mudd College.  The program they are working on, “Energy for Health” connects access to vaccines and clean water in developing countries with access to the fastest spreading technology in the world: cell phones.

According to the World Health Organization, 3 million people die each year from diseases spread by unclean water. These deaths are a direct result of the current water crisis in developing countries where more than 1 billion people have inadequate access to clean water and 2.6 billion people lack access to adequate sanitation. Together, unclean water and poor sanitation are the world’s second biggest killer of children.

Additionally, at least 2 million people die each year from vaccine preventable diseases. These deaths are not because there is a lack of vaccines and medications in the world, but because there is an inadequate cold chain — reliable refrigeration and storage units from the point of delivery of the vaccine or medicine in the country to the point of delivery to the patient in rural areas in developing countries.   Maintaining the cold chain is an almost overwhelming challenge in countries where resources are scarce.   The cold chain becomes increasingly unreliable as the distance between primary health centers and sub-health centers increases because of the lack of reliable power sources in the rural areas of developing countries.   This is where the cell phones come in.

A recent New York Times article, “Toilets and Cell phones,” informed the public that there are now more cell phones in India than toilets.  Cell phones are the fastest spreading technology in the world, and customers in developing countries account for two thirds of the universal mobile phones in use. Cell phones rely on cell towers, and each tower has its own supply of power. Our goal is to harness an adequate portion of this electrical energy to power refrigeration units and water filtration systems.  This synergy clearly benefits the cell phone service provider as well as the local population—more healthy people, more cell phone users, more cell phone users, more healthy people.  Couldn’t be a better arrangement.

This idea has received huge and enthusiastic support for its potentially transformative impact on world health and human security. By piggybacking access to viable vaccines, medications and clean water onto the fastest spreading industry in the world, we could solve a perplexing global health problem. According to the 2010 World Telecommunications/ICT Development Report, approximately 75% of the world’s rural inhabitants are covered by a mobile cellular signal, and it is estimated that close to 100% of the world will have mobile coverage by 2015.  In order to have mobile coverage you must be within the range of a cell tower (a matter of miles, depending on the territory), which means that if we can utilize the power from the towers to sustain cold chains and water filtration units, by 2015 close to 100% of the world could have access to viable vaccines, medication and clean water.

So far, our first-round calculations behind this technology suggest that it is completely doable. Cell phone towers run on alternating current (AC) power, have a backup energy generator in case the primary electrical supply goes down, and most units already have AC power outlets built into them!  Basic cold chain refrigeration units also run on AC power and consume approximately 200 Watts of power.

As we continue to expand on the research behind “Energy For Health”, we are exploring solutions to the following questions:

1) How does the cell tower distribution correspond with population distribution?

2) How will we monitor the security of the refrigeration and water filtration units?

3) What is a fair and equitable financial model for the installation and maintenance of the systems?

Excitement is growing in our team the University of Pennsylvania and with our partners as we continue to plan the pilot project of this technology and anticipate the enormous impact it will have on healthcare in developing countries. We welcome any ideas and suggestions.