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FROM CHALLENGES
TO OPPORTUNITIES
SUSTAINIA
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MONDAY MORNING
FROM CHALLENGES
TO OPPORTUNITIES
ACKNOWLEDGEMENTS
DNV GL and Monday Morning Sustainia would like to thank the following for their
contribution to the publication:
The participants at the roundtables in Shanghai, Brussels and Washington DC.
For each roundtable we were happy to see a diverse group of patient representatives, professionals, policy makers, providers and researchers working together
on mapping challenges in their region and pointing towards opportunities for the
future. Their willingness to share experiences and thoughts has been an invaluable part of this publication.
The regional experts. Thank you to Mr. Alex Lam, Ms. Weiwei Zhang, MEP
Christel Schaldemose, Professor Francesco De Lorenzo, Professor Bob Smith and
Ms. Britanni Kessler for sharing their perspectives on the present challenges and
future possibilities for healthcare in China, Europe and the USA.
The change-makers. Thank you to Ms. Susan Sheridan, Professor Jeffery Lazarus
and Professor Stephen MacMahon for sharing their stories of creating change
in the healthcare system and thereby inspiring others to dare dream of a safer,
smarter and more sustainable future for healthcare.
© DNV GL and Monday Morning Sustainia 2015
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FOREWORD
The unfolding science of
patient engagement
Over the last 5 years of evangelizing a
new view of the role of the patient in
medicine, it has become apparent to me
that changing the cultural conversation
about who is capable of what is challenging because it creates a shift in the balance of power. The people that had been
viewed as the responsible leaders can
experience a loss of power and authority.
While the Scientific Revolution brought
an understanding of how medicine works,
one of the unintended side effects was
the disenfranchisement of anyone without
medical training. Today, we are in an era
of awakening that recognizes the need to
better incorporate patients in their own
treatment programs. We cannot co-create healthcare systems if providers do
not accept patient engagement as both
helpful and necessary.
In my case, my oncologist agreed to be
quoted in the British Medical Journal
saying that the information I got from a
patient community about how to cope
with side effects of a treatment that
sometimes kills people increased my
chances of survival. Clearly, change is
possible when knowledge in the patient
community is harnessed.
In order to create that, we must acknowledge the clear evidence that activated,
engaged and informed patients today are
quite capable of truly improving their outcomes. If we create a scientific model for
patient engagement, one of the parameters will be usability. In any other industry,
if what you want the customer to do is
too difficult, you go out of business. In
medicine, you blame the victim.
The art of culture change – in healthcare
as well as any other matter – is to see
clearly what is newly possible without
giving up what has always been valuable.
This publication helps guide us to that
goal by outlining our current state of
affairs and offering exciting opportunities
for change.
One of the most wonderful things that
could happen in my view is for the doctors and nurses and researchers whose
work saved my life to find that they themselves now have a better life because
their contributions can unfold in a richer
more effective environment.
That is co-creation.
E-PATIENT DAVE BIO
Dave deBronkart, known on the internet as e-Patient Dave, is the author
of the highly rated Let Patients Help: A Patient Engagement Handbook
and one of the world’s leading advocates for patient engagement. After
beating stage IV kidney cancer in 2007 he became a blogger, health policy
advisor and international keynote speaker. An accomplished speaker in
his professional life before cancer, he is today one of the best-known
spokesman for the patient engagement movement, attending nearly 300
conferences and policy meetings internationally, including testifying in
Washington for patient access to the medical record under Meaningful
Use.
e-Patient Dave was a participant at the Co-Creating Healthcare
Roundtable in Washington DC
By e-Patient Dave deBronkart, healthcare expert, author and cancer survivor
dedicated to patient engagement and
advocacy
I propose that we need a new scientific
approach to understanding the role of
the patient.
4
5
Table of
Contents
8
66
INTRODUCTION
EUROPE– SHARING A
HEALTHCARE GOAL
68
Protecting universal care
71
Creating a patient safety
culture
10EXECUTIVE
SUMMARY
75
Towards co-creation at
different speeds
79
Growing demand and
shrinking budgets
81
EU guides the way to more
effective care
13 WHAT WE DID
AND WHY
14
16 17
18
MAPPING THE STATE
OF HEALTHCARE
ROUNDTABLES WITH
KEY STAKEHOLDERS
HIGHLIGHTING
OPPORTUNITIES,
INSPIRING CHANGE
WHAT YOU SHOULD
KEEP IN MIND WHEN
READING THIS
PUBLICATION
25GLOBAL
HEALTHCARE
OUTLOOK
28AFRICA
30
THE AMERICAS
43 HEALTH SYSTEMS
IN FOCUS
FROM EAST TO WEST
46
CHINA – RECALIBRATING A
SYSTEM FOR NEW DISEASE
PATTERNS
32EASTERN
MEDITERRANEAN
48Physical and social inequalities
34EUROPE
50
6
CO-CREATING
HEALTHCARE
22
SEEING THE WHOLE
SYSTEM
22
STANDARDS FOR COCREATION
Safety is a challenge for patients
and professionals
36
SOUTH-EAST ASIA
38
WESTERN PACIFIC
52
The patient is a resource
40
GLOBAL OVERVIEW
54
The economic burden of no
86
A healthy environment
88
Brussels roundtable
Effectiveness is improving but
60
64
Worth the wait?
In need of a breath of fresh air
door to universal healthcare
119
Case in Kenya: A doctor to
the masses
121
122
92
Case in USA: Bringing the
patient safety
94
96
Watch the access gap
98
103
Healthcare: more than the
Case in Australia: Strong
106
108
128
Case in Germany: Improving
quality by measuring the
130
131
133
134
– Steven MacMahon, China
154WHO’S
BEHIND THIS
PUBLICATION
155FURTHER
READING
156REFERENCES
Case in England:
Bridging time lags with
Case in China: It’s time for
a change in healthcare
Towards a sustainable
provision
healthcare agenda
Expert insight
Chronic disease
management in rural China
better communication
Healthcare on time…
112
148
Knowledge sharing helps
increases effectiveness
Washington DC roundtable
– Susan Sheridan, USA
healthcare do its job
worth?
110
Improving patient safety
through advocacy
true value of care
Commissioning for Value
sometimes
144
Knowing the value of
Getting your money’s
Too much and not enough
– Jeffrey V. Lazarus, Europe
healthcare is key
Towards healthcare of, by
and for the people
101
127
The fight to improve patient
safety
Bridging the
“Knowing-Doing” Gap
sum of its parts
Expert insight
THE UNITED STATES OF
AMERICA – BALANCING
THE SCALES
140
The patient as the expert
patient voice to the world of
125
139 THE CHANGE MAKERS
Mobile health apps open the
healthcare
Shanghai roundtable
Expert insight
118
A JOURNEY TOWARDS
OPPORTUNITIES
alliances create integrated
not incentivized
58
116
125
gatekeeping
62
21
Timing is everything
90
44
56
19SYSTEMS
THINKING AND
CO-CREATION
84
115 ROADMAP TO
CHANGING
HEALTHCARE
136
Green thinking is becoming
the new normal
137
Case in USA: Hospitals are
leading the green battle
7
INTRODUCTION
A Journey Towards
Co-Creating Healthcare
DNV GL and Sustainia share a vision of a future
with safer, smarter and more sustainable healthcare systems throughout the world.
The two organizations wish to help bridge the
gap between the systemic healthcare challenges
and the opportunities, solutions and people that
are creating the healthcare systems of tomorrow, today.
In April 2014, at the BMJ IHI International Forum on Quality and Safety in Healthcare, we
launched our guide to Person-Centred Care: Co-Creating a Healthcare Sector for the Future.
That guide analyzes the benefits of putting the patient at the center and promoting co-creation between the different stakeholders of health systems. Since then, we have traveled
around the world disseminating the publication in different cultural settings and discussing the
state of healthcare with experts and influential stakeholders in each region we visited.
We presented knowledge and insights from the publication at 10 healthcare conferences in 10
different regions across four continents. On top of these events, we conducted roundtables to
discuss the work ahead with key participants in China, Europe, and the USA in order to uncover
the barriers to and the opportunities for co-creating more sustainable healthcare systems.
Furthermore, we have engaged people online, creating a network of health experts to share
opinions, frustrations and solutions with each other in order to scale and spread opportunities.
The ambition of our journey is twofold. On one hand, we wish to give an overview of the challenges that global healthcare systems face and how these issues determine the quality of care
that these systems produce. One the other hand, we want to highlight the good news, which is
that many of the healthcare solutions we need already exist today.
There are people, initiatives and organizations all over the planet that are currently developing innovative ways of solving problems faced by healthcare systems.
With this publication we hope to inspire the process of change by highlighting and promoting
co-creation within healthcare systems around the world. Equipped with a thorough understanding of the current state of the world’s healthcare systems and the challenges they face,
this publication moves us closer to realizing the healthcare innovations of tomorrow.
There is still a long way to go before global healthcare systems are truly economically, socially
and environmentally sustainable, and before they are able to co-create healthy, happy and
independent lives. We believe that in order to succeed we must make the journey a co-created
effort that reaches across sectors and fields and includes stakeholders from all parts of the
healthcare system.
Regardless of whether you participate in the healthcare system as a patient, professional, policy maker, researcher or provider, we hope that this publication will inspire you and that we can
join together on a journey towards safer, smarter and more sustainable healthcare systems.
8
HENRIK O. MADSEN
ERIK RASMUSSEN
President & CEO DNV GL Group
Founder of Sustainia and CEO of Monday Morning
9
Executive
Summary
HEALTH SYSTEMS IN FOCUS
This section of the publication
gram tackling the challenge of NCDs
can seem so enormous and sys-
in rural China. It is our hope that the
USA in order to map out the differ-
temic that it may feel impossible
stories of their efforts will inspire
ences and similarities and flesh out
to separate them from each other.
and galvanize each reader to take
how and why healthcare systems
But improvement is possible and is
charge of healthcare in his or her
struggle to deliver the best quality
happening.
own community.
selected because they face similar
This final chapter of the publication
challenges in terms of rising demand
puts the spotlight on seven case
CO-CREATION
and costs, concerns with quality
studies highlighting opportunities
and changing disease patterns.
for improvement within the seven
They represent different underlying
dimensions of healthcare. From
causes, different types of health
mobile health apps in Kenya to
systems and different responses. A
cost-efficiency measurements at
comparison of these three health-
clinics in Germany, the solutions that
Before making an improvement,
care systems offers valuable insight
will form the healthcare systems of
we need to know where we stand
into changing healthcare dynamics
tomorrow are popping up all around
today. In this section we synthe-
in the world today.
the world to address the specific
of care. These three regions were
GLOBAL HEALTHCARE
process that went before it is to
closer look at healthcare systems
OUTLOOK
enrich the conversation about the
around the world in order to exam-
future of healthcare by including
ine what is holding the quality of
solutions, innovations and people
care back and what solutions exist
that are co-creating greener and
today.
size data on health systems from
process of stakeholder engagement
The overall challenge that this pub-
throughout 2014 and the first half
lication addresses is the fact that
of 2015. Over the last 18 months we
quality improvement1 and evidence
have met with people from around
based practice movements2 have
the world who are showing that
not been able to change health sys-
change in healthcare is possible.
tems so that they deliver consistent
care that improves both individual
Our findings are presented in the
and population well-being.
following chapters: Global Healthcare Outlook, Health Systems in
A key reason for this is that such
Focus and Roadmap to Changing
attempts at change have tended
Healthcare.
to focus on preventing the reoccurrence of particular ailments and
their immediate causes rather than
needs of specific locations.
around the world to give a snapshot
China, Europe and the USA are
of healthcare. We frame this by
examined through seven dimensions
Finally, revolutions need leaders, and
placing it in the context of the WHO
of healthcare quality: equity, safety,
healthcare is no exception. To guide
regions.
person-centered care, effective-
the reader from learning about the
ness, cost-efficiency, timeliness
inspirational performances of others
The data offer insight into the chal-
and environmental sustainability.
towards creating change in their
lenges faced in different regions.
Healthcare in China is challenged by
own system of healthcare, three
For instance, NCDs cause 87% of
its extreme urban and rural divide,
change makers tell the story of how
deaths in Europe, but only 28% in
while in the USA, historical social
they saw a need and created a solu-
Africa. However, developing coun-
inequalities continue to have an
tion to meet it.
tries struggle with a lack of health-
impact on the healthcare systems
care resources compared to more
of today. Europe, meanwhile, is
We learn how Susan Sheridan, after
industrialized regions.
performing a balancing act between
her family experienced two serious
leaving health issues to the nations
medical system failures, succeed-
Importantly, when compared, alarm-
and consolidating policymaking at
ed in changing the standards of
ing figures from one region can
an EU level.
care. We meet Jeffrey Lazarus,
be seen as warning signs for other
understanding and strengthening
the underlying system and promoting co-creation between different
stakeholders. 3
MacMahon and Lifeseeds, a pro-
systems in China, Europe and the
On the following pages, we take a
This publication is the result of a
And we hear the story of Stephen
Challenges in healthcare systems
The aim of this publication and the
healthcare systems of tomorrow.
CHANGING HEALTHCARE
sets out to examine the healthcare
“We cannot solve our problems with the
same thinking we used when we created
them.” This quote from Albert Einstein
hits the nail on the head when it comes
to the publication you hold in your hands.
smarter pathways towards the
ROADMAP TO
– FRONT AND CENTER
Voices of patients, professionals,
policy makers and researchers are
all vital in collecting the puzzle
pieces that constitute a healthcare
system. Without this complete
picture, long term, systemic change
is unlikely.
Through our roundtables in Shanghai, Brussels and Washington DC;
interviews with experts at each location; and in-depth profiles of three
leading change makers, healthcare
experts – in every sense of the word
– have helped outline the current
challenges and illuminate the future
opportunities. This publication is a
truly co-created effort.
who co-founded the HIV in Europe
regions hoping to avoid the same
But despite the differences, all three
Initiative as a way of closing the gap
health problems in due time.
regions have been subject to polit-
between what we know and what
ical reforms and policy change on
we do.
the subject of health and healthcare,
pointing to the fact that the unsustainability of current healthcare systems is on the top of the agenda for
decision makers in all three regions.
Dixon-Woods M et al. Explaining
Matching Michigan: An Ethnographic Study of a Patient Safety
Initiative. Implementation Science
2013; 8(70):1-13.
1
10
Greenhalgh T et al. Evidence
Based Medicine: A Movement in
Crisis? BMJ 2014; 348: 1-7.
2
World Health Organization. Systems Thinking for Health Systems
Strengthening. 2009.
3
11
WHAT WE
DID AND
WHY
THE GOAL OF THIS PUBLICATION IS TO
GIVE AN OVERVIEW OF THE CHALLENGES
THAT ARE MAKING HEALTHCARE SYSTEMS
WORLDWIDE UNSUSTAINABLE.
MORE THAN POINTING TO THE PROBLEMS,
IT ALSO AIMS TO SHIFT THE FOCUS FROM
CHALLENGES TO HEALTHCARE SOLUTIONS
AND INITIATIVES THAT ARE READY AND
AVAILABLE TODAY.
This publication builds on Monday Morning Sustainia and DNV GL’s
2014 publication: Person-Centred Care: Co-Creating a Healthcare
Sector for the Future.
In our writing, we have used different approaches and sources of
knowledge in order to gather relevant information. Hence our analysis
and synthesis triangulates a critical literature review, expert interviews
and roundtables with key stakeholders.
12
13
1) Mapping The
State Of Healthcare
The challenges that healthcare systems around the
HEALTH SYSTEMS IN FOCUS
THE 7 QUALITY DIMENSIONS OF HEALTHCARE
By adding it to the existing quality dimensions, we
world are facing are known – they are documented and
Here, we present the reader with an examination of
We have adapted the six quality dimensions of
provide a framework for identifying priority areas
communicated in various indices, reports and fore-
healthcare systems in China, Europe and the USA
the Institute of Medicine by adding sustainabili-
that, if improved, would increase healthcare’s abili-
casts. A key element in our work has been to gather
by using 7 quality dimensions of healthcare as an
ty. The impact of healthcare on the environment
ty to meet the needs of service users and commu-
the newest information on the challenges, select the
analytical framework, outlined on page 15. The health
and the environment on healthcare is increasingly
nities today and tomorrow.
relevant data and present them in an easy to under-
systems profiled in this section are chosen due to
recognized as an important factor in the ability of
stand and engaging way that enables comparison
their importance and impact on the global economy,
healthcare to deliver services that meet the needs
between regions.
the sheer size of their populations, and their different
of individuals and populations.1
healthcare schemes. They each represent different
The result of the literature review is presented in the
funding models but each are going through periods of
Global Healthcare Outlook and in the Health Systems
significant change.
in Focus section.
The data used to create the Global Healthcare Outlook
THE GLOBAL HEALTHCARE OUTLOOK
and Health Systems in Focus are found by gathering
This chapter uses the WHO-defined 6 world regions
knowledge and research from leading global health-
and highlights key and comparable figures on health-
care organizations and institutions such as the Com-
care and society in every region, each time touching
monwealth Fund, the WHO and EU institutions. We’ve
down in 10 specific spots to shed some light on exam-
analyzed and synthesized data from leading regional
ples of healthcare in action.
and national healthcare authorities and institutions
to compile a snapshot of current performance and
The data we have chosen for the Global Healthcare
challenges.
EQUITY
SAFETY
PERSON-CENTERED
EFFECTIVENESS
Providing care that does
Avoiding harm arising from
CARE
Providing services based
not vary in quality because
the way care is delivered.
Providing care that is
on scientific knowledge to
of personal characteristics
respectful of and respon-
all who could benefit, and
such as gender, ethnicity,
sive to individual patient
refraining from providing
geographic location, and
preferences, needs, and
services to those not likely
socioeconomic status.
values, and engaging them
to benefit.
Outlook gives the reader a quick overview of the
as equal partners in co-cre-
healthcare system and health in society for each
ating care.
region.
The following data has been used for the global healthcare outlook:
DATA
USED
FOR THE
HEALTHCARE
SYSTEM
OVERVIEW
Physicians
Hospital beds
Total
General
per 10,000
people
Out-of-pocket
Per capita total
per 10,000
expenditure
people
on health as %
Government
expenditure
expenditure
Expenditure
as % of private
on health
of GDP
of total
expenditure on
at average
expenditure on
health
exchange rate
health
COST-EFFICIENCY
TIMELINESS
ENVIRONMENTAL
Avoiding waste, including
Reducing waits and some-
SUSTAINABILITY
waste of equipment, sup-
times harmful delays for
Limiting the negative
plies, ideas, and energy.
both those who receive
impact of the healthcare
and those who give care.
sector on the environment
and simultaneously better
managing the impact of
the environment (including,
DATA
USED FOR
THE HEALTH
IN SOCIETY
OVERVIEW
climate change) on the
healthcare sector2
Life
expectancy
Under-five
Deaths
HIV
Obesity
mortality rate
caused by
mortality rate
rate
NCDs
Alcohol
consumption
and tobacco use
NHS Sustainable Development Unit. Sustainable, Resilient, Healthy People & Places: A Sustainable Development Strategy for the NHS, Public
Health and Social Care system. 2014.
1
The definitions are adapted from the 2001 Institute of Medicine report,
Crossing the Quality Chasm, except for the sustainability dimension, which
we have defined.
2
14
15
WASHINGTON DC
9TH OF FEBRUARY
2015
BRUSSELS
18TH OF NOVEMBER
2014
SHANGHAI
28TH OF OCTOBER
2014
3) Highlighting Opportunities,
Inspiring Change
2) Roundtables With
Key Healthcare
Stakeholders
An overview of the challenges for global health-
We identified numerous cases that fit the above
care systems lets us know where we stand. But a
criteria and then focused on the 7 selected based
focus on opportunities helps us share the solu-
on their quality, potential and diversity.
tions. Therefore, this publication includes seven
inspirational performances from across the globe.
In order to inspire the reader to initiate change in
They illustrate the fact that innovative, sustainable
his or her own healthcare setting, we also present
developments already exist and are tackling some
three change maker interviews with people that
of the challenges within healthcare.
have a proven track record for tackling healthcare
challenges and changing healthcare systems for
THE CRITERIA FOR SELECTING THE CASES
the better.
The aim of this chapter is to highlight a variety of
Although gathering and analyzing existing knowl-
The roundtable participants were selected by com-
solutions which demonstrate that opportunities are
The change makers, and the initiatives for which
edge gives the publication a strong foundation,
bining DNV GL and Monday Morning Sustainia’s
created all around the world and come in different
they are responsible, correspond to the three loca-
we also wanted to listen to key stakeholders in our
networks, and reaching out to experts in each loca-
shapes and sizes.
tions of the Health Systems in Focus: China, Europe
three core regions and extract what they consid-
tion. This process ensured that each participant list
ered to be the biggest challenges and opportuni-
included patients, professionals, providers, policy
The seven inspirational performances reflect our
each change maker using core questions in order
ties for healthcare in their region. The roundtable
makers and researchers.
7 quality dimensions of healthcare. They span
to extract common threads and best practices for
different countries, costs, and scopes of change.
success in transforming healthcare sectors around
the world.
locations were chosen to match the policy epicen-
16
and the USA. An interview was conducted with
ters of each of our three Health Systems in Focus:
After the roundtables, we conducted interviews
Some are multi-million dollar, large scale initiatives,
Shanghai, Brussels and Washington DC.
with two participants from each region in order to
while others are home grown and locally supported
harvest even more of their knowledge within the
campaigns. They also differ in terms of where they
The roundtables were in the format of one-day
field, giving the reader a more in-depth under-
are in the implementation process. This breadth
interactive workshops. Each roundtable included
standing of the different healthcare systems.
of coverage is important in order to stress that
an inspirational talk from an expert participant, fol-
solutions to healthcare issues exist at every level of
lowed by structured group-work and discussions.
operation.
17
What you should keep
in mind when reading
this publication
In the pursuit of creating a publication that is
accessible and inspiring for a broad group of
readers, we have created a narrative that gives
an overview and a taste of the different challenges and opportunities. It is not an extensive
review of all the challenges and opportunities.
We are aware that with a different focus, we
could have found other inspirational performances or other experts with different
viewpoints and included other challenges that
would have painted a different picture of the
healthcare landscapes.
For the purposes of this publication, we have used the
WHO global regions to frame our analysis. The exception is in relation to Europe where we have drawn on
both the broader WHO region as well as the narrower
European Union (EU) that sits within it. The WHO
includes 53 countries within its definition of Europe;
the EU consists of 28 Member States. Although we
This publication does not target one specific
type of reader but rather is meant to inspire all
the different stakeholders across healthcare
systems worldwide and to encourage discussion
and debate on how we can collectively change
SYSTEMS
THINKING
AND COCREATION
healthcare for the better.
have included examples from across the 53 countries
defined by the WHO, we have also focused particualrly on the policies and regulations of the EU as these
represent an attempt to create a common ambition
to improve the well-being of populations across
national borders.
In order to allow easy comparisons between the different regions and health systems, we have converted all currency to American dollars through Google
Finance’s currency exchange system. The figures
express the exchange rates from 2 March 2015.
BEYOND MAPPING THE STATE OF GLOBAL HEALTHCARE
AND THE CHALLENGES IT FACES, THIS PUBLICATION HIGHLIGHTS EXAMPLES FROM LOW, MIDDLE AND HIGH INCOME
COUNTRIES IN WHICH PATIENTS, HEALTH PROFESSIONALS, MANAGERS AND POLICY MAKERS ARE PROVING,
FROM MICRO TO MACRO LEVELS, THAT CHANGE IS BOTH
DESIRED AND ACHIEVABLE.
What connects each of these stories is their focus of patient empowerment, systems-thinking approaches to problem-solving, and cultivation
of healthcare environments that allow for and encourage the
co-creation of person-centered care.
18
19
CO-CREATING SAFER, SMARTER
Co-Creating
Healthcare
AND MORE SUSTAINABLE SYSTEMS
Healthcare has changed greatly over the last century. New technology and
advances in treatment mean that a girl born in 2012 can expect to live around
73 years and a boy to the age of 68 years. This is six years longer than average
global life expectancy for a child born in 1990.1
Co-creation means delivering services “… in an equal and reciprocal relationship
Yet, as the regional analyses in the following chapters show, all countries are cur-
between professionals, people using services, their families and their [communi-
rently struggling to deliver safe and sustainable healthcare. Ageing populations,
ties … so that both services and communities] become far more effective agents
the pandemic of non-communicable diseases, rising costs, disparities in access
of change”.4 Engaging patients as active partners in the design and delivery of
between rich and poor and unacceptably high rates of patient harm are clear and
services is a powerful tool for transformational change, resulting in:
significant threats to sustainable healthcare around the world.
1) IMPROVED COSTS
The growing complexity of healthcare, with care becoming ever more sub-specialized, poses an additional challenge. Increasing numbers of health and social
Patients who are actively engaged have better health outcomes at lower costs
care professionals are involved in each patient’s journey through the system, par-
compared with less activated patients. For example, patients with the lowest
ticularly those with multiple co-morbidities. Within this complexity the patient is
activation scores (i.e. people with the least skills and confidence to participate in
in danger of becoming lost as different parts of the health and social care system
their own healthcare) can cost 8 to 21% more than patients with the highest acti-
struggle to coordinate with one another. 2 Too often services are fractured and
vation levels, even after adjusting for health status and other factors. 5
fragmented: reflecting the evolution of abstract political ambitions rather than a
purposeful and coherent system design based on what patients need or want.
2) IMPROVED OUTCOMES
Attempts to improve healthcare have relied on narrowly defined, technocrat-
Working with patients and their family members to co-create person-centered
ic approaches with inadequate attention to context and engagement of local
care is proven to have a positive impact on outcomes in low, middle, and high
providers, practitioners and patients as co-creators of health systems. 3 There is,
income countries, including: health status6, knowledge7, adherence 8 , and patient
therefore, a clear need to look for ways that build on the knowledge of quality
and practitioner satisfaction. 9, 10
improvement and evidence based practice by involving stakeholders in strengthening health systems as a whole.
But to achieve this requires an understanding of how systems and their different
components work together to produce results.
Such change is possible.
Beyond mapping the state of global healthcare and the challenges it faces, this
publication highlights examples from low, middle and high income countries in
which patients, health professionals, managers and policy makers are proving,
from micro to macro level; that change is both desired and achievable. What
connects each of these stories is their focus on patient empowerment, systems-thinking approaches to problem-solving, and cultivation of healthcare environments that allow for and encourage the co-creation of person-centered care.
1
WHO. World Health Statistics. 2014.
Donaldson L in Monday Morning Sustainia &
DNV GL. Person-Centred Care. 2014.
2
Leyshon S & McAdam S. The importance of
taking a systems approach to person-centred
care. BMJ Spotlight Supplement on Patient
Centred Care. 2015.
6
Boyle D & Harris M. The challenge of co-production: How equal partnerships between professionals and the public are crucial to improving
public services. 2009.
7
3
4
20
Hibbard JH et al. Patients with lower activation
associated with higher costs; delivery systems
should know their patients’ “scores”. Health
Affairs 2013; 32: 216-22.
5
Sidani S. Effects of patient-centered care on
patient outcomes: An evaluation. Research And
Theory For Nursing Practice: An International
Journal 2008; 22(1): 24-37.
DiMatteo MR et al. Patient adherence and
medical treatment: A meta-analysis. Med Care
2002; 40: 794 – 811.
8
The King’s Fund. Patient-Centred Leadership:
Rediscovering Our purpose. 2013.
9
Stewart M et al. Patient-Centered Medicine:
Transforming the Clinical Method. 2003.
10
Mead N & Bower P. Patient-centred consultations and outcomes in primary care: a review of
the literature. Patient Education and Counselling
2002; 48: 51–56.
21
Seeing the whole system
Systems-thinking is an approach to improvement that
sees challenges to quality as part of a wider, dynamic
structure: looking for patterns of distributed risk rather
than fragments or individual episodes.11 It involves
more than a reaction to a particular outcome or event;
it requires a deeper understanding of the distribution,
linkages and relationships among the processes that
characterize the entire system.12 As such, systems
thinking is a:
SYSTEMS-THINKING IN HEALTHCARE, AS WELL AS OTHER SAFETY CRITICAL AND
COMPLEX ADAPTIVE SECTORS, FOCUSES ON:
“… mindset that views systems
and their sub-components as
intimately related and connected to each other, believing that
mastering our understanding
of how things work lies in interpreting interrelationships and
interactions within and between
systems.” 13
Creating pre-emptive and
mitigation controls to deliver safe and consistently
reliable results
Establishing policies
that set clear and
explicit goals and directions regarding quality
(including defining what
quality means for an
organization)
Standards for co-creation
Identifying and assessing
risks to human, technologiContinuously improving
cal and organizational safety
through the analysis of
and performance (including
One way to ensure that the co-creation of person-cen-
The Global Healthcare Outlook examines and com-
tered care and systems-thinking are put into practice is
pares systems on a macro and regional level giving the
through accreditation. Accreditation provides a prac-
reader an immediate overview of the state of health-
tical, structured framework for addressing the quality
care around the world. In the Health Systems in Focus
improvement needs of healthcare. Trained external
chapter, we zoom in to the Chinese, American and Eu-
peer reviewers evaluate an organization’s compliance
ropean healthcare systems and examine the different
Mapping processes and iden-
with pre-established performance standards that
quality components of a healthcare system, offering
tifying indicators to monitor
can be applied to specific threats (such as managing
the reader a basis for further discussing what the
infection risk) or across services. Evidence shows that
systems have in common, what needs to be changed
healthcare providers “… that have either ISO certifica-
and what three seemingly different health systems can
tion or accreditation are safer and better than those
learn from each other.
performance and the
how these are distributed
adoption of necessary
within and across organiza-
process changes to
tions and who owns them)
achieve results
those processes (including
Measuring process
performance and
how they connect within and
between organizations)
monitoring the
efficacy of controls
that have neither” 14 and that “… accreditation programs
should be supported as a tool to improve the quality of
Lastly, in the Roadmap to Changing Healthcare
healthcare services”.15
chapter, we continue to dig deeper, highlighting the
solutions, organizations and people that constitute
Combining systems-thinking with the co-creation of
the disruptive elements in healthcare systems in low,
person-centered care plus frameworks such as accred-
middle and high income countries. These solutions
itation offers a powerful way to redesign healthcare.
address system failures with truly co-created efforts.
In this publication, we examine systems on different
levels of action.
Leyshon S & McAdam S. The importance of taking a
systems approach to person-centred care. BMJ Spotlight
Supplement on Patient Centred Care. 2015.
11
12
World Health Organization. Systems Thinking for Health
Systems Strengthening. 2009.
Adam T. Advancing the application of systems thinking in
health. Health Research Policy and Systems 2014; 12(50):
1-5.
13
22
Shaw C et al. Accreditation and ISO certification: do they
explain differences in quality management in European
hospitals? International Journal for Quality in Health Care
2010; 22(6): 445-451.
14
Alkhenizan A & Shaw C. Impact of accreditation on the
quality of healthcare services: a systematic review of the
literature. Ann Saudi Med 2011; 31(4): 407-416.
15
23
GLOBAL
HEALTHCARE
OUTLOOK
AS THE PROVERB GOES,
“A JOURNEY OF A THOUSAND MILES
BEGINS WITH A SINGLE STEP.”
ON THIS JOURNEY FROM HEALTHCARE
CHALLENGES TO OPPORTUNITIES FOR
IMPROVEMENT, THE GLOBAL HEALTHCARE
OUTLOOK IS OUR FIRST STEP
TOWARD CHANGE.
24
25
Algeria
Angola
AFRICA
Global Healthcare
Outlook
Benin
Botswana
Burkina Faso
Burundi
Cabo Verde
Cameroon
Central African
Republic
Chad
Comoros
Congo
Côte d’Ivoire
Democratic
Republic of the
Congo
Equatorial
In this chapter, we map out the state of healthcare throughout the
Guinea
Lesotho
Niger
South Sudan
Eritrea
Liberia
Nigeria
Swaziland
Ethiopia
Madagascar
Rwanda
Togo
Gabon
Malawi
Uganda
Gambia
Mali
Sao Tome and
Principe
Ghana
Mauritania
Guinea
Mauritius
Guinea Bissau
Mozambique
Kenya
Namibia
Senegal
Seychelles
Tanzania
Zambia
Zimbabwe
Sierra Leone
South Africa
world, using the six WHO regions as guides, in order to give a broad,
chapter.
The Outlook includes key health-related financial indicators, such as
total expenditure on health and out of pocket expenditures, but also
figures on social elements of health, like the prevalence of non-communicable diseases and life expectancy. These numbers provide a
THE AMERICAS
global overview before diving into our three health systems in the next
Antigua and
Barbuda
Brazil
Dominican
Republic
Haiti
Peru
Canada
Honduras
Argentina
Chile
Ecuador
Jamaica
Saint Kitts and
Nevis
Bahamas
Colombia
El Salvador
Mexico
Saint Lucia
Barbados
Costa Rica
Grenada
Nicaragua
Cuba
Guatemala
Panama
Bolivia
Dominica
Guyana
Saint Vincent
and the
Grenadines
Paraguay
Suriname
Afghanistan
Iran
Lebanon
Pakistan
Sudan
Bahrain
Iraq
Libya
Qatar
Djibouti
Jordan
Morocco
Saudi Arabia
Syrian Arab
Republic
Belize
Trinidad and
Tobago
United States
of America
Uruguay
Venezuela
Therefore, each regional outlook also presents 10 illustrations of
healthcare in particular countries, allowing the reader to zoom in and
get a more complete look at the challenges, opportunities and com-
EUROPE
plexities of healthcare in every region.
EASTERN
MEDITERRANEAN
general overview of healthcare in each region, but lack a local context.
Egypt
Kuwait
Oman
Somalia
Tunisia
Albania
Croatia
Hungary
Malta
Andorra
Cyprus
Iceland
Monaco
Russian
Federation
Armenia
Czech Republic
Ireland
Montenegro
Austria
Denmark
Israel
Netherlands
Azerbaijan
Belarus
Belgium
Bosnia and
Herzegovina
SOUTH
EAST ASIA
WESTERN
PACIFIC
Finland
France
Georgia
Italy
Kazakhstan
Kyrgyzstan
Latvia
Germany
Lithuania
Greece
Luxembourg
Bhutan
Democratic
People’s
Republic of
Korea
Australia
Brunei
Darussalam
Bulgaria
Norway
Poland
Portugal
Republic of
Moldova
Yemen
San Marino
The former
Yugoslav
Republic of
Macedonia
Serbia
Turkey
Slovakia
Turkmenistan
Slovenia
Ukraine
Spain
United Kingdom
Sweden
Uzbekistan
Switzerland
Romania
Tajikistan
India
Maldives
Nepal
Thailand
Indonesia
Myanmar
Sri Lanka
Timor-Leste
Fiji
Marshall Islands
Niue
Micronesia
Palau
Republic of
Korea
Tuvalu
Japan
Kiribati
Mongolia
Samoa
Vietnam
Cambodia
Lao PDR
Nauru
Papua New
Guinea
China
Malaysia
New Zealand
Philippines
Solomon Islands
Bangladesh
Cook Islands
26
Estonia
United Arab
Emirates
Vanuatu
Singapore
Tonga
27
AFRICA
PHYSICIANS
PER 10,000
PEOPLE
(2006 – 2013)
2.6
0.1 – 12.1
Tanzania, Liberia – Algeria
Ethiopia’s community-based
nutrition interventions have
HOSPITAL
BEDS
PER 10,000
PEOPLE (2000
– 2009)
increased primary healthcare coverage from 77% of communities
in 2004 to 92% in 2010. This preventive care has also decreased
10 facts about healthcare
in the region
2
1 – 63
Mali – Ethiopia, Gabon
deaths per 1,000 live births in
2000 to 77 in 2011.7
The removal of user fees for
Rwanda has mandatory health in-
children’s healthcare in 12 districts
surance (even for visitors staying
in Burkina Faso led to an average
less than 15 days). Currently 92%
increase of 2,000 visits per year
of the population is covered. 2
per center – a 110% spike. 3
THE HEALTHCARE SYSTEM
under –five mortality from 139
tile in Madagascar were attended
by skilled health personnel, while
this was only the case in 22% of
births in the poorest quintile. 4
sick children sought treatment
TOTAL
EXPENDITURE
ON HEALTH
AS % OF GDP
(2011)
GENERAL
GOVERNMENT
EXPENDITURE
OF TOTAL
EXPENDITURE
ON HEALTH (2011)
90% of births in the richest quin-
In Ghana, 92% of caregivers of
PER CAPITA
TOTAL
EXPENDITURE
ON HEALTH
AT AVERAGE
EXCHANGE RATE
(US$) (2011)
$99
$12 – $1,051
Eritrea – Equatorial Guinea
6.2%
1.7% –16.3%
South Sudan –Sierra Leone
48.3%
16.2% –94.8%
Sierra Leone – Seychelles
from community-based agents
OUT-OF-POCKET
EXPENDITURE
AS % OF PRIVATE
EXPENDITURE ON
HEALTH
trained to manage pneumonia
and malaria and most sought care
for their children within 24 hours
of the onset of fever. 5
A study in Zambia found that
56.6%
12.7% –100%
Botswana – Comoros, Eritrea
68% of children with pneumonia
received early and appropriate
treatment from community health
workers, and that overtreatment
of malaria significantly declined. 9
The introduction of results-based
and the McArthur Foundation
financing (RBF) in Burundi – the
worked together on the devel-
allocation of bonuses based on
opment, installation, monitoring,
performance and quality – result-
and maintenance of micro-solar
ed in visits per child increasing
installations in 28 health facilities
from 1.16 in 2009 to 1.6 in 2010,
in Nigeria. 6
and institutional deliveries increasing from 51% in 2009 to 62%
in 2010.11
Only five countries: Botswana,
Studies on hospital-wide health-
Madagascar, Rwanda, Togo
care associated infections from
and Zambia, have been able to
African countries report high
achieve the target set in the Abuja
infection rates e.g. Mali 18.9%, the
Declaration – dedicating more
Tanzania 14.8% and Algeria 9.8%. 8
than 15% of general government
expenditure to healthcare.10
Pfizer. The Global Burden of Noncommunicable
Diseases. 2011.
1
World Health Organization. The
African Regional Health Report. 2014.
2, 3, 4, 5, 7, 8, 9, 10
eHealth Africa. Micro-Solar Systems for Maternal Health. Undated.
6
28
The World Bank. Results Based Financing
at the World Bank: Burundi’s National Performance Based Financing (PBF) Program. 2011.
11
58
LIFE
EXPECTANCY
AT BIRTH IN
YEARS (2012)
HEALTH IN SOCIETY
eHealth Africa, WE CARE SOLAR
46 –74
Sierra Leone – Cape Verde, Seychelles, Mauritius
DEATHS
CAUSED BY
NCDS 1
(2008)
28%
20% – 85%
Central African Republic – Mauritius
UNDER-FIVE
MORTALITY
RATE
DEATHS PER
1,000 LIVE
BIRTHS (2012)
95
13 – 182
Seychelles – Sierra Leone
29
low health literacy are estimated
my between $106 billion and $236
billion annually. 4
pitals in Cuba found the overall
prevalence rate of device-associated healthcare-associated infections (DA-HCA) to be 22.4%. 6
10 facts about healthcare
in the region
HOSPITAL BEDS
PER 10,000
PEOPLE
(2006 – 2013)
to cost the United States econo-
A 3-year study of two ICU hos-
Partners in Health’s mobile clinics
in Haiti have helped more than
33,000 patients since 2013, and
By staggering start-times for sur-
who tested HIV+ to receive fur-
equipment, wait times dropped
ther care.7
75% and the number of surgeries
PER CAPITA
TOTAL
EXPENDITURE
ON HEALTH
AT AVERAGE
EXCHANGE RATE
(US$) (2011)
completed increased by 136% in
23
6 – 62
Guatemala – Barbados
$3,482
$62 – $8,467
Haiti – USA
TOTAL
EXPENDITURE
ON HEALTH
AS % OF GDP
(2011)
GENERAL
GOVERNMENT
EXPENDITURE
OF TOTAL
EXPENDITURE
ON HEALTH (2011)
have referred over 450 people
gery and standardizing surgical
20.8
2.1 – 67.2
Guyana – Cuba
The economic repercussions of
THE HEALTHCARE SYSTEM
THE
AMERICAS
PHYSICIANS
PER 10,000
PEOPLE
(2006 – 2013)
14.1%
4.5% – 17.7%
Venezuela – USA
49.5%
21.5% – 94.7%
Haiti – Cuba
some Canadian hospitals. 9
OUT-OF-POCKET
EXPENDITURE
AS % OF PRIVATE
EXPENDITURE ON
HEALTH
In Brazil, it is estimated that 76%
of towns dispose of medical and
municipal wastes together at the
An estimated 1.6 million chronic
Costa Rica has one of the most
patients could benefit from
effectively universalized health-
mHealth in Mexico, which would
care systems in Latin America. Its
result in per capita healthcare
health insurance coverage rate
spending reductions of 25%. 3
rose from 87.6% in 2006 to 91.9%
Webster P. “Health in Colombia: a system in crisis.” Canadian Medical Association Journal
2012; 184(6): 289-290.
2
in adult intensive care units
of Cuban university hospitals:
International Nosocomial
Infection Control Consortium
(INICC) findings.” International
Journal of Infectious Diseases
2011; 15(5): 357-362.
Skoll Foundation. Partners in
Health. 2015.
7
PricewaterhouseCoopers.
Socio-economic impact of
mHealth. 2013.
3
covered by health insurance, only
controls for essential medicines,
40% of the country receives high
which account for more than 54%
quality care, typically at private
in the Ecuadorian pharmaceutical
hospitals. 60% of people rely
market, making access to these
on inadequate care at crowded,
drugs less expensive and more
public facilities. 2
equitable.10
Center for Health Care
Strategies Inc. Health Literacy
Implications of the Affordable
Care Act. 2010.
4
Meticillin-resistant Staphylococcus aureus is the most common
hospital acquired infection in Latin America, and the disease had
a 51% infection rate in Argentine
hospitals in 2006. 5
Guzman-Blance M, et al.
”Epidemiology of meticillin-resistant Staphylococcus aureus
(MRSA) in Latin America.”
International Journal of
Antimicrobial Agents 2009;
304-308.
5
Guanche-Garcell H, et al. “Device-associated infection rates
6
30
Pan American Health Organization. Costa Rica. 2012.
8
Canadian Health Coalition.
Wait Times: Causes and Cures.
2009.
9
IHS Inc. Ecuadorian government introduces price controls
for essential medicines. 2014
10
Health Care Without Harm.
Medical Waste and Human
Rights. 2011.
11
76
LIFE
EXPECTANCY
AT BIRTH IN
YEARS (2012)
HEALTH IN SOCIETY
Pfizer. The Global Burden of
Noncommunicable Diseases.
2011.
1
Ecuador has introduced price
3.5% – 100%
Haiti– Barbados, Cuba, Saint Vincent
and the Grenadines
municipal landfills.11
in 2010. 8
While 97% of Colombians are
30.1%
62 – 82
Haiti – Canada
79%
DEATHS
CAUSED BY
NCDS 1
(2008)
47% – 88%
Guatemala – Canada, USA
UNDER-FIVE
MORTALITY
RATE
DEATHS PER
1,000 LIVE
BIRTHS (2012)
15
5 – 79
Canada – Haiti
31
10 facts about healthcare
in the region
HOSPITAL BEDS
PER 10,000
PEOPLE
(2006 – 2013)
between 50,000 and 100,000
Iraqis travel each year to countries in the region like Lebanon,
Pakistan’s government spent only
$36 per person on health in 2011,
the lowest in the region, while
Qatar spent the most, at $1,738.
HAI prevalence rate to be 9.4%.
TOTAL
EXPENDITURE
ON HEALTH
AS % OF GDP
(2011)
OUT OF POCKET
EXPENDITURE
AS % OF PRIVATE
EXPENDITURE ON
HEALTH
husband decides whether contraKing Faisal Specialist Hospital &
PER CAPITA
TOTAL
EXPENDITURE
ON HEALTH
AT AVERAGE
EXCHANGE RATE
(US$) (2011)
GENERAL
GOVERNMENT
EXPENDITURE
OF TOTAL
EXPENDITURE
ON HEALTH (2011)
7
For 55% of Qatari women, their
10
ception is used or not. 2
Research Center in Saudi Arabia
Out-of-pocket health expendi-
is ranked in the top 5% of hospi-
tures account for 59% of total
tals worldwide for safety, quality
health financing in Egypt – the
of care and efficiency. 5
0.4–77.4
Somalia–Qatar
8
1– 37
Iran – Libya
healthcare. 6
hospitals in Iran determined the
tons of medical waste every
11.4
Jordan, Iran and Turkey to receive
A study of 4,350 patients at 8
Palestine generates about 512.6
month.
Due to instability caused by war,
THE HEALTHCARE SYSTEM
EASTERN
MEDITERRANEAN
PHYSICIANS
PER 10,000
PEOPLE
(2006 – 2013)
$195
$36 – $1,738
Pakistan– Qatar
4.2%
1.9% – 8.8%
Qatar – Jordan
51%
19% – 82.4%
Afghanistan – Kuwait
88.9%
58.8% – 100
Saudi Arabia– Iraq, Libya, Syrian Arab
Republic
highest in the Region, and 4% in
the Saudi Arabia, the Region’s
100% of the population in the
lowest. 9
of the population live less than
to local health services, while this
5 km from a healthcare facility,
The rate of antiretroviral
whereas in rural areas, this number is only 30%.
figure is only 57% in Afghanistan. 3
treatment (ART) coverage for
4
HIV-positive patients in Yemen
has increased by 115% in three
years (2010-2013). 8
Pfizer. The Global Burden
of Noncommunicable
Diseases. 2011.
1
Mobaraki A & Soderfeldt
B. ”Gender inequity in
Suadi Arabia and its role
in public health.” Eastern
Mediterranean Health Journal 2010; 16(1): 113-118.
2
32
WHO Regional Office for
the Eastern Mediterranean.
Demographic, Social
and health Indicators for
Countries of the4 Eastern
Mediterranean. 2013.
3
Global Health Workforce
Alliance. The Morocco
Country Case Study: Positive Practice Environments.
2010.
4
HIMSS Analytics. Saudi
hospital first in the Middle
East to achieve global recognition for its healthcare
IT. 2012.
5
6
Bossone A. “Sharing the
pain: Improving healthcare
in warzones.” Nature –
Middle East. 2014.
Askarian M, Yadollahi
M & Assadian O. “Point
prevalence and risk factors
of hospital acquired infections in a cluster of university-affiliated hospitals
in Shiraz, Iran.” Journal of
Infection and Public Health
2012; 5: 169-176.
7
Medecins Sans Frontieres.
Yemen: Enrolment for
antiretroviral treatment
increasing in health facilities. 2014.
8
The World Bank. Who
Pays?: Out-of-Pocket
Health Spending and
Equity Implications in the
Middle East and North
Africa. 2010.
9
10
Al-Khatib I. “Medical
waste management in
healthcare centres in
the occupied Palestinian
territory.” Eastern Mediterranean Health Journal
2007; 113(3): 694-705.
68
LIFE
EXPECTANCY
AT BIRTH IN
YEARS (2012)
United Arab Emirates has access
HEALTH IN SOCIETY
In urban areas of Morocco, 100%
53 – 80
Somalia –Lebanon
52%
DEATHS
CAUSED BY
NCDS 1
(2008)
19% – 85%
Somalia – Lebanon
UNDER-FIVE
MORTALITY
RATE
DEATHS PER
1,000 LIVE
BIRTHS (2012)
57
7 – 147
Qatar – Somalia
33
PHYSICIANS
PER 10,000
PEOPLE
(2006 – 2013)
EUROPE
Only 7.7% of the healthcare
11.5 – 71.7
Albania – Monaco
facilities in Russia are capable of
using electronic health histories or
electronic medical records. Less
HOSPITAL BEDS
PER 10,000
PEOPLE
(2006 – 2013)
than 3% are equipped with the
means to use telemedicine.
4
53
25 – 138
Andorra, Turkey – Monaco
In 2011 administrative costs in
Scotland accounted for 12%
of total hospital expenditures
while in the Netherlands this
In Georgia, pharmacies and doc-
figure was 19.8%.7
tors are incentivized to dispense
brand name drugs in preference
to generics. By contrast, studies in
Scotland, which has been a test
Kyrgyzstan and Tajikistan show a
bed for telehealth innovation
high level of generic prescription,
since 2006, currently has approx-
about 70% in both countries. 8
imately 180,000 people signed up
to its telecare services, delivered
through 32 local partnerships. 5
THE HEALTHCARE SYSTEM
10 facts about healthcare
in the region
33.1
PER CAPITA
TOTAL
EXPENDITURE
ON HEALTH
AT AVERAGE
EXCHANGE RATE
(US$) (2011)
TOTAL
EXPENDITURE
ON HEALTH
AS % OF GDP
(2011)
GENERAL
GOVERNMENT
EXPENDITURE
OF TOTAL
EXPENDITURE
ON HEALTH (2011)
100,000 people waited over 12
$2,370
$48 – $9,908
Tajikistan – Norway
9%
2.1% – 11.9%
Turkmenistan – Netherlands
73.9%
18.1% – 88.6%
Georgia – Monaco
months for an outpatient appointment at public hospitals in Ireland
Hospital in-patient medicines, all
during April of 2013. 9
cancer medicines, and medicines
OUT OF POCKET
EXPENDITURE
AS % OF PRIVATE
EXPENDITURE ON
HEALTH
prescribed by family doctors
are free of charge to patients in
Turkey.
2
In the Netherlands, almost 70% of
the population return their unused
In Latvia only 6% do the same.11
The average waiting times for a
hip replacement in 2012-13 was
less than 40 days in the Netherlands, but around 150 days in
Spain and Hungary.10
Pfizer. The Global Burden of
Noncommunicable Diseases. 2011.
1
WHO Regional Office for
Europe. Better noncommunicable
disease outcomes: challenges
and opportunities for health
systems. Country assessment:
Turkey. 2014.
2
34
European Commission. Special
Eurobarometer 411: Patient Safety
and Quality of Care. 2014.
Management Systems Society.
Integrated Health Innovations
Conference: Press Release. 2013.
WHO European Observatory
on Health Systems and Policies.
Health Systems in Transition:
Russian Federation. 2011.
6
3
4
5
Healthcare Information and
is 82% in Cyprus – the highest in
The cost of unnecessary Cae-
Europe, and lowest is Austria at
sarean sections in Italy was $101
21%. 3
million in 2008 – the highest in
Europe. This cost was lowest in
Bulgaria, at $2.3 million. 6
WHO. The Global Numbers and
Costs of Additionally Needed and
Unnecessary Caesarean Sections
Performed per Year: Overuse as
a Barrier to Universal Coverage.
2010.
Himmelstein D, et al. “A Comparison of Hospital Administrative
Costs in Eight Nations: US Costs
Exceed All Others By Far.” Health
Affairs 2014; 33(9): 1586-1594.
9
WHO Regional Office for
Europe. Regional Pharmaceutical
Situation Report. 2013.
10
7
8
WHO European Observatory on
Health Systems and Policies. The
impact of the financial crisis on
the health system and health in
Ireland. 2014.
European Commission & OECD.
Health at a Glance: Europe 2014.
2014.
Health Care Without
Harm. Unused Pharmaceuticals Where Do They End
Up? A Snapshop of European Collection Schemes.
Undated.
11
HEALTH IN SOCIETY
harmed by healthcare services
hazardous waste collection point.
32.1% – 100%
France – The former Yugoslav
Republic of Macedonia, Turkmenistan
76
LIFE
EXPECTANCY
AT BIRTH IN
YEARS (2012)
The perceived likelihood of being
medicines to the pharmacy or a
68.8%
63– 83
Turkmenistan – Andorra, Italy,
San Marino, Switzerland
87%
DEATHS
CAUSED BY
NCDS 1
(2008)
62% – 95%
Tajikistan – Serbia, The former Yugoslav
Republic of Macedonia
UNDER-FIVE
MORTALITY
RATE
DEATHS PER
1,000 LIVE
BIRTHS (2012)
12
2– 58
Iceland, Luxembourg – 58 Tajikistan
35
In 2010 North Korea spent less
HOSPITAL BEDS
PER 10,000
PEOPLE
(2006 – 2013)
than $1 per person on healthcare.
This was less than any other country in the world. 8
29% of Indonesians have mobile
internet access, making them
10 facts about healthcare
in the region
5.9
0.7 – 14.2
Timor-Leste – Maldives
prime candidates for mobile
health apps. 5
THE HEALTHCARE SYSTEM
SOUTHEAST ASIA
PHYSICIANS
PER 10,000
PEOPLE
(2006 – 2013)
A project at the cardiology
outpatient department of a large
About 10% of hospitalized
university hospital in India was
patients in Indonesia suffer an
able to significantly reduce wait-
adverse event and 5–10% acquire
ing times. In 2011, 64% of patients
a healthcare associated infection. 6
PER CAPITA
TOTAL
EXPENDITURE
ON HEALTH
AT AVERAGE
EXCHANGE RATE
(US$) (2011)
TOTAL
EXPENDITURE
ON HEALTH
AS % OF GDP
(2011)
GENERAL
GOVERNMENT
EXPENDITURE
OF TOTAL
EXPENDITURE
ON HEALTH (2011)
waited 3 hours or more for their
10
6– 59
Bangladesh,
Myanmar – Timor-Leste
$69
$19 – $525
Myanmar – Maldives
3.7%
1.8% – 8.1%
Myanmar – Maldives
36.7%
15.9% – 83.9%
Myanmar – Bhutan
consultation, while after the
OUT-OF-POCKET
EXPENDITURE
AS % OF PRIVATE
EXPENDITURE ON
HEALTH
project’s completion, in 2013, this
number had dropped to just 8%. 9
84.3%
15.4% – 96.6%
Timor-Leste – Bangladesh
While Bangkok has about 1 doctor
510 tons of medical waste is pro-
per 1,000 people, the poorer
duced in the Maldives each year.11
northeast region of Thailand has
only 1 doctor per 8,000 people. 3
LIFE
EXPECTANCY
AT BIRTH IN
YEARS (2012)
In 2010 Sri Lanka had a maternal
mortality rate of only 39 deaths
per 100,000 live births – an
In their first 1.5 years of operation,
dedicated telemedicine centers in
Bangladesh provided over 5,800
consultations. 4
exceptional achievement for a
developing country.7
Pfizer. The Global Burden of Noncommunicable Diseases. 2011.
4
WHO Regional Office for SouthEast Asia. Health in South-East
Asia. 2013.
5
2
OECD. Structural Policy Country
Notes: Thailand. 2013.
3
36
WHO Regional Office for SouthEast Asia. eHealth in South East
Asia Region of WHO. 2013.
1
Mobile Monday. Mobile Southeast
Asia Report 2012: Crossroads of
Innovation. 2012.
new mothers in Myanmar had
difficulties in raising necessary
funds to cover the cost of safe
Village Health Volunteers in
birth practices. 17% even forewent
Thailand provide essential basic
essential food in order to cover
healthcare services to 65 million
these payments. 2
Thai villagers, all free of charge.10
Peerapakorn S & Jayawickramarajah PT. “Role of Medical Education
in patient safety.” South East Asian
Journal of Medical Education
2008; 1(1).
6
Commonwealth Health Online.
Health in Sri Lanka. Undated.
7
WHO Regional Office of South-East Asia.
A Decade of Public Health Achievements in
WHO’s South-East Asia Region. 2013.
8
Amnesty International. The Crumbling State of Health Care in North
Korea. 2010.
10
Dinesh TA, et al. “Reducing Waiting Time in Outpatient Services of
Large University Teaching Hospital
– a Six Sigma Approach.” Management in Health 2013; 1(17).
11
9
The World Bank. Climate Change in the
Maldives. 2010.
HEALTH IN SOCIETY
67% of pregnant women and
67
66 – 77
Myanmar, Timor-Leste – Maldives
55%
DEATHS
CAUSED BY
NCDS 1
(2008)
44% – 81%
Timor-Leste – Maldives
UNDER-FIVE
MORTALITY
RATE
DEATHS PER
1,000 LIVE
BIRTHS (2012)
50
10 – 57
Sri-Lanka – Timor-Leste
37
with chronic conditions can be expected to secure same-day access
HOSPITAL BEDS
PER 10,000
PEOPLE
(2006 – 2013)
spending for many countries in
the Western Pacific are among
the highest in the world. In the
Philippines, household spending accounts for 58% of health
spending. 2
MRSA (methicillin-resistant
Staphylococcus aureus )were
reported in the Philippines
(38.1%) compared to the Republic
had very high prevalence rates of
77.6% and 74.1%, respectively. 8
Region. It is estimated that air
PER CAPITA
TOTAL
EXPENDITURE
ON HEALTH
AT AVERAGE
EXCHANGE RATE
(US$) (2011)
TOTAL
EXPENDITURE
ON HEALTH
AS % OF GDP
(2011)
GENERAL
GOVERNMENT
EXPENDITURE
OF TOTAL
EXPENDITURE
ON HEALTH (2011)
of Korea and Vietnam, which
2012 lived in the Western Pacific
43
The levels of out-of-pocket
Lower rates of hospital-acquired
killed by air pollution globally in
0.5 – 32.7
Papua New Guinea – Australia
5 – 137
Philippines – Japan
10 facts about healthcare
in the region
40% of the 7 million people
15.3
to a healthcare provider.7
THE HEALTHCARE SYSTEM
WESTERN
PACIFIC
PHYSICIANS
PER 10,000
PEOPLE
(2006 – 2013)
About 65% of Japanese patients
pollution caused 350,000 to
$679
$35 – $5,991
Lao PDR – Australia
6.6%
2.2% – 17.6%
Brunei – Tuvalu Darussalam
65%
22.6% – 99.9%
Cambodia – Tuvalu
400,000 premature deaths in
China alone.11,12,13
OUT-OF-POCKET
EXPENDITURE
AS % OF PRIVATE
EXPENDITURE ON
HEALTH
6.3% of admissions into Ministry
Initiatives to address financial bar-
of Health non-specialist hospitals
riers to accessing care in Cambo-
in Malaysia had an adverse event
dia include Health Equity Funds
78.4%
0.5% – 100%
Kiribati – Cook Islands, Niue, Tuvalu
(AE) and 78.8% of the AEs were
which now cover 80% of the
due to errors. 5
poorest people in the country. 3
76
A skilled birth attendant was pres77.2% of Singaporeans rated their
overall satisfaction levels with
public healthcare institutions as
“excellent” or “good”. 6
The healthcare system in
50% of patients who had been
Singapore was ranked “most
placed on a public hospital
efficient in the world” by
ent at only 37% of births in Lao
PDR. The number is 100% for Fiji. 4
elective surgery waiting list in
Bloomberg Rankings in 2014.
Australia waited 36 days or less.10
The city-state’s life expectancy
is 82.1 years and healthcare costs
account for just 4.5% of GDP. 9
Chen C & Bennett S. “China
Smog at Center of Air Pollution
Deaths Cited by WHO.”
Bloomberg Business. 2014.
11
Pfizer. The Global Burden
of Noncommunicable
Diseases. 2011.
3
WHO. Health System
Financing Country Profile:
Philippines. 2012.
4
1
2
38
WHO. Country Cooperation Strategy at a glance:
Cambodia. 2014.
WHO. Achieving the
health-related Millennium
Development Goals in the
Western Pacific Region.
2012.
Institute for Health
Systems Research. Adverse
Events in MOH Non-Specialist Hospital. 2010.
7
Ministry of Health, Singapore. Patient Satisfaction
Survey 2013. 2013.
8
5
6
Orlanes JE. “Health
Check: The Cost of Medical
Care in Japan.” Tokyo
Weekender. 2014.
WHO Regional Office
for the Western Pacific.
Antimicrobial Resistance.
2014.
Bloomberg. Most Efficient
Health Care 2014: Countries. 2014.
9
Australian Institute of
Health and Welfare. Survey
in Australia’s hospitals.
2014.
10
WHO. Public health, environmental and social determinants
of health (PHE). 2015.
12
Moore M. “China’s ‘airpocalypse’ kills 250,000 to 500,000
each year.” The Telegraph. 2014.
13
HEALTH IN SOCIETY
LIFE
EXPECTANCY
AT BIRTH IN
YEARS (2012)
62 – 83
Papua New Guinea – Australia, Singapore
DEATHS
CAUSED BY
NCDS 1
(2008)
80%
42% – 91%
Papua New Guinea – Australia
UNDER-FIVE
MORTALITY
RATE
DEATHS PER
1,000 LIVE
BIRTHS (2012)
16
3 – 72
Japan, Singapore – LAO PDR
39
PHYSICIANS
PER 10,000
PEOPLE
(2006 – 2013)
AFRICA
THE
AMERICAS
EASTERN
MEDITERRANEAN
EUROPE
SOUTHEAST ASIA
WESTERN
PACIFIC
2.6
20.8
11.4
33.1
5.9
15.3
2
23
8
53
10
43
HOSPITAL BEDS
PER 10,000
PEOPLE
(2006 – 2013)
AFRICA
THE
AMERICAS
EASTERN
MEDITERRANEAN
EUROPE
SOUTHEAST ASIA
WESTERN
PACIFIC
58
76
68
76
67
76
28%
79%
52%
87%
55%
80%
95
15
57
12
50
16
377
20
5.5
20
22
6.8
29.7% 23.5%
24.5% 13%
23.1% 20.4%
3.7% 1.7%
6.8% 5.1%
LIFE
EXPECTANCY
AT BIRTH IN
YEARS (2012)
DEATHS
CAUSED BY
NCDS 1
(2008)
UNDER-FIVE
MORTALITY
RATE
DEATHS PER
1,000 LIVE
BIRTHS (2012)
$99
$3,482
$195
$2,370
$69
$679
PER CAPITA
TOTAL
EXPENDITURE
ON HEALTH
AT AVERAGE
EXCHANGE RATE
(US$) (2011)
HIV
MORTALITY
RATE
DEATHS
PER 100,000
PEOPLE (2012)
OBESITY RATE
TOTAL
EXPENDITURE
ON HEALTH
AS % OF GDP
(2011)
6.2%
14.1%
4.2%
9%
3.7%
6.6%
AMONG ADULTS
OVER 20 YEARS
OLD
(2008)
11.1%
women
ALCOHOL
GENERAL
GOVERNMENT
EXPENDITURE
OF TOTAL
EXPENDITURE
ON HEALTH (2011)
48.3%
49.5%
51%
73.9%
36.7%
65%
OUT-OF-POCKET
EXPENDITURE
AS % OF PRIVATE
EXPENDITURE ON
HEALTH
56.6%
30.1%
88.9%
68.8%
84.3%
78.4%
40
USE
AMONG ADULTS
OVER 15 YEARS
OLD
(2011)
men
women
6
CONSUMPTION
LITERS PER
YEAR AMONG
ADULTS OVER
15 YEARS OLD
(2011)
TOBACCO
5.3%
men
women
8.4
men
0.7
women
men
women
10.9
men
women
3.5
men
6.8
7%
22%
16%
26%
4%
38%
19%
38%
4%
34%
3%
47%
women
men
women
men
women
men
women
men
women
men
women
men
41
HEALTH
SYSTEMS
IN FOCUS
TAKING THE
TEMPERATURE OF
HEALTHCARE IN
CHINA, EUROPE
AND THE USA.
42
43
CHINA
FROM EAST
TO WEST
China faces some unique challenges in terms of sustainable healthcare provision in
the coming decades. Its demographic and economic transitions have resulted in a
massively expanding healthcare system, even outpacing the country’s economic
growth.
While government reforms in 2009 have acknowledged the need for a more personcentered healthcare system, the country is still struggling to institute such changes
From China over Europe to the United States of
America, healthcare systems are under pressure
to fulfill their task of delivering quality healthcare.
across the board.
Drastic differences in access to quality healthcare between rural and urban
populations is a major challenge, as are safety and hospital payment structures that
incentivize over- and under-treatment of patients.
Although the challenges China faces in relation to healthcare quality and sustainability
This chapter gives three of the largest and most prominent healthcare
are significant, certain bright spots, such as hospital coordination improvements and
systems in the world a check-up in order to describe some of the systemic
the Essential Drug List, could have the potential to help transform China’s healthcare
challenges that are holding them back from becoming safer, smarter and
system into one that is more equitable, person-centered and sustainable.
more sustainable. By giving an objective diagnosis of the healthcare sysPAGES 46-65
tems in China, Europe and the United States of America, we can begin to
discuss the differences as well as the common healthcare denominators
for the world today.
The state of healthcare is uncovered by examining how the seven dimensions of quality in healthcare – adapted from the Institute of Medicine –
EUROPE
measure up with the reality on the ground.
The healthcare systems of Europe are a
microcosm of the region as a whole: constantly
evolving and increasingly coherent, yet still
fragmented in many respects. The Euro Debt
Crisis and subsequent financial instability has
put a serious strain on the region’s healthcare
systems.
THE SEVEN DIMENSIONS OF HEALTHCARE QUALITY ARE:
EFFECTIVENESS
growing burden of NCDs have only exacerbated
these challenges. Despite national autonomy, the
SAFETY
region’s countries are intertwined and deeply
TIMELINESS
connected. Citizens have an increasing choice in
where to live, work and seek healthcare.
PERSON-CENTERED CARE
ENVIRONMENTAL
SUSTAINABILITY
COST-EFFICIENCY
under serious pressure due to high costs, the
growing burden of NCDs, and the extreme
variation in care quality. The country’s inefficient
payment model has led to healthcare costs that
Yet still, the care received by many Americans
is of a markedly lower quality than many of
their Western counterparts. Such inefficiencies
are compounded by the increasing problem of
NCDs and the growing divide between wealthy
and poor citizens. Progress is being made1, as
Such interconnectedness has led the region
recent healthcare reforms have been designed
to adopt European-wide healthcare initiatives,
to address some of these disparities and
aimed at providing all of Europe with more
challenges. 2
equitable, safe and person-centered care in the
years to come.
There remains, however, a long road ahead for
the country in terms of equalizing access to care,
The analysis is coupled with insights from the three roundtables conducted
lowering healthcare spending, and cultivating
in the regions, where professionals, patients, policy makers and researchers
an all around more sustainable and efficient
discussed the future of healthcare and pointed us towards challenges and
PAGES 66-91
opportunities.
healthcare system.
PAGES 92-113
U.S. Department of Health and
Human Services. The Affordable
Care Act is Working. 2015.
1
44
The healthcare system of the United States is
far outpace any other industrialized nation.
Social factors such as aging populations and the
EQUITY
THE UNITED STATES
OF AMERICA
Patient Protection and Affordable Care Act, 42 U.S.C. § 18001.
2010.
2
45
CHINA
RECALIBRATING A
SYSTEM FOR NEW
DISEASE PATTERNS
In 2009, the central government in China announced that a
series of reforms would be implemented in an effort to provide
safer, more convenient, and more affordable care to its population of 1.3 billion. The reforms affect nearly every aspect of
healthcare, from insurance and primary care, to hospital management, medications, and public health.
There are also some positive developments, as
recent decades, serious challenges remain in
programs are seeking to help balance healthcare
The reforms underline the fact that the health-
are more likely to live longer. In 2010, people
the country’s approach to healthcare delivery.
resources between rural and urban populations6,
care sector has become an economic and
aged 60 and over accounted for 13% of the total
As explained in the analysis below, the divide
and new reforms like the redesign of the Essen-
strategic priority for China. Healthcare spending
population and it is expected that this will further
between wealthier urban residents and poor-
tial Drug List have the potential to provide more
in China is expected to near $890 billion a year
increase to 24% by 2030. 2
er rural citizens is apparent in their respective
equitable and safer access to pharmaceuticals.7
by 2017, growing by an average rate of 13.8%
46
While China has made remarkable progress in
healthcare access. Corruption is a serious issue
annually in local currency terms from 2013-2017.
As the country’s demographics and citizen
and person-centered care, while gaining traction,
Total spending is forecast to reach the equivalent
lifestyles have changed, so have the diseases
remains almost entirely absent in some regions.4
of 5.9% of GDP by 2017, up from an estimated
which afflict them. The rate of non-communica-
5.3% in 2012.1
ble diseases (NCDs) has increased dramatically in
Due to major structural problems, safety for
Deloitte. Global healthcare
outlook: Shared challenges, shared
opportunities. 2014.
1
China, and today more than 85% of the country’s
both patients and doctors alike is a concern. 5
China has made impressive strides since the mid-
mortality is attributed to NCDs. While NCDs have
The healthcare sector is growing at a rapid pace,
20th century in terms of healthcare. Notably, life
become the primary disease burden, communi-
consuming more economic resources, but the
expectancy at birth rose from 35 years before
cable diseases remain a problem in some western
allocation and use of such funds is, at times,
1949 to 75 years in 2010. This increase has also
provinces, illustrating the often extreme divide
wasteful and inefficient.
resulted in a rapidly aging population, as people
between urban and rural livelihoods in China. 3
WHO. Health sector reform in
China. 2015.
2,3
Ministry of Health, China. “Counterpart Technical Support between
Urban Tertiary Hospitals and Rural
Hospitals in China.” WHO – Global
Health Workforce Alliance. 2011.
6
IMS Consulting Group. New
Game. New Opportunities. New
Direction. 2013.
7
Yip W & Hsiao W. “The Chinese
Health System At A Crossroads.”
Health Affairs 2008; 460-468.
4
5
Hesketh T et al. “Violence against
doctors in China.” BMJ 2012; 345.
47
CHINA
/ EQUITY
DIVIDED BY PHYSICAL
AND SOCIAL
INEQUALITIES
While more Chinese citizens than ever now have health
insurance, ensuring equal access to high quality care is
still a major challenge for China’s healthcare system. The
country’s physical and social divides continue to lead to
inequality in terms of access to healthcare.
Third-level hospitals are more likely to be in large
ruption has become extremely widespread in the
cities, while first- and second-level hospitals are
healthcare sector and exists at multiple levels. 20
more often located in local townships and smaller
Patients offer bribes, or as it is called in Chinese
cities.13 In 2011, China had 1,350 public third-level
hongbao, to doctors in the hopes of getting the
hospitals, 6,034 second-level hospitals and 2,908
best treatment possible. Drug companies and
first-level hospitals.14
medical manufacturers are also complicit in these
schemes, as seen in the high profile case of Brit-
Rural China also has a drastically low supply of
ish pharmaceutical giant GlaxoSmithKline’s 2013
doctors, due in large part to their hospitals’ less
$488 million bribery fine for channeling nearly
technologically advanced equipment, physicians’
that same amount of money through conduits to
lower salaries, as well as lower prestige.15 As Law-
physicians and other medical staff to prescribe
ton Burns, a healthcare management professor at
their drugs at inflated prices. 21 Such practices
the Wharton Business School notes; “Why would
worsen an inequitable system as access to care
a doctor move from a class three urban hospital
becomes a matter of wealth rather than respond-
to the lower pay of a class one or two hospital in
ing to a clinical need.
a rural area? Doctors lose prestige and money by
going outside the cities.” 16
Despite these challenges, rural hospitals have
made substantial strides in providing better
quality care in recent years. From 2005 to 2008,
5 KEY PRIORITIES OF THE
CHINESE HEALTH REFORM
OF 2009
as part of a WHO project, 10,000 physicians from
well-respected urban third-level hospitals were
Stark differences between rural and urban China
have cultivated a system in which urban dwellers
have greater access to care than rural residents.
As China’s Ministry of Health reports through the
WHO, while 70% of China’s population is located
in rural areas, only 20% of total health resources
are allocated to the rural population. 8 Physically
separated from care, and often with low incomes that restrict travel abilities, rural Chinese
tend to receive lower quality care. 9,10 Large, well
equipped Chinese hospitals are typically only
located in large cities, meaning rural residents
must travel great distances or utilize lower quality
health centers.11
THE URBAN/RURAL CHASM
While healthcare in China has improved dramatically in recent years, it has not improved equally
across the entire country. Where a Chinese
citizen lives, particularly whether it is in a city or
the countryside, impacts that person’s access to
care. According to the WHO, at the end of 2011,
China had an average of 3.5 medical institution
beds per thousand residents – with a total of
877,727 medical institutions. However, there is a
striking difference between urban and rural areas, with 6.24 medical beds per thousand people
in urban areas, but only 2.80 in rural areas.12
The divide is also evident in the types of hospi-
This section will focus on the division between
urban and rural China and corruption as barriers
for creating equitable healthcare.
assigned to work at rural county-level hospitals
and township health centers. These doctors
agreed to work in rural areas for one year, also
providing training for healthcare workers in these
communities, in exchange for higher wages and
guarantees of future promotion.17 Additionally, a
World Bank project in the rural Henan Province
restructured hospital payment schemes and
subsequently discouraged over-prescription,
increased patient satisfaction, and increased physician salaries.18 To read more about alleviating
healthcare treatment gaps in rural China, head to
depending on their size and capabilities, with
first-level hospitals being the smallest and least
well-equipped and third-level hospitals being the
largest and best equipped.
identified five priority areas and established
a committee across ministries to coordinate
their policy formulation and implementation.
The five priorities are:
• Accelerating the establishment of the
basic medical security system
• Establishing a national essential
medicines system
• Strengthening health services at grass
roots level
• Promoting the equalization of basic
public health services
• Promoting pilot projects for public
hospital reform 22
page 148 of our Change Makers chapter to learn
Pilot project in practice: In June 2014,
about LifeSeeds.
China announced that 17 new pilot
cities will fully implement hospital
tals that exist in a given region. Chinese hospitals
are divided into three classification schemes
The Chinese government’s 2009 reforms
reforms, intended to strengthen policy
interpretation, provide training for
CORRUPTION IS A FACTOR
relevant management personnel and
Given the sensitivity of the subject, little data
heads of pilot hospitals, and improve
exists concerning corruption in China’s healthcare
management. They will also work to
system. But according to Transparency International’s annual corruption perception index, China
publicize and communicate changes to
the community. 23
ranks 117 out of 175 nations.19 By all accounts cor8
Ministry of Health, China. “Counterpart Technical Support between Urban Tertiary Hospitals
and Rural Hospitals in China.” WHO – Global
Health Workforce Alliance. 2011.
11
Yip W & Hsiao W. “The Chinese Health System
At A Crossroads.” Health Affairs 2008; 460-468.
12
9
Lua W. “Universal Rural healthcare in China?
Not So Fast.” The Atlantic. 2013.
10
48
Chen Y, Zhou Y & Xie Q. “Suggestions to
ameliorate the inequity in urban/rural allocation
of healthcare resources in China.” International
Journal for Equity in Health 2014; 13:34.
WHO. Health sector reform in China. 2015.
WHO Western Pacific Region. Health Sector
Reform in China. 2015.
13
The State Council of the People’s Republic of
China. Guideline targets improving healthcare.
2015.
14
15
HIMA Research. Untitled.2013.
Swedish Agency for Growth Policy and Analysis. China’s Healthcare System – Overview and
Quality Improvements. 2013.
16
Wharton – University of Pennsylvania.
Healthcare in China: Is There a Doctor in the
House? 2013.
17, 18
19
WHO. Counterpart Technical Support between
Urban Tertiary Hospitals and Rural Hospitals in
China. 2011.
21
World Bank. Hospital Reforms in Rural China
Increased Patient Satisfaction. 2013.
22, 23
20
Transparency International. Corruption Perceptions Index 2014: Results. 2014.
Beech H. “How Corruption Blights China’s
Healthcare System.” Time. 2013.
49
CHINA
/ SAFETY
THE CASE OF LEE MEGNAN
SAFETY AN ISSUE
FOR PATIENTS AND
PROFESSIONALS
The case of Li Megnan, a 17-year old boy who attacked and killed hospital intern,
Wang Hao, in 2012, drew national attention in China. Megnan’s story came to
symbolize the collapse of doctor-patient and a fundamental dysfunction in China’s
healthcare system, plagued by high costs, questionable diagnose, and poor care
provision.
Experiencing severe leg pain in his village, Megnan travelled 6 times over the course
of 2 years to doctors in larger city hospitals, as those closer to home were unable
to properly treat his condition. However, his care in Beijing and Harbin were hardly
improvements.
Faced with repeated bureaucratic hurdles, incorrect diagnoses, late detection of
secondary ailments that necessitated pausing care for his leg pain and raising the
cost of treatment through additional prescription drugs, Megnan reached a breaking
point. While condemning his actions, many in China sympathized with Megnan’s utter
Safety is perhaps the most basic component
of any healthcare system, but it is one in which
China still struggles.
he have a history of violence. He was a man whom society had failed so completely
that he was impelled to lash out.” 37
According to the limited information on the
EDUCATION AND TRAINING LEVEL OF
subject, the rate of hospital-acquired infections
DOCTORS VARIES
MORE DATA NEEDED ON HOSPITAL ACQUIRED
WHEN THE SYSTEM ATTACKS
appears to be relatively low in China. The educa-
Having adequately educated and skilled care
INFECTIONS
When most of us think of safety in the healthcare
tion and training of doctors, however, is a public
providers is one of the most vital components of
Generally speaking, little data exist on the issue
sector, we think primarily of patient safety. Yet,
health concern, particularly for lower-income pa-
ensuring patient safety. China had about 2.3 mil-
of healthcare associated infections in China. 30
in China, safety and treatment of patients has
tients in rural communities. 24,25 Additionally, a re-
lion doctors in 2010, 90% of whom are trained in
Therefore, knowledge on this burden comes from
become increasingly tied to the safety of doctors
cent phenomenon of patient attacks on doctors
Western medicine. However, the level and quality
small scale studies in various regions and cannot
and other healthcare providers. A survey by
illuminates another side of the safety challenge
of training varies a great deal. Many doctors have
be regarded as representative of the country as
the China Hospital Management Association
in China, as frustrations with poor and danger-
only a 3 year post-secondary certificate and the
a whole. Still, the different studies can give the
found that violence against medical personnel
ously inefficient treatment has been blamed for a
typical 8 year MD training of Western institutions
reader an idea of the state of HAI’s in China.
increased an average of 23% each year between
drastic increase in the number of incidents where
was, as of 2010, available only at two universi-
patients attack doctors. 26
ties. 27
2002 and 2012. 33 By then, Chinese hospitals were
One such study surveyed nearly 400,000
reporting an average of 27 attacks a year, per
patients in 398 ICUs of 70 hospitals in Shanghai
hospital. 34
Qualification of doctors and hospital acquired
Additionally, lacking a history of primary care,
from September 2004 to December 2009 and
infections are highlighted below as indicators
China has very few GPs. As such, most doctors
determined that the rate of device-associated
The survey identifies four primary contributing
of the state of patient safety in Chinese health-
working at Community Health Centers (CHCs)
healthcare-associated infections was 5.3%. 31
factors to this phenomenon in China, name-
care. In addition, the aspect of physician safety
are not trained as GPs and are not necessarily
Another report from 2014 – a one-day point
ly a deteriorating doctor-patient relationship,
is presented as a unique propensity in Chinese
equipped to diagnose and treat common diseas-
prevalence study of HAIs in the Yijishan Hospital
caused by the shortcomings of the health system;
healthcare.
es and chronic ailments experienced by patients
of Wannan Medical College – found that the
seeking high level specialist care even for minor
at those facilities. 28,29
prevalence rate of such infections was 3.53%
conditions, leading to unrealistic expectations;
among a survey of 2,434 patients. 32 While these
physician unhappiness and low morale; and inef-
studies act as examples of large and small
fective and inefficient legal channels for handling
scale surveillance of HAIs, the lack of a wider
malpractice disputes. 35 Solving this problem will
breadth of knowledge at a national scale results
take structural changes, such as improved insur-
Burkitt L. “Violence Against
Doctors on the Rise in China.” Wall
Street Journal. 2013.
in a significant knowledge gap. More extensive
ance coverage and lower out-of-pocket costs, a
Hesketh T et al. “Violence
against doctors in China.” BMJ
2012; 345.
studies on HAIs in China would therefore be
better system of legal redress, and an increase in
needed before firm conclusions about their
the use of primary care facilities. 36
Tao X et al. “Hospital-acquired
infection rate in a tertiary care
teaching hospital in China: a
cross-sectional survey involving
2434 inpatients.” International
Journal of Infectious Diseases.
2014; 27: 7-9.
24
Q & Lu Y. “Medical Education
Reforms in China.” Asia Pacific Biotech News 2014; 10(15): 805-808.
Wannian L & Chan D. “Community Healthcare Reform and General
Practice Training in China – Lessons Learned.” Medical Education
Online 2004; 9(10).
28
McKinsey & Company. China’s
Healthcare Reforms. 2010.
29
25
Beam C. “Under the Knife.” The
New Yorker. 2013.
26
McKinsey & Company. China’s
Healthcare Reforms. 2010.
27
50
frustrations. As the New Yorker reported in 2014, “Li Mengnan wasn’t a lunatic, nor did
Tao L et al. “Device-associated
infection rates in 398 intensive care
units in Shanghai, China: International Nosocomial Infection Control
Consortium (INICC) findings.”
International Journal of Infectious
Diseases 2011; 15(11): 774-780.
31
Tao X et al. “Hospital-acquired
infection rate in a tertiary care
teaching hospital in China: a
cross-sectional survey involving
2434 inpatients.” International
Journal of Infectious Diseases.
2014; 27: 7-9.
32
Hu B et al. “Device-associated
infection rates, device use, length
of stay, and mortality in intensive
care units of 4 Chinese hospitals:
International Nosocomial control
Consortium findings.” American
Journal of Infection Control 2013;
41(4): 301-306.
30
Beam C. “Under the Knife.” The
New Yorker. 2013.
33
34
35, 36
Beam C. “Under the Knife.” The
New Yorker. 2013.
prevalence and impact can be made.
37
51
CHINA
/ PERSON-CENTERED CARE
tion exists in the Chinese hospital system. Appointment
booking, for example, often includes bureaucratic hur-
THE PATIENT IS A
RESOURCE
dles, with patients typically unable to book consultations
over the phone, instead needing to appear in person at
their hospital of choice to wait in line in order to receive
an appointment time.42 Some great strides are being
made in this area though, as explained in the Journey
Toward Opportunities chapter on p. 133. A small, qualitative 2014 study on the care of older adults with chronic
illness from two general hospitals, two nursing homes,
China’s approach to person-centered care has made
significant strides in recent years. Yet, while some
mindsets have changed, many structural practices
have not. Person-centered care, therefore, remains a
goal rather than an achievement.
one community hospital and one clinic in the city of
Tianjin found that nurses may lack an understanding of
continuity of care for patients.43
Though limited, there are some indications of efforts to
improve coordination at some large, busy hospitals. An
initiative began in 2013, piloted in several major municdepartments so that beds could be utilized in an inte-
Person-centered care has been discussed in
to create patient organizations. According to
grated and coordinated manner, with greater efficiency
China’s healthcare system since at least 1997, and
the Stockholm Network’s report “Patient Power
and exploitation.44 Currently, some hospital departments
has, since the 2009 blueprint for future health-
– what it takes for patient associations to help
are at full capacity while others, in the same building,
care, been an official consideration of the govern-
shape public policy,” China is among the nations
have vacant beds, but due to restrictions they cannot
ment. 38 The approach to person-centered care
least conducive to the inclusion of the patient
share beds between divisions. This restructuring plan
has been top down, with policy makers imposing
voice in health policy, when compared with seven
could potentially allow more patients to be admitted.
new rules on practitioners, such as to improve
other key emerging markets. There is no formal
communication with patients, respect privacy,
process of incorporating patients’ views.41
Although China’s constitution officially includes
freedom of speech and of assembly, there are
Studies at the University of Technology in Sydney
certain barriers preventing patients from exer-
and expert in Chinese healthcare, reports, the
cising their rights. According to the Stockholm
person-centered care reforms “provided some
Network’s report, the existing legislation on the
change in the way doctors and patients interact –
rights of patients still suffers from inconsistencies
and helped to create a culture that focuses more
and there are difficulties in organizing patient
on patients, but the Chinese healthcare sector is
associations. Some patient groups also suffer
not patient-centered through and through.”40
discrimination e.g. those that advocate for HIV/
AIDS awareness. As long as these structural
As described below, person-centered care is
barriers are in place, China will have tremendous
beginning to be seen in coordination efforts
difficulties in developing a truly patient-centered
at certain hospitals, but in other areas, such as
healthcare system.
patient involvement and eHealth, it still has some
contribute a great deal to person-centered care, as they
make it easier for both patients and care providers to
access and share health information. Both have been
expanding in China since the early 2000s, but the
systems have been afflicted by numerous problems
preventing optimal use and coordination. These include
insufficient funds to create a widespread and meaningful
system; a lack of unification and coordination, resulting
in the simultaneous creation of over 100 electronic
record keeping systems in various regions and cities
regulation; reluctance toward information sharing,
particularly with large metropolitan hospitals not willing
to share information with smaller Community Health
Centers (CHCs), nor likely to recognize a diagnosis or
test from such facilities due to concerns of personnel’s
proficiency and the accuracy of their equipment.45
Additionally, access to eHealth material can be difficult
for many Chinese – especially rural residents who are
furthest from medical centers – due to low internet penetration throughout the country. While internet use has
skyrocketed in recent years, from 10.5% in 2006 to 46%
in 2014, over half of the country still remains without
home- or mobile device-based access.46 See figure 1.
treat patients with dignity, and smile more. 39
Jingqing Yang of the Institute for International
eHealth and the use of electronic medical records
without interoperability; a lack of legislation and
ipal hospitals, to break down barriers between hospital
Still, these reforms have yet to truly take hold. As
E-HEALTH LANDSCAPE STILL FRAGMENTED
FIGURE 1.
50
INTERNET IS SPREADING
RAPIDLY
40
Percentage of internet users in China
over time
30
In the last decade the number of Internet
users has exploded – paving the way for
a more widespread implementation of
eHealth.
20
10
Source: Internet Live Stats. China
Internet Users. 2014.
0
way to go.
2004
2006
2008
2010
2012
2014
SMALL STEPS TOWARDS CONTINUOUS CARE
Ensuring smooth transitions between different
NO TRADITION FOR INVOLVING PATIENTS
stages of care and providing patients with a
A strong indicator of patient engagement is the
seamless experience between nurses, doctors
opportunity for patients to be a part of health-
and hospitals is a central aspect of person-cen-
care policy development, as well as their ability
tered care. As it stands now, very little coordina-
38
Yang J. The side-effects of China’s patient-centered
healthcare reform. 2010.
42
Sustainia & DNV GL. Guide to Person-Centred Care.
2014.
43
39, 40
Stockholm Network. Patient Power – What it takes for
patient associations to help shape public poilcy. 2013.
41
52
Huang E. “It Isn’t Getting Any Easier to Get a Doctor’s
Appointment in China.” The Atlantic. 2013.
Cheng S.L, Zhao JZ, Bai J & Zang XY. “Continuity of Care
for Older Adults with Chronic Illness in China: An Exploratory Study.” Public Health Nursing 2014.
Gao X, Xu J, Sorwar G & Croll P. “Implementation of
E-Health Record Systems and E-Medical Record Systems in
China.” The International Technology Management Review
2013; 3(2): 127-139. p131
45
46
Internet Live Stats. China Internet Users. 2014.
China-Japan Friendship Hospital. Municipal Hospitals to
Pilot Internal Beds Coordination. 2013.
44
53
CHINA
/ COST-EFFICIENCY
THE ECONOMIC
BURDEN OF NO GATE
KEEPING
Without an effective primary care system in
ESSENTIAL DRUG LIST IS
LOWERING COSTS AND
IMPROVING ACCESS
place, and without well-functioning CHCs, China’s
hospitals are likely to remain overcrowded, with
resources spent on minor, easily treatable conditions rather than on patients in the most need.
Maintaining quality care while lowering costs is a difficult challenge for all healthcare systems. While China’s
legacy of a lack of primary care exacerbates this burden, administrative problems are also to blame.
The Essential Drug List (EDL) is a list of
FRAGMENTATION IS WASTING RESOURCES
drugs approved for use in China’s primary
healthcare facilities and is one of 5 central
The 2013 report, “China’s Healthcare System –
components of the Chinese government’s
Overview and Quality Improvements,” conducted
2009 healthcare reforms. The goal of
by the Swedish Agency for Growth Policy Analy-
the EDL is to establish a “comprehensive
sis, found that China’s insurance system is deeply
system which facilitates access and ensures
fragmented, leading to inefficiencies and wasted
affordable care for all citizens by 2020.” 51
resources. While the insurance schemes designed
Hospitals are banned from applying their
traditional 15% mark-ups on sales of EDL
to serve urban residents are managed by the
drugs to patients, ideally ensuring that low-
Ministry of Human Resources and Social Security,
Keeping costs low while maintaining a high
A LACK OF GATE KEEPING LEADS TO
the plan meant for rural residents is operated by
quality of treatment is a fundamental challenge
CROWDED CITY HOSPITALS
the Ministry of Health. Information on insured
for healthcare systems across the world. In China,
the concrete results of these efforts appear quite
mixed. The country’s lack of gate keeping with
use of primary care facilities places an enormous
and unnecessary burden on hospitals, and thus
overcrowding can lower the quality of care.
Certain political reforms implemented in the last
couple of years, such as the reform of the essential medicines system including the Essential
Drug List, provide some hope that funds in the
near future can and will be better managed from
the top down.
This section will hone in on the level of gate
keeping in Chinese healthcare and the system’s
administrative fragmentation.
In healthcare, a gate keeper is “a primary-care
provider... who coordinates patient care and
provides referrals to specialists, hospitals,
laboratories, and other medical services.” 47 This
role is helpful in addressing conditions early
on and deferring non-serious ailments from
emergency rooms so hospitals can treat those
in most urgent need. The lack of gate keeping
and utilization of community health centers
income patients can gain affordable access
to these basic medicines. 52
While the initial 2009 EDL system was
individuals in the different systems is not shared
afflicted by inconsistencies and poor
between departments and some people take part
enforcement, the 2012 reincarnation shows
in both urban and rural schemes, which increases
great improvements. The number of
the burden on both the government and the indi-
Western drugs increased from 205 to 317
and coverage broadened to include more
vidual. A report by the Central Auditing Bureau in
treatments. 53 While the national list was
2011 showed that 5.47 million people take part in
expanded to include more drug options,
both resident medical insurance schemes, forcing
greater restrictions were placed on regional
the government to spend an additional nearly
supplementations, thereby ensuring greater
$150 million in subsidies. 50
consistency across geographic locations. 54
These new policies have the potential to
contributes to overcrowded and inefficient care
improve both safety and cost-efficiency, by
at hospitals in large cities.48 Patients travel long
balancing expanded coverage with restricted
distances to these hospitals, unsatisfied with
supplementations.
the care they would receive closer to home, or
they are referred to these facilities by their local
Community Health Centers (CHCs). While the
CHCs were designed and implemented to act
as gate keepers, treating common ailments that
require less intensive care and procedures, the
poor quality of care they offer has prevented
them from relieving the burden of overcrowding
at the better respected city hospitals.49
The Free Dictionary by Farlex.
Medical Dictionary. 2015.
47
WHO. Health insurance systems in
China: A briefing note. 2010.
48
IMS Consulting Group. New Game.
New Opportunities. New Direction.
2013.
51
Yang H et al. “Determinants of
Initial Utilization of Community
Healthcare Services among Patients
with Major Non-Communicable
Chronic Diseases in South China.”
PLOS One 2014: 9(12).
49
54
Swedish Agency for Growth Policy and Analysis. China’s Healthcare
System – Overview and Quality
Improvements. 2013.
50
McKinsey & Company. An essential strategy for the essential drug
list. 2013.
53
IMS Consulting Group. New
Game. New Opportunities. New
Direction. 2013.
54
McTiernan R. “China’s EDL release
a positive for patients, pharma firms
to face pricing pressure.” IHS Life
Sciences Blog. 2013.
52
55
CHINA
/ EFFECTIVENESS
EFFECTIVENESS IS
IMPROVING, BUT IS NOT
INCENTIVIZED
2%
FIGURE 2.
THE INCENTIVE TO
OVERTREAT
Hospital income structure in China
91% of hospital income comes from
drug sales and medical treatments, thus
incentivizing overtreatment and overprescription of medications.
Sale of drugs
Other
POOR INCENTIVES PROMOTE INAPPROPRIATE
This combined with a fee system, in which
TREATMENT
hospitals are reimbursed by the government for
The double-edged challenge of over- and
under-treatment contributes negatively to the
effectiveness of healthcare in China. Since the
and 80s, the central government has cut vast
insurance. Total health expenditures were $156
billion and per capita costs were $119. By 2011,
these numbers had dramatically changed, with
95% of the population now covered under some
form of health insurance, and total health expenditures more than doubling to $357 billion. Per
capita expenditures also more than doubled, to
$261. 55 Despite these improvements, out-of-pocket healthcare costs remain very high due to the
fact that insurance often does not cover the full
amount of many treatments. Additionally, due to
poor incentive structures and systemic corruption many patients pay for tests and procedures
they do not need, thus increasing their bill and
wasting resources. 56,57,58 Conversely, under-treatment is also a problem, with patients unable
to receive needed care due to cost, insurance
status, or hospital constraints.
The current magnitude of underinsurance and
status of over- and under-treatment are indicators of the challenges that the Chinese healthcare system is faced with in terms of providing
effective care.
UNDERINSURANCE IS WIDESPREAD
The drastic increase in the number of insured
amounts of public money for hospitals. As such,
these facilities have had to fund themselves, ultimately redirecting costs to patients.
citizens does not necessarily translate into
better or less expensive care for patients. 59
Another method of obtaining revenue is by
Hospital bills are enormously high in China, and
increasing the cost of pharmaceuticals, and as
insurance rarely covers the full amount, meaning
such, hospitals can charge a 15% mark-up on the
patients must pay a great deal out-of-pocket
price non-EDL drugs, and sometimes higher,
or forego care. Costs of care also vary a great
which often encourages physicians to prescribe
deal depending on both the type of insurance
more expensive medicines and more of them.
someone has and where they live. Ultimately,
For example, 75% of patients suffering from a
China has one of the highest ratios of out-of-
common cold are prescribed antibiotics, as are
pocket payments to total health expenditure
79% of hospital patients – over twice the inter-
of any Asian country, and in 2012, 78% of all
national average of 30%.62 Given the extremely
private expenditures on health came in the form
low salaries of Chinese doctors – officially about
of out-of-pocket payments.60 Additionally, over
$7,500 a year – this incentive to over-prescribe is
one-third of households have reduced their
particularly great.63
services performed, regardless of necessity or
quality of care, provides doctors an incentive
to perform unnecessary tests, prescribe unnecessary medicine and recommend unnecessary
treatments.64 See figure 2.
Under-treatment is an equally serious problem
in Chinese healthcare, as patients are rushed
through the system in order for doctors to see as
many people as possible. The Economist reported in 2013 that budget caps at certain hospitals
caused doctors to keep the cost of treating each
patient under a certain amount. Should that
amount be exceeded, the remainder would be
deducted from the physician’s own paycheck.65
This misguided tactic incentivizes rushed care
and early discharges, and can be extremely
dangerous for patients. While over- and under-treating patients may at first glance appear
to be opposing problems, they in fact operate in
tandem and signify numerous flaws in the healthcare system.
consumption or been impoverished by healthrelated expenditures.61 Such a high amount
indicates that while a 95% insurance coverage
rate is impressive, it may mask more systemic
problems with the quality and depth of that
coverage.
McKinsey & Company. Healthcare
in China: Entering ‘uncharted
waters’. 2012.
55
Huang C. “Healthcare Is So
Corrupt In China That Patients Have
To Bribe Doctors For Proper Care.”
Business Insider. 2014.
56
Beech H. “How Corruption Blights
China’s Healthcare System.” Time.
2013.
57
56
7%
Source: KPMG. “The changing
face of healthcare in China”. 2010.
Page 8.
liberalization of China’s economy in the 1970s
In 2006, only 45% of the population had health
42%
Government subsidy
Medical treatment income
In many respects, China’s healthcare system has made
immense strides in productivity and effectiveness in recent years, with reforms improving how healthcare operates and serves its citizens. Still, there exists a great deal
of waste and poorly managed care, due in large part to
distorted incentive structures.
49%
Fan R. “Corrupt Practices in
Chinese Medical Care: The Root
in Public Policies and a Call for
Confucian-Market Approach.”
Kennedy Institute of Ethics Journal.
2007; 111-131.
58
McKinsey & Company. Healthcare
in China: Entering ‘uncharted
waters’. 2012.
The World Bank. “Out-of-pocket
health expenditure (% of private
expenditure on health)”. Data. 2015.
60
The Economist. “Feeling your
pain.” The Economist. 2013.
64, 65
Yip W & Hsiao W. “The Chinese
Health System At A Crossroads.”
Health Affairs 2008; 460-468.
61, 62
59
Woodhead M. “How much does
the average Chinese doctor earn?”
Chinese Medical News. 2014.
63
57
CHINA
/ TIMELINESS
FIGURE 3.
WAITING TIMES AND PATIENT
DISSATISFACTION
WORTH
THE WAIT?
Long wait time Sources of dissatisfaction with hospital care in
Beijing, Shanghai, and Chengdu hospitals
Poor personnel attitude
High price or overcharge Poor physical environment Qualification of physicians
Other
For patients in Beijing, Shanghai, and Chengdu that were
dissatisfied with their hospital experience, long waiting
times were the most common reason for this dissatisfaction.
Long waiting times have been a wellknown aspect of the Chinese healthcare
system. While many hospitals show no
sign of change in this regard, others are
taking strides to boost efficiency and cut
waiting times in the process.
Source: PricewaterhouseCoopers. Emerging Trends in
Chinese Healthcare. 2010.
BEIJING
7.3%
75.6%
SHANGHAI
43.9%
7.3%
32.6%
64%
46.3%
Crowded conditions in China’s largest and best
Since the 2009 healthcare reforms, though, wait-
hospitals – due in large to inadequate or per-
ing times are beginning to go down in a handful
ceived inadequate care at smaller, community
of hospitals. In 2012, Beijing Friendship Hospital,
hospitals – mean that long waiting times are a
for instance, was part of a pilot program de-
norm. Anecdotes abound of hours-long lines that
signed to improve the patient experience. As part
stretch outside just to receive a doctor’s appoint-
of the program, patients would pay more to see a
ment.66, 67, 68, 69 A 2010 PricewaterhouseCoopers
doctor, but drugs sold by that hospital would be
survey of Shanghai, Chengdu and Beijing found
much cheaper, lowering the total bill.71 This also
that while patients are generally satisfied with
resulted in shorter waiting times. Such a program
their choice of hospital, 75% of those dissatisfied
indicates how small changes in hospital income
with the service at their hospital of choice in
models (paying more for doctors rather than
Beijing indicated long waiting times as the pri-
drugs) can serve to improve the patient experi-
mary reason for dissatisfaction.70 This figure was
ence, lower costs, curtail corruption, disincentiv-
also high in Shanghai and Chengdu, at 64% and
ize over-prescription, and reduce long waits.
35.5%
9.8%
CHENGDU
54.1%
22.7%
86.7%
40%
11.6%
86.7%, respectively. See figure 3.
20%
Huang E. “It Isn’t Getting Any
Easier to Get a Doctor’s Appointment in China.” The Atlantic. 2013.
68
China Smack. “Waiting All Night
Outside A Hospital Hoping to See
A Doctor.” China Smack. 2009.
69
66
58
China Economic Review. “China’s
healthcare reform needs to address hospital waiting times.” China
Economic Review. 2009.
65
Lim L. “China’s Professional
Queuers Paid to Stand Around.”
NPR. 2011.
20%
53.3%
PricewaterhouseCoopers.
Emerging Trends in Chinese
Healthcare. 2010
70
Einhorn B & Loo D. “China Raises
Doctor Fees, Lowers Drug Bills to
Ease Anger.” Bloomberg Business.
2012.
71
59
CHINA
/ ENVIRONMENTAL SUSTAINABILITY
IN NEED OF
A BREATH OF
FRESH AIR
ADDRESSING THE
WASTE CHALLENGE
Some regions are attempting to address the
Air is not the only natural element in China being
degraded by rapid industrial development. In
medical waste problem, such as Guangxi’s
2014, Chinese state media reported that 60%
Qinzhou City, which invested $3 million in a
of the country’s underground water was pol-
medical waste disposal center outside the city.
luted.79 It was also reported in 2013 that about
Results, however, are not meeting expectations,
one-third of China’s water resources are ground-
as particularly rural hospitals still choose to
burn their hazardous waste rather than recycle
The relationship between healthcare and environmental sustainability is an often-discussed issue in China. While the impact of
the environment on healthcare is well documented and discussed,
the healthcare industry’s impact on the environment is less so.
...NOT A DROP TO DRINK
water-based, and that only 3% of the country’s
and process it properly.72 It remains to be seen
urban groundwater can be classified as “clean”. 80
whether these efforts can make an impact on the
Some regions are worse than others, with the
actions of hospitals and medical centers in terms
land ministry reporting that 70% of groundwa-
of their medical waste disposal protocols.
ter in the north China plain – an area that covers
approximately 400,000 sq km and is some of the
world’s most densely populated land is unfit for
human touch, let alone consumption. 81 In 2007
The World Bank estimated that the health cost of
cancers and diarrhea associated with water pol-
An increasingly important aspect of the health-
without compliance with national or international
of Europe and the United States. This reflects
lution reached approximately $8 billion in 2003 in
care system in China is its environmental impact.
standards of pollution control.72 According to a
their inability to reach what is elsewhere consid-
rural areas of China. 82
Medical waste is a serious concern in China,
recent study in the Shandong Province, a great
ered safe and healthy pollution levels.
and as the world’s largest developing country it
deal of disparity exists between urban and rural
produces a lot of it. Another connection between
hospitals in terms of generation of medical waste.
Pollution has drastic consequences for China’s
source from which they are coming. The fact
healthcare and the environment in China is the
In second- and third-level hospitals, for example,
healthcare system. The OECD reported that in
that Chinese state media are voluntarily produc-
impact that pollution – of both air and water – has
the average waste generation rate was 0.74kg
2010 the health impact of air pollution in China
ing such alarming information about their own
on the health of Chinese citizens. This leads to a
and 0.56kg per bed per day, whereas in first-level
was approximately $1.4 trillion.76 With data from
pollution habits appears to be a sign of increasing
less healthy population with greater healthcare
rural community hospitals this rate rose to 1.53 kg
a Global Burden of Disease study, the New York
transparency and accountability. Additionally, in
needs and higher healthcare costs.
per bed per day.73
Times reports that air pollution contributed to 1.2
2013 the government announced plans to invest
million premature deaths in China in 2010, nearly
$277 billion to curb air pollution, aiming to reduce
40% of the global total that year. Nationally, this
air emissions by 25% by 2017 compared with 2012
In the following, medical waste, air and water pol-
One positive element of these reports is the
lution are presented as primary indicators of the
AIR POLLUTION IS OFF THE CHARTS
means China lost 25 million healthy years of life
levels. 83 Such transparency and financial invest-
current status of sustainability and the environ-
Pollution is undoubtedly an enormous concern
from the population.77 Beijing’s Center for Disease
ment are positive signs that the Chinese govern-
mental challenges the Chinese healthcare sector
of China’s, and one that severely impacts both
Control and Prevention recently reported that an
ment is serious about addressing its pollution
is faced with today.
its health and environmental sustainability. Air
average 18 year old living in the city can expect
problems.
pollution is particularly apparent, with stories of
to spend as much as 40% of their remaining life
China’s dense, grey air making headlines around
in less than full health, suffering from cancer, car-
MEDICAL WASTE IS PILING UP
the world. Typically, air pollution is measured by
diovascular disease, arthritis, and other ailments
While most of the discussion around sustainabil-
the concentration of particulates in the atmo-
related to the city’s extremely poor environmen-
ity in China’s healthcare sector revolves around
sphere, and WHO guidelines state that anything
tal conditions.78
environmental hazards that impact public health,
over 10 micrograms per cubic meter (PM2.5) of
another serious concern is the negative effect
these particulates is considered dangerous to
that the healthcare industry has on the environ-
human health. To put in perspective how bad Chi-
ment. As a rapidly growing developing country,
na’s pollution problem is, we can compare notori-
safe and efficient disposal of medical waste is
ously smog-filled Los Angeles, which averages an
of serious challenge in China. In 2007, the State
16.2 PM2.5, with the Chinese city of Xingtai, with
Environment Protection Administration reported
a population of over 7 million, which averages a
that China produces about 1,800 tons of med-
truly astounding 155.2 PM2.5.75 China has even
ical waste a day, much of which is disposed of
60
adapted its own air quality scale, relative to that
International Finance Corporation
– World Bank Group. IFC Investment in Medical Waste Treatment
Plants in China is Expected to Benefit 120 million people. 2007.
72
Gai R et al. “Hospital medical
waste management in Shandong
Province, China.” Waste Management & Research 2009; 27(4):
336-42.
China Daily. “China’s medical
waste piles up.” China Daily. 2013.
Minter A. “Why Living in Beijing
Could Ruin Your Life.” Bloomberg
View. 2014.
Kan H. ”Environment and Health
in China: Challenges and Opportunities.” Environmental Health Perspectives 2009; 117(2): 530-531.
74
78
82
Washington Post. “Worst air
pollution in China and the U.S.”
Washington Post. 2014.
79, 80
Kaiman J. “China says more
than half of its groundwater is
polluted.” The Guardian. 2014.
83
75
73
OECD. The Cost of Air Pollution.
2014.
76
Wong E. “Air Pollution Linked
to 1.2 Million Premature Deaths in
China.” New York Times. 2013.
77
China Water Risk. North China
Plain Groundwater: >70% Unfit for
Human Touch. 2013.
81
Reuters. “China to invest $227
billion to curb air pollution: state
media.” Reuters. 2013.
61
SHANGHAI
ROUNDTABLE
The first of three roundtables on our global journey
to co-create better healthcare systems took place
in Shanghai, China. The discussions and active
participation of stake holders from all parts of the
Chinese healthcare system resulted in co-created
outcomes in the form of identified challenges and
opportunities for how we can change the system for
the better.
CHALLENGES FOR HEALTHCARE IN CHINA
OPPORTUNITIES FOR CHANGE
There is a lack of financing and long-term
Involve patients in their treatment plan and
establish feedback systems
planning to support the Chinese healthcare
reform
Doctors are concentrated in urban areas,
limiting access to care for rural populations
Improve measurement of quality of care
Establish incentives that improve quality of
care for all
Incentives and hospital payment structures
lead to over- and under-treatment of patients
Focus less on check-lists and more on the
patient’s needs
Scandals in the healthcare system have resulted in a lack of trust between patients and
Establish trust throughout the system
healthcare professionals
The healthcare professionals are overworked, compromising safety and quality
To spur discussions, Dr. Duan Tao, President of Shanghai First Maternity
of care
& Infant Hospital and Mr. Alex Lam, Vice Chairman of Hong Kong Alliance
of Patients’ Organizations (profiled in an interview on page 64) gave
inspirational presentations and summarized the conclusions of the day.
THREE GLOBAL ROUNDTABLES
62
In late 2014 and early 2015, DNV GL and Monday Morning Sustainia traveled to
The roundtables were in the format of one-day interactive workshops that gathered key
Shanghai, Brussels, and Washington DC to gain insights for this publication and start
stakeholders from across the healthcare system, including patients, professionals, providers,
a conversation on challenges and opportunities for improving the quality of care in
policy makers and researchers, with the aim of identifying possible trajectories for change
the healthcare systems of China, the EU and the USA. The guiding question for the
by spurring dialogue and discussions based on the various perspectives from the different
roundtables was: HOW DO WE IMPROVE THE QUALITY OF CARE?
stakeholders.
63
CHINA
/ EXPERT INSIGHT
one example: there have been sever-
within healthcare. We have to see
al cases of patients or family mem-
the patient as the starting point of
bers hurting hospital professionals
healthcare and have their interests at
because they have not received
the center of all we do.
correct or timely treatment.
There is no way of expressing
Participant at the
Shanghai roundtable
HOW CAN THE CHINESE HEALTH-
CHALLENGE FACING THE CHINESE
CARE SYSTEM OVERCOME THE
HEALTHCARE SYSTEM?
CHALLENGES OF AN AGEING
China’s large population is a big
POPULATION?
Patients should be willing to
receive care outside of their home
because it is in their own best interest, both socially and physically.
In the future, when the Chinese
challenge but it is also an oppor-
Ageing is stressing the system
anger or dissatisfaction within the
views and have a say in choice of
tunity, as fixing the problems that
and there is a need for a new mind-
care is provided in other parts of the
system as the formal channels for
treatment through dialogue before
afflict the healthcare system has the
set from patients and their families.
world, I believe that we will see the
complaints are not working.
and after treatment. Currently the
potential to improve the lives of a lot
In China, it is part of the culture that
needed mindset shift.
approach of the Chinese healthcare
of people.
families take care of their elderly
WHAT IS TO COME IN THE FUTURE
FOR PATIENT ORGANIZATIONS IN
CHINA?
professionals is more paternalistic,
portunities for patient organziations
Another challenge we are seeing
members. This is, in many instances,
with doctors telling patients what
is that the Chinese population is age-
not a good solution because the care
treatment they will be given without
ing, which will change the healthcare
puts great strains on families and
listening to patients’ needs.
system considerably in the future.
in some cases means that elderly
Today, we are already seeing more
patients do not receive the right
patients with diseases related to
treatment.
Currently there are limited opto champion the voice of patients
WHAT ARE SOME TANGIBLE WAYS
HOW CAN PATIENT ORGANIZATIONS INFLUENCE THE POLITICAL
DECISION-MAKING PROCESS IN
CHINA?
My organization has good access
to the government, but we are not
change the mindset of families and
a large group and have problems in
patients to accept that nursing
regards to resources. We are trying
homes and other facilities that can
our best to push for a mindset where
deliver care to the elderly are op-
patients and families are at the
complaint committee within the
tions that benefit all parties involved.
center of care. We have suggested
is that Chinese people are becoming
Hospital Authority. The commit-
The government will have to show
that the government sets up more
are small scale and not yet seen as
more aware of their rights. When
tee includes a representative from
leadership and establish health-
healthcare facilities that can provide
important institutions in the Chinese
they pay their taxes, they also want
patient organizations, making the
care facilities that can provide care
the care that is needed for the
healthcare system. It is very difficult
to receive high quality services in
committee more representative and
to elderly patients and treat their
elderly.
to form patient organizations be-
the healthcare system. This push
impartial in terms of considering
diseases.
cause they are seen as challenging
may result in service providers within
complaints.
the system, and we do not have a
healthcare becoming more aware
strong history of service users ques-
of patients’ needs. In the future, I
established for patients to express
tioning the way in which healthcare
think the government may be more
their views and it is important to
is delivered or being involved in the
willing to accept the existence of
stress that these views will include
co-design of services. The result is
patient organization but they would
both complaints and appreciation.
probably still ask for a high degree
Patients are very grateful when they
of monitoring of activities.
receive the right treatment.
HOW DO YOU SEE THE
ROLE OF PATIENT ORGANIZATIONS IN CHINA?
Currently patient organizations
“Without patients,
healthcare professionals don’t have a
job to do.”
providers like hospitals and doctors
as working against the interest of the
system.
What could change the situation
spected or recognized as it could be.
The lack of focus on their inter-
COME MORE ACTIVELY INVOLVED
HOW CAN THE MINDSETS OF
CHINESE HEALTH PROFESSIONALS
BE CHANGED TO FOCUS MORE
ON THE PATIENT AS AN ACTIVE
PARTICIPANT OF THEIR OWN
dementia.
IN THEIR HEALTHCARE?
In Hong Kong we have a public
the number of people expressing
gratitude is four times higher than
Professor
Weiwei Zhang
Board Member of the
Beijing Association
of Alzheimer’s
Disease
Participant at the
Shanghai roundtable
HOW CAN PATIENTS AND FAMILIES BE INVOLVED IN THE TREAT-
that focus solely on providing care to
Alzheimer’s and dementia patients.
MENT OF ALZHEIMER’S?
Alzheimer’s patients are mostly
elderly. The Government provides
their medicine for free, but patients
have to stay in their homes and be
cared for by their families. There are
no specialized nursing homes for
complaints. That is also why it is
patients with Alzheimer’s, which is a
important to find a balance between
risk factor because their treatment
the negative and positive feedback.
and medicine are not managed by
We need to not only focus on com-
health professionals.
plaints but also start to integrate ap-
Alzheimer’s is on the rise in
proaches where patient appreciation
China. We must think of new ways
professionals don’t have a job to
is used actively to improve quality in
of treating the disease, but it is very
do. A mindset has to be devel-
the Chinese healthcare system.
important that the patients and their
Without patients, healthcare
This could also be done by establishing departments within hospitals
I hope that more platforms will be
In Hong Kong, for instance,
CARE?
that the patient voice is not as re-
THAT CHINESE PATIENTS CAN BE-
age, such as Alzheimer’s disease and
have become aware of how health-
My organization is working to
as they are seen by medical service
64
WHAT IS THE BIGGEST
allow for patients to express their
Mr. Alex Lam
Vice Chairman of the
Hong Kong Alliance of Patients
Organizations
The healthcare system needs to
ests has resulted in a lot of anger
oped where the patient’s interest is
families are involved in this process
and frustration from patients. Take
seen as pivotal for all professionals
and that we respect their culture.
“Patients should be
willing to receive care
outside of their home
because it is in their
own best interest, both
socially and physically.”
65
EUROPE
SHARING A
HEALTHCARE
GOAL
The 53 countries that make up the WHO European
Region represent healthcare systems that are located
within different social, economic, political and cultural
contexts.
Even though it is easy to view Europe as a fragmented region, 28 states are already coordinating health
and healthcare policy through their participation in the
European Union. Common challenges, such as ageing
populations, increases in chronic diseases, and greater
demand for healthcare for less money call for more coordination in the future – not less.
Recent years have been has characterized by
The healthcare challenges and solutions of tomor-
a growing body of common guidelines and
row are not staying within country borders but
cross-border healthcare initiatives in Europe.
demand transnational collaborations and knowledge sharing.
One concrete example is the “Communication on
Effective, Accessible and Resilient Health Systems,”
Although the policies, organization, and delivery of
which came from the European Commission in
healthcare remain the responsibilities of individual
2014. It advocates the use of performance assess-
governments, the EU plays a role in helping to set
ment results, improved patient safety and develop-
new standards, promoting change, and exchanging
ment of integrated care.
best practice across borders.
Another cross border initiative is the European
Through the seven dimensions of quality in health-
health policy framework, Health2020, which was ini-
care, this chapter gives you an insight to the chal-
tiated by the WHO and adopted by the 53 member
lenges that the European healthcare systems face.
states of the Region in 2012. It urges governments
to cooperate in fulfilling two strategic objectives: 1)
improving health for all and reducing health inequalities, and 2) improving leadership and participatory
governance for health.
66
67
EUROPE / EQUITY
PROTECTING
UNIVERSAL CARE
According to sociological monitoring carried out in
Russia for problems with the nations’ health systems,
ROMANIA IS STRUGGLING
TO PROVIDE EQUAL ACCESS
high drug prices and out-of-pocket
payments are two of the most crucial problems
facing the country’s healthcare system, according to
In Romania, access to healthcare is a serious
concern, especially for low income groups.
Despite the economic crisis, access to healthcare
is still considered a fundamental right in European
countries. This does not mean that all healthcare
needs in the region are met – especially for low
income groups.
70% and 35% of respondents, respectively.
According to a review of the Romanian Health
Additionally, nearly half of the respondents men-
Sector by The World Bank from 2011, many poor
tioned that they would have to limit their food
individuals who are in need of healthcare do not
spending and purchase of staple goods to pay for
seek care.
medical services.12 High healthcare costs are there-
This is the case for almost 10% of the population. 8
fore having a significant impact on the quality of life
This gap is particularly large in the treatment
of many Russian citizens.
of chronic disease, as 42% of the poor with a
chronic condition do not seek care, compared
with 17% of the rich.
CRISIS CREATES VULNURABILITY IN
The true gap is likely even larger, as, according
Access to healthcare constitutes a basic right
UNMET CARE – PARTICULARLY FOR
according to the Charter of Fundamental Rights
THOSE MOST IN NEED
of the European Union.¹ This right, however, has
been challenged by the recent economic crisis
where health expenditures fell in half of the EU
countries and growth significantly slowed in the
other half.
The crisis meant cuts in health workforce and
salaries, reductions in fees paid to health providers, lower pharmaceutical prices, and increased
patient co-payments.² These measures have had
a negative effect on patients’ abilities to access
the health system.³
Universal (or near universal) health coverage
in most EU countries has remained the norm
during and after the crisis.⁴ Still, The Euro Health
Consumer Index from 2014 states that the financial crisis has resulted in a “slight but noticeable
increase in inequity of healthcare services across
Europe” and detects the biggest equity gap
between wealthy and less wealthy European
countries in the nine year history of the index.⁵
In all European countries, the large majority of
the population does not experience unmet care
needs, according to the 2012 EU Statistics on
Income and Living Conditions Survey.⁶ However, in Latvia, Poland, Romania and Bulgaria, for
to the World Bank’s report, many low income
individuals with chronic conditions are not aware
Most European countries have universal or near-uni-
9
of their need for care. Simulations that assume
versal coverage for a core set of healthcare services
that the need for care for chronic conditions
– exceptions are Bulgaria, Greece and Cyprus where
is similar between wealthy and poor people
a significant proportion of the population is unin-
estimate that a whopping 85% of the poor who
need medical care are not getting it.
In March 2014, the World Bank approved a loan
to Romania of $338.8 million for the objective of
example, more than 10% of the respondents had
improving access to, and quality and efficiency of
unmet needs for a medical examination, and this
public health services in Romania.10
burden fell unevenly on low income groups.
The reforms include the streamlining of hospital
services; enhancing primary care services,
On average across EU member states, more than
twice as many people in low income groups reported unmet needs as did people in high income
groups.
HEALTHCARE
sured.
In Bulgaria, public insurance is not automatic for the
unemployed and self-employed. Instead, they have
the option to buy it.
In Greece, coverage is reduced after 24 months of
particularly at the community level; and
unemployment. Both systems, and the people they
increasing sector governance and stewardship
serve, are very vulnerable to economic crises that
in order to improve management, strengthen
cause high unemployment rates.
departmental communication and better
incentivize primary care.
The main reason for people in low income groups
to report unmet healthcare needs was that care
These reforms are expected to improve the
performance of the health system as a whole and
reduce existing inequities in terms of access to
was too expensive. The proportion of people
quality care amongst the population. The World
in low income groups reporting unmet needs
Bank program will run until 2020.11 for financial reasons is two times greater than
that of the population as a whole and over four
times greater than among people in high-income
groups on average across EU countries.⁷
⁶ European University Institute. EU
Statistics on Income and Living
Conditions. 2015.
⁷ OECD & European Commission.
Health at a Glance: Europe 2014.
2014.
⁸ The World Bank Europe and
Central Asia Region. Romania
Functional Overview – Health
Sector. 2011.
The World Bank. Romania –
Health Sector Reform – Improving
Health System Quality and Efficiency Project. 2015.
10
The World Bank. Project appraisal
document on a proposed Loan in
the amount of Euro 250 million to
Romania for a health sector reform
– improving health system quality
and efficiency project. 2014.
11
European Observatory on Health
Systems and Policies. Health
Systems in Transition – Russian
Federation: Health system review.
2011.
12
This section will hone in on coverage of healthcare costs, unmet care needs and doctor consultations examining the overall question: How
equitable are the European healthcare systems?
The World Bank Europe and
Central Asia Region. Romania
Functional Overview – Health
Sector. 2011. Page ix.
9
¹ European Parliament. Charter of
Fundamental Rights of the European Union. 2000.
⁴ European Commission. Health at
a Glance: Europe 2014 Executive
Summary. 2014.
² European Commission. Health at
a Glance: Europe 2014 Executive
Summary. 2014.
⁵ Health Consumer Powerhouse.
Euro Health Consumer Index. 2014.
³ Health Consumer Powerhouse.
Euro Health Consumer Index. 2014.
68
69
EUROPE / SAFETY
FIGURE 4.
COUNTRIES INTRODUCING COSTS FOR ACCESS TO HEALTHCARE
Greece
In 2011 copayments increased
from approximately $3 to $5 for
outpatient hospital care and
health centers.
Ireland
Portugal
In 2008, it cost about $65 to access
emergency care and $65 per day
for hospital care, capped at 10 days
per year ($650). By 2013, this was
increased to over $100 to access
emergency care and $80 per day
for hospital care, capped at 10 days
per year ($800).
These fees are waived for people
with a medical card (40% of the
population in 2013).
The 2014 Eurofund report, “Access to healthcare
in times of crisis,” which explores the impacts of
the financial crisis on access to public healthcare
services, also found that economic crises are
contributing to the emergence of new types of
vulnerable groups which have difficulties accessing healthcare.13
Job loss – and the loss of work-associated health
insurance – is creating new groups of Europeans
that struggle to access quality healthcare.
At the same time, though, several countries have
recently introduced measures that increase the
cost of healthcare or restrict access to it. Spain,
for instance, passed a measure in 2012 denying universal healthcare entitlements to nearly
From 2007 to 2013, copayments
for both inpatient and outpatient
care were raised, with the largest
increase occurring in 2012.
Exemptions for chronically
ill patients were restricted to
consultations/ treatments for their
specific condition.
Source: European Foundation for
the Improvement of Living and
Working Conditions. Access to
healthcare in times of crisis. 2014.
CREATING A
CULTURE OF
PATIENT SAFETY
Over the last decades patient safety has moved
far up the political agenda in Europe. But despite
a line of common guidelines aimed at improving
patient safety, fragmentation still rules. Some
countries have made patient safety a top priority
while others remain reluctant to take on the
challenge.
UNEQUAL USE OF HEALTHCARE SERVICES
Throughout the region, there are income-related
differences in the use of healthcare services. According to the OECD report, “Health at a Glance”
from 2012, there is evidence of inequity in terms
of doctor consultations by income group in European counties.
Looking at the EU in general, patient safety
remains an unresolved issue in healthcare.
An estimated 8-12% of patients admitted to
hospitals in the EU suffer from adverse events
while receiving healthcare. 25% of these adverse events are healthcare-associated infec-
The probability of a generalist visit is equal in
most countries and lower income individuals actually consult a GP more frequently. In regard to
specialist visits, however, a different story emerges. In nearly all countries, high income individuals
are more likely to see a specialist than those with
low incomes and also do so more frequently.15
tions (HAIs), but adverse events also include
medication-related errors, surgical errors,
medical device failures, errors in diagnosis, or
•The establishment and development of
national policies and programs on patient
safety
• Making patients part of the process
• Education and training of healthcare workers
failure to act on the results of tests.16
•Sharing knowledge, experience and best
practice at community level
In 2009, the European Council put forward 13
• Prevention of healthcare associated infections
recommendations for patient safety measures, including the prevention and control of
Variation in the implementation of the EU
900,000 non-registered residents and intro-
HAIs, and invited the Commission to report
recommendations, the state of HAIs, and a
duced copayments for drugs on the grounds of
on progress and further action.
lack of healthcare professionals are discussed
austerity.14 These simultaneous phenomena are
below as indicators of the development of
placing a double burden on vulnerable Europeans seeking healthcare. Figure 4 shows three
examples.
patient safety in the Europe.
European Foundation for the Improvement of Living and Working Conditions.
Access to healthcare in times of crisis. 2014.
13
14 Legido-Quigley H. Erosion of universal
health coverage in Spain. The Lancet 2013;
382(9909): 1977.
70
The overall recommendations include:
15 OECD & European Commission. Health at
a Glance: Europe 2012. 2012.
16 European Commission. Special Eurobarometer 411: Patient
Safety and Quality of Care. 2014.
71
FIGURE 5.
HARMED BY HEALTHCARE
WHAT IS STANDING IN THE
WAY OF PATIENT SAFETY
RECOMMENDATIONS?
ECONOMIC
CRISIS AND
RESULTING
CONFLICTING
PRIORITIES
LACK OF
POLITICAL
WILL
Every year an estimated 4.1 million patients acquire
There is still room to improve information provided
a HAI in the EU, and at least 37,000 die as a result.
to patients and their involvement in HAI prevention.
The financial cost of HAIs in Europe is approximately
According to the Eurobarometer survey on patient
$6.2 billion annually.20
safety and quality of care from 2014, only 39% of the
respondents that had been hospitalized or admitted
Economic strain, technology and
fragmentation are among the main reasons
for the lack of implementing patient safety
recommendations among the EU countries
Source: European Commission.
Report on the Public Consultation
on Patient Safety and Quality of
Care. Undated.
FRAGMENTATION OF
PROVISIONS AND
ORGANIZATION
BARRIERS
DOMINATING
“BLAME
CULTURE”
LACK OF
PATIENT
SAFETY
CULTURE
Although HAIs are a challenge, the solutions are
to a long term facility in the past 12 months report-
within reach. It is thus estimated that 20-30% of
ed that they had received information on the risk of
HAIs can be prevented by intensive hygiene and
HAI – the majority of those who did came from the
control programs.21
western and northern areas of the EU.23 The Eurobarometer report also notes that there has been an
According to a report from the European Com-
increase in how many adverse events are reported,
mission based on member states’ reports on the
from 28% in 2009 to 46% in 2014. At the national
implementation of the Council Recommendation on
level there have been even more dramatic changes,
patient safety, about two out of three EU countries
for instance in France (+61% points), Spain (+40) and
had defined a national strategy and/or action plan
Luxembourg (+32).
for the prevention and control of HAIs in 2011:
Sadly, 37% of the respondents report that the most
•More than 80% of national action plans included
likely outcome of reporting an adverse event was
hospital implementation of: infection prevention
that nothing happened. 20% received an apology
and control programs; appropriate organizational
from the professional and only 17% received an ex-
PUSHING SHARED PATIENT
governance arrangements and qualified infection
planation for the error.
SAFETY GUIDELINES FORWARD
control staff; surveillance of targeted HAIs; surveil-
The report from the European Commission from
Over the last couple of years, some progress has
lance of particular events for timely detection of
During the past few years, the EU has funded further
2012, which analyzes Member countries’ imple-
been made in regards to the 13 recommenda-
alert microorganisms or HAIs; and high quality mi-
projects aimed at improving the state of HAIs, such
mentation of the 13 recommendations, indicates
tions.
crobiological documentation and patient records.
as the Third Health Programme 2014-20, which aims
that while some countries focus intently on pa-
to improve patient safety and reduce HAIs in Euro-
tient rights, patient safety strategies, and patient
An evaluation from 2014 shows that most
•14 out of 17 countries with an action plan at the na-
inclusion policies, others take a more passive
pean countries.24 This program focuses specifically
countries have implemented at least half of the
tional level had set up mechanisms to encourage
on the control of healthcare-associated infections
stance and place the burden on individual hospi-
Council’s 13 measures. Ireland, with 12 out of 13
its implementation.
through exchanging good practices on quality
tals to introduce patient safety measures.
actions in place, is near completion, followed
closely by the UK and Germany, each with 10
assurance systems, developing guidelines and tools
•15 countries had considered nursing homes and
to promote quality and patient safety, increasing
Similarly, some EU member states have instituted
actions implemented. On the other end of the
healthcare institutions other than acute care hos-
the availability of information to patients on safety
official legislation on these strategies, while oth-
scale, Romania and Slovenia only have 3 out of 13
pitals when designing their action plans.22
and quality, and improving feedback and interaction
ers rely on less formal networks and platforms.17
actions implemented.19
between health providers and patients.25
Despite this development, the latest evaluation from
From 2013-2014 the European Commission con-
EU “Patient safety and Health-Associated Infections”
ducted an online survey on patient safety in the
from 2014 concludes that HAIs continue to be a
EU, particularly in order to highlight the barriers
problem in Europe.
to implementing the 13 Council Recommendations
for patient safety measures. Economic strain, lack
of political will, limited technology and fragmentation were among the primary barriers.18 See
figure 5.
17 European Commission. Detailed
analysis of countries’ reports on
the implementation of the Council
Recommendation (2009/C 151/01) on
patient safety, including the prevention
and control of healthcare associated
infections. 2012.
18 European Commission. Report on the
Public Consultation on Patient Safety
and Quality of Care. Undated.
72
19 European Commission. Patient
Safety and Healthcare-Associated
Infections. 2014.
20 Cilag GmbH International. Healthcare
Associated Infections – Fact & figures.
2015.
21
European Center for Disease Prevention and Control. Healthcare-associated infections. 2015. 22 European Commission. Detailed analysis of countries’
reports on the implementation of the
Council Recommendation (2009/C
151/01) on patient safety, including the
prevention and control of healthcare
associated infections. 2012.
24 European Commission. Patient
Safety and Healthcare-Associated
Infections. 2014.
25 Official Journal of the European
Union. Regulation (EU) No 282/2014
of the European Parliament and of the
Council. 2014.
23 European Commission. Special
Eurobarometer 411: Patient Safety and
Quality of Care. 2014.
73
EUROPE / PERSON-CENTERED CARE
DOCTORS WITHOUT BORDERS
All across Europe, the shortage of healthcare professionals is a reality. In 2012, on average across
EU countries, one in three doctors was over 55
years of age, up from one in six in 2000. This
aging workforce, combined with other factors,
SHORTAGE OF HEALTHCARE
PROFESSIONALS IN FINLAND
In Finland, the demand for healthcare services is
increasing, while there are not enough applicants
will likely cause an estimated shortage of 1 million
for the vacant positions. The primary reason for
health workers in Europe by 2020.26
this shortage is not a lack of sufficient training
at educational institutions, but rather that a
The healthcare sector is clearly affected by these
shortages and the 2014 Care Quality Commission
significant proportion of the qualified labor
works in sectors other than healthcare. For
example, there are 20,000 qualified practical
report assessing the UK’s National Health Service
nurses working outside the healthcare sector,
(NHS) and social care services stated that short-
meaning that their skills and training are not
ages of doctors and nurses posed safety risks for
being properly utilized. Partly to blame for this
patients.27
TOWARDS
CO-CREATION AT
DIFFERENT SPEEDS
The idea of putting the patient in the center of
healthcare is gaining momentum – and becoming
an integrated part of care delivery in European
countries. Still, a shared understanding of the term is
missing. The focus on and interpretation of personcentered care varies within the region of Europe.
is the fact that salaries in the healthcare sector
are fairly low, the work physically and mentally
demanding and the working conditions often
According to the Euro Health Consumer Index
study also identified different levels of
The 2014 European Commission report, “Map-
unfavorable.31 Reconciling this challenge will
patient rights legislation and involvement in
person-centered care in what they define as
ping and Analysing Bottleneck Vacancies in
be critical if Finland is to fulfill its demand for
policy-making became standard in Europe
Eastern and Western Europe.
EU Labour Markets,” examines the occupations
healthcare workers in the coming years.
by 2013, and only 2 countries have not yet
where there is evidence of recruitment difficul-
introduced healthcare legislation based on
In Russia, patient rights, as outlined in the
ties. In total, 21 of 29 European countries reported
patient rights.32
WHO’s “Declaration of Patients’ Rights in
vacancies in their healthcare workforce.
Europe,” have not been actively implemented
Despite the positive development, Europe
and patients typically lack the information
The findings show different reasons for the short-
still faces challenges in terms of delivering
needed to fully understand their illness or
age of healthcare professionals. For instance, in
person-centered care. The “Eurobarometer
potential treatment options. Without such
most EU1528 countries not enough people are
Projects and organizations are being developed
qualitative study” conducted for the Europe-
information, it is hard for patients to make
training as health professionals, whereas the
in an effort to alleviate the problems caused by
an Commission in 2012, which was based on
informed choices about their medical care.
challenge in newer EU states is that healthcare
cross border migration of professionals. The
interviews in 15 EU member states33, revealed
professionals seek employment in other coun-
European Joint Action on Health Workforce
that the meaning of the term “patient involve-
In the following dimension, we examine the
tries, where the salary and the working condi-
Planning and Forecasting, for instance, gathers
ment” was not clearly understood by either
state of integrated care, eHealth and health
tions are better.
experiences and best practices in planning and
practitioners or patients.34
literacy as three indicators of person-cen-
assessing health workforce needs. Their work
tered care in Europe, as they help to gauge
Furthermore, mitigation strategies used by
seeks to uncover sustainable solutions to the
In fact, it was often perceived by both groups
how well patients understand their involve-
some countries to actively fill the gaps in their
challenge of the growing demand for healthcare
“as medical compliance and following doc-
ment in their own health and healthcare
recruitment of healthcare professionals can have
workers throughout Europe.30
tors’ orders,” which is quite the opposite of
system.
a detrimental impact on other countries in the
the co-creation approach that person-cen-
region. For example, Norway is attracting labor
tered care is meant to evoke.35 The same
from neighboring countries, which consequently further depletes the supply of labor in those
nations.29
26Joint Action Health Workforce Planning and Forecasting. Leaflet. Undated.
74
27 Campbell D. “NHS staff
shortages pose risk to
patients, warns watchdog.”
The Guardian. 2014.
28 Austria, Belgium,
Denmark, Finland,
France, Germany,
Greece, Ireland, Italy,
Luxembourg, the
Netherlands, Portugal, Spain, Sweden
and the United
Kingdom
29 European Commission. Mapping and
Analysing Bottleneck
Vacancies in EU Labour Markets. 2014.
30 Joint Action Health
Workforce Planning
and Forecasting.
Welcome page.
Undated.
31 European Commission. Mapping and Analysing Bottleneck Vacancies in EU Labour
Markets. 2014.
32 Health Consumer Powerhouse. Euro
Health Consumer Index. 2014.
33 Austria (AT), Belgium (BE), Czech
Republic (CZ), Finland (FI), France (FR),
Germany (DE), Greece (EL), Hungary (HU),
Italy (IT), Latvia (LV), Poland (PL), Romania
(RO), Spain (ES), Slovakia (SK) and the
United Kingdom (UK).
36 WHO Regional Office for Europe.
Roadmap: Strengthening people-centred
health systems in the WHO European
Region. 2013.
European Commission. Eurobarometer
Qualitative Study – Patient Involvement.
2012.
37,38
34,35
Center for Strategy and Evaluation Services & Oxford Research. Final Evaluation
of the Lead Market Initiative. 2011.
75
FIGURE 6.
DIFFERENT APPROACHES TOWARDS MORE INTEGRATED CARE
From E-health records in Estonia to integrated HIV treatments programs in Ukraine,
integrated care is unfolding in different settings
FIGURE 7.
ESTONIA
UKRAINE
GERMANY
HEALTH LITERACY
IS STILL A GREAT
CHALLENGE
Percentage distributions of general
health literacy for each country
and the 7,795 respondents
AIM
OUTCOMES
To fully integrate communication through National Electronic
Health Records, hosting over
3,000 e-services and health
insurance systems for claims, reimbursement and prescriptions.
Efficiency gains via the direct
communication between institutions and providers.
More patient empowerment via
personal health records, virtual
medical centers and mobile
patient applications.
To implement integrated care
pathways for selected treatments through an integrated
contracting model designed to
improve coordination between
managers, doctors, psychiatrists
and psychotherapists.
Patients treated through integrated networks able to return
to work 72 days earlier than
those treated via conventional
care pathways.
To develop integrated services
for people with a history of
injection drug use through
innovations including pharmacy-based needle exchanges,
overdose prevention services
and improved case management services.
Improved HIV treatment outcomes, as well as reduced drug
use through improved adherence to treatment and retention
in care.
Inadequate health literacy
Sufficient health literacy
Problematic health literacy
Excellent health literacy
AUSTRIA
BULGARIA
GERMANY
GREECE
Across countries in Europe, health
literacy continues to pose a great
challenge in healthcare. The results
vary significantly between countries.
For example, inadequate health literacy
was present in 2% of the population of
the Netherlands, but 27% in Bulgaria.
SPAIN
IRELAND
NETHERLANDS
POLAND
TOTAL
Source: European Health Literacy Project. Final
Report – Executive summary (D17) – The European
Health Literacy Project (HLS-EU). 2012.
0 10 20 30 40 50 60 70 80 90 100 Improved user satisfaction.
TREMENDOUS POTENTIAL FOR EHEALTH
Source: WHO Regional Office for Europe. Roadmap: Strengthening people-centred health systems in the WHO European Region. 2013.
In 2007, the European Commission selected eHealth
Aside from a promising economic potential, eHealth
as one of six promising lead markets, meaning that
can empower patients through greater transparen-
it is innovative, responds to customers’ needs, has a
cy, access to services and information, and the use
strong technological and industrial base in Europe
of social media for health.39 Furthermore, patient
A EUROPEAN VISION FOR INTEGRATED CARE
To help address some of these barriers, WHO
and depends on public policy actions to create
empowerment is mentioned as part of the vision in
In the common policy framework – Health 2020 –
launched “Framework for Action towards Coor-
favorable framework conditions.
the eHealth Action Plan 2012-2020, put forward by
that the 53 member states in the WHO European
dinated/Integrated Health Services Delivery" in
Region have agreed on, people-centered health
2013, which supports countries with policy options
The European Commission was proven right in their
systems are defined as a shared goal. Figure 6
and recommendations that target key areas for
prediction, since the market potential of eHealth has
However, eHealth is still not a common standard
shows a selection of different nations’ integration
strengthening the coordination/integration of
remained strong, despite the economic crisis.
in the region. The study, “Overview of the national
initiatives. While they are very different cases, they
health services.
do illustrate that steps towards more integrated
the European Commission.
laws on electronic health records in the EU member
The global telemedicine market, for example, has
states and their interaction with the provision of
The framework focuses on ensuring the participa-
grown from $9.8 billion in 2010 to $11.6 billion in
cross-border eHealth services,” from 2013 concludes
tion of partners, including a network of focal points
2011, and is expected to continue to expand to $27.3
that, “there are major disparities between countries
One of the barriers standing in the way of further
in member states, external experts and leading
billion in 2016.38 This increase indicates a growing
on the deployment of EHRs40 [as] part of an interop-
expanding people-centered initiatives is that ad-
organizations in the field, such as the International
potential for the use of eHealth measures through-
erable infrastructure that allows different healthcare
vocating coordination and integration of services
Foundation for Integrated Care.
out the world, including Europe.
providers to access and update health data in order
health systems are being taken.
takes a backseat to other political priorities in
to ensure the continuity of care of the patient”.41
times of economic crisis.36
76
77
EUROPE / COST-EFFICIENCY
Another disconcerting finding from the study is
Unfortunately, according to WHO’s Health Litera-
the fact that EHR systems use very different ter-
cy Survey, nearly half of all Europeans have inad-
minology and coding methods depending on the
equate and problematic health literacy skills, and
country in which they operate, and this semantic
as such have difficulties in accessing, understand-
diversity is considered one of the main barriers
ing, appraising and applying information to make
to the transfer of health data making it difficult to
healthcare decisions.43 See figure 7. This poses
ensure continuity in care.
a threat to the future of person-centered care in
Europe, as low health literacy makes it difficult for
LOST IN TRANSLATION
patients to take their health in their own hands,
Health literacy is a key dimension of Health 2020
thereby leaving professionals as the only experts
– the European health policy framework adopted
in health.
by member states in 2012 – and it remains a chal-
GROWING DEMAND
AND SHRINKING
BUDGETS
Economic strain is the reality and the future
for healthcare systems throughout the European region. These constraints will hopefully pave the way for a delivery of healthcare
where cost-efficiency is named king – not
through reductions in healthcare, but through
new models, new priorities and new incentives.
lenge in the region.
According to WHO, low health literacy is strongly
The healthcare sector accounts for 8% of
associated with more hospitalization and less
the total EU workforce and 10% of the GDP.
self-management. An individual’s level of literacy
According to the 2013 report, “Investing in
directly affects his or her ability to access health
Health,” from the European Commission,
information, learn about disease prevention and
the high healthcare costs in the EU pose the
health promotion, follow healthcare regimens and
question of “cost efficiency and the finan-
communicate about health messages with other
cial sustainability of the region’s healthcare
people.42
systems.”44
The pressure for finding a sustainable healthcare model is rising. On one hand, the economic crisis caused enormous reductions in
public health spending. In Iceland, Ireland and
Greece public expenditure on health was reduced by 9.3%, 9.9% and 10.8%, respectively,
between 2009 and 2010. On the other hand,
39 Center for Strategy and Evaluation
Services & Oxford Research. Final
Evaluation of the Lead Market Initiative. 2011.
40 Electronic Health Records
41 Health Programme of the European
Union. Overview of the national laws
on electronic health records in the EU
member states and their interaction
with the provision of cross-border
eHealth services – Final report and
recommendations. 2014. Page 7.
78
42 WHO. Working document for discussion at the 7th Global Conference
on Health Promotion, “Promoting
Health and Development: Closing the
Implementation Gap”, Nairobi, Kenya,
26-30 October 2009.
Focusing on disease prevention can reduce
high long-term treatment costs and improve
health outcomes by avoiding tens of thousands of premature deaths.46
However, little relative importance is currently given to health promotion in budgetary
terms. Between 70% and 80% of healthcare
budgets across the EU is currently spent on
treating chronic diseases, and 97% is spent on
treating patients with both acute and chronic
conditions. But only 3% is spent on prevention, with chronic diseases being among the
most preventable illnesses.47 See figure 8.
ageing populations and the prevalence of
chronic diseases are also stressing the need
for better quality care for less money.45
In the following, healthcare promotion and
43 European Health Literacy Project.
Final Report – Executive summary
(D17) – The European Health Literacy
Project (HLS-EU). 2012.
PRESCRIBING PREVENTION
costs of pharmaceuticals will serve as measurements of cost efficiency within European
healthcare.
European Commission.
Investing in Health. 2013.
44,45,46
47 Spongenberg H. “Chronic
diseases: forcing change in EU
healthcare management.” EU
Observer. 2014.
48 Friends of Europe. Healthcare
in Times of Austerity: Boosting
Cost-Effective Prevention. 2013.
79
EUROPE / EFFECTIVENESS
FIGURE 8.
PREVENTION IS NOT
TOP PRIORITY
Current health expenditure
by function, 2012 (or nearest
year)
In-patient care
Outpatient care
Medical goods
Prevention and adminstration
100
90
80
70
60
50
40
30
Prevention efforts are taking
20
10
One example of the benefits of prevention is
EFFORTS TO CUT
the flu vaccine. According to the WHO, season-
PHARMACEUTICAL SPENDING
al influenza can cost $6.5 million per 100,000
residents each year in countries like France and
Germany. If vaccination rates in Europe went up
to 75%, 1.7 million more cases of flu could be prevented. In addition, achieving this target would
reduce the number of visits to GPs by approximately 770,000 annually.48
Between 2000 and 2009, pharmaceutical expenditure grew by 3.2% annually in EU member
states, an increase that exceeded GDP growth.49
As the economic crises hit Europe, this picture
changed and the pharmaceutical sector was targeted by governments seeking to cut costs without harming patient outcomes. A range of measures has been introduced across the EU member
countries, including price cuts, centralized public
procurement of pharmaceuticals, promoting
the use of generics, reduction of package sizes,
50 OECD & European Commission.
Health at a Glance: Europe 2014.
2014.
51 Deloitte Center for Health
Solutions. Impact of austerity on
European pharmaceutical policy
and pricing: Staying competitive in
a challenging environment. 2013.52
OECD & European Commission.
Health at a Glance: Europe 2014.
2014.
53 European Federation of Pharmaceutical Industries and Associations. Annual Review of 2011 and
Outlook for 2012. Undated.
reduction in coverage, and increases in co-payments by households.50 In terms of the increasing
use of generics, Germany has introduced systems
to benchmark prices and started to link reimbursements to the lowest available price of the
drug as a way to reduce public spending.51 The
result of these initiatives has been falling annual
growth rates of spending on pharmaceuticals of
2.7% in 2011-2012 across EU member states.52,53
ICELAND
SWITZERLAND
NORWAY
SPAIN
SLOVAK REPUBLIC
HUNGARY
PORTUGAL
SWEDEN
LUXEMBOURG
DENMARK
LATVIA
CROATIA
GERMANY
ESTONIA
FINLAND
SLOVENIA
NETHERLANDS
EU23
CZECH REPUBLIC
CYPRUS
LITHUANIA
POLAND
Source: OECD & European Commission.
Health at a Glance: Europe 2014. 2014.
AUSTRIA
0
GREECE
Region.
ROMANIA
spending across the European
FRANCE
up a small part of the overall
49 Deloitte Center for Health
Solutions. Impact of austerity on
European pharmaceutical policy
and pricing: Staying competitive in
a challenging environment. 2013.
EU GUIDES THE WAY
TO MORE EFFECTIVE
CARE
Long-term care
Policy recommendations from the EU are trying
to promote effectiveness in healthcare in the
region. In recent years, a line of improvements
has taken place, but there are still shared
challenges and great variations when it comes to
effectiveness between established EU countries
and new additions to the Union.
In 2014, the European Commission issued the
“Communication on Effective, Accessible and
Resilient Health Systems” which addresses
the effectiveness of EU healthcare systems by
calling for member states to apply performance assessment results, improve patient
safety and develop integration of care.54 The
Communication also acknowledges that assessing the effectiveness of health systems is
a complex process and states that, “healthcare measures may only show their effects
after a long period, and comparability and
reliability of data is a challenge.”55
From 2000 to 2010 virtually all EU member
states have succeeded in reducing the rate of
‘amenable mortality.
However, the distribution of the rate of
amenable mortality across the EU member
countries shows a clear divide between the
‘old’ Western member countries and the ‘new’
Eastern member countries and highlights a
trend towards large variations in the effectiveness of healthcare systems in the EU28.
See figure 9.
While it can take many years to collect the
data needed to assess a healthcare system’s
effectiveness, this section examines two indicators that offer more immediate feedback
on a system’s effectiveness, namely the rate
of premature deaths (deaths that should not
have occurred if timely and effective healthcare was provided) and the underuse and
overuse of healthcare.56, 57 These indicators
give insight into how well a healthcare system
is performing its primary job: properly and
safely treating those in need.
80
STATE OF AMENABLE MORTALITY
54 European Commission. On effective, accessible and resilient
health systems. 2014.
55 European Commission. On effective, accessible and resilient
health systems. 2014. Page 7.
56 European Commission. On effective, accessible and resilient
health systems. 2014.
57 Amenable mortality combines
the standardized mortality rates
for a selected set of diseases on
which healthcare is estimated to
have a direct impact.
58 Measuring the effectiveness
of EU healthcare systems is
challenged by the lack comparable data across the 28 member countries of the union.
59 EU Health & Consumer
Protection Directorate-General.
European guidelines for quality assurance in breast cancer
screening and diagnosis. 2006.
60 European Commission.
European guidelines for quality assurance in breast cancer
screening and diagnosis. 2006.
81
Amenable mortality, standardized death rates per 100,000
inhabitants, 2010
FIGURE 9.
BIG DIFFERENCES IN
AMENABLE MORTALITY
Despite improvements in all EU countries, there are still great
differences in the amenable mortality in the region. France and the
EU GUIDELINES FOR THE FUTURE ACTION ON HEALTH SYSTEMS
ACCORDING TO MARIA IGLESIA GOMEZ FROM DG SANTE
Netherlands are at the top, while Latvia and Lithuania are at the
bottom. Data for Greece not available.
600
Female
Source: Eurostat (2010)
Males
500
400
In April 2014, the Commission adopted the “Communication
ACCESSIBILITY
on effective, accessible and resilient health systems,” which
“Access to healthcare is a multidimensional phenomenon; we
presents some overall guidelines for the future action on
can identify at least four dimensions of it: share of the popu-
health systems. Ms. Maria Iglesia-Gomez from DG Sante
lation that is covered, the basket of care, the affordability of
explains key elements of the recommendations:
care and the availability of care. Measuring access to health-
EFFECTIVENESS
“Health systems should improve the health of the population.
300
The challenge is to measure improvements in the health
status that are due to the health system, and not for instance
200
to better nutritional habits, or safer roads and cars. The
100
0
Commission is currently supporting member states with using
health system performance assessment, through an expert
FR NL
IT
ES LU BE DK SE PT
FI
CY DE MT AT
IE
SI
UK PL CZ HR BG EE SK HU RO LT
LV
group that started in the framework of the reflection process
on modern, responsive and sustainable health systems,
initiated by the Council in 2011. The goal of this process is
to improve the coordination on health systems performance
CHALLENGE: ENSURING APPROPRIATE CARE
assessment at EU level.”
care encompasses significant difficulties. Available indicators
allow for the measurement of self-perception of unmet needs
for care but not for objective measurement of access; indicators for coverage, waiting times and affordability are either
non-existent or inadequate."
RESILIENCE
“Resilience is the ability to adapt effectively to changing
environments, tackling significant challenges with limited
resources. member states’ future ability to provide high quality
care to all will depend on making health systems more resilient,
more capable of coping with the challenges that lie ahead.
And they must achieve this while remaining cost-effective
Overall figures for comparing under- and overuse
Antibiotic use is an ideal indicator of medication
of treatments and medicines across the European
overuse, as the volume of antibiotics prescribed
be cost-effective; we give a great importance to increasing
Union are hard to come by, and instead breast
at a community level and prevalence of resistant
co-operation on Health Technology Assessment.”
cancer screenings and the use of antibiotics will
bacterial strains are linked. Infections caused by
serve as examples of under- and overuse re-
resistant microorganisms often fail to respond to
spectively. All though not drawing the complete
conventional treatment, resulting in prolonged
picture, these two cases will serve as inspiration
illness, greater risk of death, and higher costs.62
for further comparisons.
Hence, it is essential that antibiotics are prescribed based on evidence-based needs and not
In the case of breast cancer screening, a num-
for viral conditions like a mild throat infection.63
ber of European countries are underusing
and fiscally sustainable. Clearly, innovation in health must
AVOIDING HOSPITALIZATION THROUGH
EFFECTIVE PRIMARY CARE
Healthcare systems can avoid unnecessary hospitaliza-
However, variations across countries are prevalent.
certain treatments and thus not living up to
The volume of antibiotic use varies substantially
tion through an effective primary care system. Looking
Asthma-related admissions in the Slovak Republic and
EU guidelines.58, 59 The European Commission
across EU member countries with the Nether-
at chronic diseases such as asthma, chronic obstruc-
Latvia were more than double the EU average, where-
has established the “European guidelines for
lands and Estonia reporting the lowest volumes
tive pulmonary disease (COPD), and diabetes, a high
as Italy, Portugal, Germany, Sweden and Luxembourg
quality assurance in breast cancer screening and
and Greece, Cyprus and Belgium reporting
performing primary care system could, to a significant
report rates that were less than half the EU average.
diagnosis”, which promotes a desirable breast
volumes around 1.5 times the European Union
extent, avoid acute deterioration for people living with
Hospital admission rates for uncontrolled diabetes
cancer screening target of at least 75% of eligible
average.64 According to “Health at a Glance”,
these diseases and prevent admission to hospital.66
vary 8-fold across the EU member countries with Italy,
women in European member states.60 Despite all
reducing antibiotic use is a pressing, yet complex
countries having uniformly established programs
problem in the European Union. Improvement
These are all conditions that affect EU healthcare
and Austria and Hungary reporting rates that are near-
according to the guidelines, only six countries
of this issue should involve multiple coordinated
systems substantially with e.g. COPD accounting for
ly double the OECD average.69
had reached the target of 75% in 2010.
initiatives that include surveillance, regulation and
approximately 3% of total deaths in the European
education of professionals and patients.65
Union and diabetes resulting in an estimated 10% of
Participation in the programs also varied consid-
United Kingdom and Spain showing the lowest rates,
total adult deaths in Europe.67, 68
erably across EU member countries, ranging from
8% in Romania and 16% in the Slovak Republic,
to over 80% in Finland, Denmark, Austria and the
Netherlands.61
61 OECD & European Commission.
Health at a Glance: Europe 2014.
2014.
EU member countries have reported a reduction in
admission rates for each of the three aforementioned
conditions over recent years.
62 OECD & European Commission.
Health at a Glance: Europe 2014. 2014.
68 International Diabetes Federation.
IDF Diabetes Atlas, Sixth Edition.2013.
63 Cochrane Collaboration. The
Cochrane Acute Respiratory Infections
Group.2013.
69 OECD & European Commission.
Health at a Glance: Europe2014. 2014.
OECD & European Commission.
Health at a Glance: Europe 2014. 2014.
64,65,66
67 World Health Organization. Background Paper 6.13: Chronic Obstructive
Pulmonary Disease (COPD). 2013.
82
83
EUROPE / TIMELINESS
TIMING IS
EVERYTHING
Bringing down waiting lists has been a main
target in European countries in recent years.
But there are still challenges when it comes
improving the timeliness of healthcare in
Europe, and with strains on the healthcare
budgets they do not seem to be overcome
just yet.
An efficient way to measure crowdedness is
through the number of hospital beds per citizen.
If the demand for care outpaces the resources to
handle patients, long wait times can ensue. Over
the past 10 years, the number of hospital beds
per population has decreased in all European
countries except Greece. On average across EU
member states, the number fell by close to 2%
per year, coming down from 6.5 beds per 1,000
people in 2000 to 5.2 beds in 2012.73
In the survey Eurobarometer “Patient Safety
and Quality of Care” from 2013, one in five of
the respondents point to the waiting time to be
seen and treated as crucial in their evaluation of
a hospital.70
LOST IN THE CROWD
Overcrowded hospitals are an important
hindrance to the provision of timely and high
quality care. An array of issues are identified
as reasons for crowding: increased patient
Improving the timeliness of care – reducing waiting times, avoiding crowding and ensuring the
right treatment in due time – demands resources,
but it also calls for great changes in areas such as
hospital processes, culture, technology use.
In the following, hospital crowding and wait
times for elective procedures are presented as
indicators for the state of timeliness in European
healthcare.
acuity, hospital bed shortage, increasing ED
volume, radiology delays, insufficient ED space,
laboratory delays, consultation delays, nursing
shortage, physician shortage, and managed care
issues. International studies have also shown that
delays caused by overcrowded EDs can lead to
adverse effects on patient care.71 A Danish study
from 2014 found that high bed occupancy rates
were associated with a significant 9% increase
in rates of in-hospital mortality and thirty-day
mortality, compared to low bed occupancy
rates.72
70 European Commission. Special
Eurobarometer 411: Patient Safety
and Quality of Care. 2014.
71 Jayaprakash N, et al. “Crowding
and Delivery of Healthcare in
Emergency Departments: The
European Perspective.” Western
Journal of Emergency Medicine
2009; 10(4): 233-239.
84
72 Madsen F, Ladelund S & Linneberg A. “High Levels of Bed Occupancy Associated With Increased
Inpatient And Thirty-Day Hospital
Mortality In Denmark.” Health
Affairs 2014; 33(7): 1236-1244.
73 OECD & European Commission.
Health at a Glance: Europe 2014.
2014.
74 The NHS defines major incidents
as any occurrence that presents
serious threat to the health of
the community, disruption to the
service or causes (or is likely to
cause) such numbers or types of
casualties as to require special
arrangements to be implemented
by hospitals, ambulance trusts or
other acute or community provider
organizations”.
Although the reduction in beds could signify that
more patients are seeking care at primary care
facilities rather than hospitals, it can also be a
safety hazard if the number of patients seeking
care in hospitals does not decline alongside the
number of beds. Illustrating the latter, in December 2014, 15 hospitals in England declared major
incidents74 because of pressures on A&E department bed capacity.75, 76
PUTTING A PRICE ON TIME
Elective – but often very necessary – procedures
are also prone to long wait times, and these vary
a great deal between European countries. For
example, in 2012-13, the average waiting time
for cataract surgery was just over 30 days in the
Netherlands, but about three-times longer (100
days) in Spain and Finland.78
Over the past decade, waiting time guarantees
have become the most common policy tool to
tackle long waiting times in several European
countries. This has been the case in Finland, for
example, where a National Healthcare Guarantee
was introduced in 2005 and led to a reduction in
waiting times for elective surgery.
In Denmark, a key policy is the “free choice”
of hospital provider for patients. If a hospital
can foresee that the maximum time cannot be
Long wait times can also discourage people
from utilizing hospital services, as a 2007 study
in Ireland reported that out of 45,000 surveyed
fulfilled, the patient can choose another public or
private hospital, either within or outside Denmark
– and the money follows the patient.79
ED patients, 35% said that the prospect of a prolonged stay affected their willingness to come to
the ED or to return.77
75 The Guardian. Eight more hospitals declare critical incidents as
demand surges. 2015.
European Perspective.” Western
Journal of Emergency Medicine
2009; 10(4): 233-239.
76 The Independent. NHS in critical
condition as A & E waiting times
are worst in a decade. 2015.
78 OECD & European Commission.
Health at a Glance: Europe 2014.
2014.
77 Jayaprakash N, et al. “Crowding
and Delivery of Healthcare in
Emergency Departments: The
79 Siciliani L, Moran V & Borowitz
M. “Measuring and comparing
health care waiting times in EOCD
countries.” Health Policy 2014;
118(3): 292-303.
85
EUROPE / ENVIRONMENTAL SUSTAINABILITY
A HEALTHY
ENVIRONMENT
Sustainability is moving up the agenda in all
European countries – not only as an economic
phrase, but also in terms of the effects of climate
change on the region’s healthcare sector and
vice versa.
DIAGNOSIS: CLIMATE CHANGE
INNOVATIVE THINKING
CAN SAVE ENERGY
Not only does the healthcare sector affect the
environment, but the reverse is also true. Climate
change has an enormous impact on health and
At the Royal Free Hospital in the UK, the
healthcare in Europe, in terms of public health,
implementation of a Combined Heat and Power
safety, and the associated healthcare costs
plant and the installation of three new boilers –
of both. It affects human health both directly
In the coming years the European healthcare
sector will be forced to reduce its own negative
effect on the environment and also be prepared
for meeting and coping with a new pathological
picture created by climate change.
Within the EU, sustainability in the healthcare
sector is becoming a focus area and an important element of the region’s ambitious green
targets for the coming years. One example is the
EU Green Public Procurement Policy aimed at
making public authorities go green and push the
market towards a more sustainable production, in
which a main focus area is green procurement of
medical devices – currently one of the top five of
most energy intensive products in Europe.80
HEALTHCARE IS HEATING UP
The healthcare sector is a contributing factor
to the climate change experienced in Europe.
The healthcare sector is a major energy user, as
European hospitals consume on average 300
Kw of thermal and over 100 Kw of electrical
energy per square meter per hour. Considering
that there are approximately 15,000 hospitals in
Europe, this represents an expense of 10% of the
GDP and accounts for 5% of CO2 emissions.81
The NHS Sustainable Development Unit in the UK
has calculated its carbon footprint at more than
plus a number of smaller adjustments such as low
through extreme heat and damage to health
voltage distribution boards and lighting updates
service delivery infrastructure in times of envi-
– resulted in annual energy savings of $1.9 million.
The project provided a return on investment after
ronmental disaster and indirectly through forced
just seven years and allowed the site to increase
migration, flooding, and lifestyle changes.83
its energy security and meet its sustainability
targets.
Additionally, temperature-sensitive infectious diseases, such as food borne infections are likely to
grow. Recent studies show that the disease burden caused by climate change in Europe could be
significant, with 20,000 potential extra cases of
The European Commission has outlined that the
food borne diseases per year by the 2030s, and
greatest concern in terms of climate change and
25,000 to 40,000 extra cases per year by the
its effect on health is heat-related mortality and
2080s.84
morbidity due to increases in annual temperature. In EU countries, it is estimated that mortality
18 million tons of CO2 each year — 25% of total
increases by 1–4% for each one-degree rise in
public spending.82
temperature, meaning that heat related mortality could rise by 30,000 deaths per year by the
Despite initiatives like this, there is still a long
2030s and by 50,000 to 110,000 deaths per year
way for a common green goal within healthcare
by the 2080s.85
in the European region. Great challenges remain,
and the healthcare sector in general continues to
be a ‘black industry’. Energy use and the effect
of climate change on healthcare are outlined as
primary challenges when it comes to sustainability and climate change in regard to the healthcare
sector in Europe.
80 Swedish Competition Authority.
The EU GPP criteria for medical
devices. 2014.
Healthcare Without Harm. Climate change and Health. Undated.
81,82
86
83 European Commission. Commission Staff Working Document
– Accompanying document to the
White Paper: “Adapting to climate
change: Towards a European
framework for action.” 2009.
84 European Commission.
Commission Staff Working
Document – Accompanying
document to the White Paper:
“Adapting to climate change:
Towards a European framework
for action.” 2009.
85 European Commission.
Commission Staff Working
Document – Accompanying
document to the White Paper:
“Adapting to climate change:
Towards a European framework
for action.” 2009.
86 KPMG International. Improving
energy and resource efficiency.
2012.
87
BRUSSELS
ROUNDTABLE
The roundtable discussion in the European
Parliament in Brussels marked the second stop on
our journey to co-create better healthcare systems
worldwide. The roundtable participants represented
a broad range of European healthcare stakeholders
and provided their insights concerning the common
challenges and opportunities across the healthcare
systems in the 28 member countries of the EU.
To inspire the discussion, the Danish Member of the European Parliament,
CHALLENGES FOR HEALTHCARE IN EUROPE
OPPORTUNITIES FOR CHANGE
There is much variation in the quality of healthcare
services and access to treatment
Change the mindset of health professionals to
see themselves as guests in patients’ lives, not
the hosts
Increased demand for healthcare services and
strained budgets are stretching healthcare
systems at both ends
Demographic change with an ageing population
Make organizational data public in order
in most EU countries is increasing the need for
to increase learning across the member
integrated long-term care
countries
There is an inability to properly manage long term
and chronic illnesses
Enhance coordination and incentivize
collaboration on all levels
Improve quality of care for chronic diseases
Empower patients to self-care and harvest the
There is a lack of focus on how to manage the
benefits of a more efficient use of healthcare
“mobile patient” that is moving across the open
professionals’ time
EU borders
Ms. Christel Schaldemose (profiled in an interview on page 90), presented
her perspective on what the political priorities for healthcare in the EU
should be; Dr. Francesco De Lorenzo, President of the European Cancer
Patient Coalition (profiled in an interview on page 91), provided a status
update on the European healthcare systems from a patient perspective with
a special emphasis on the role of accreditation and Ms. Maria Iglesia Gomez,
Head of the Strategy and Analysis Unit in DG SANTE (profiled on page
83), outlined the European Commission’s priorities and policy initiatives for
healthcare.
THREE GLOBAL ROUNDTABLES
88
In late 2014 and early 2015, DNV GL and Monday Morning Sustainia traveled to
The roundtables were in the format of one-day interactive workshops that gathered key
Shanghai, Brussels, and Washington DC to gain insights for this publication and start
stakeholders from across the healthcare system, including patients, professionals, providers,
a conversation on challenges and opportunities for improving the quality of care in
policy makers and researchers, with the aim of identifying possible trajectories for change
the healthcare systems of China, the EU and the USA. The guiding question for the
by spurring dialogue and discussions based on the various perspectives from the different
roundtables was: HOW DO WE IMPROVE THE QUALITY OF CARE?
stakeholders.
89
EUROPE / EXPERT INSIGHT
though a lot of work is still needed
tunities for patients to take greater
to reach the full potential of better
control of their own health is a bar-
prevention.
rier to greater patient involvement.
HOW DO YOU SEE THE ROLE OF
THE EUROPEAN UNION IN OVERCOMING THE CHALLENGES FACED
BY ITS COUNTRIES’ HEALTHCARE
SYSTEMS?
Ms. Christel
Schaldemose
Member of the
European Parliament
Participant at the
Brussels roundtable
I sincerely hope that the new
Commission is serious about taking
responsibility for the healthcare
agenda instead of just leaving it to
the member states alone.
Obviously, it is the responsibility
of the individual countries to design
their own healthcare systems, but I
WHAT CHALLENGES DO
YOU SEE FOR HEALTHCARE SYSTEMS IN THE EU?
tions and the economic crisis. These
issues have resulted in countries not
being willing to invest a larger share
more on patient involvement both in
terms of changing organizations and
introducing new technologies.
HOW SHOULD HEALTHCARE
ORGANIZATIONS ENGAGE WITH
OTHER SECTORS TO IMPROVE THE
DELIVERY OF SAFER, SMARTER
AND MORE PERSON-CENTERED
CARE?
Civil society and local communi-
problems, but I believe patients shall
prevention means avoiding the
be formally involved in the very pro-
recurrence of cancer or preventing
cess of implementing the Directive,
other chronic diseases. Effective
hence ensuring a more concrete
screening is also the only reliable
application of the European norm.
instrument we have to effectively
WHAT ARE SOME TANGIBLE WAYS
HOW DO YOU SEE THE
THAT PATIENTS CAN BECOME
ROLE OF THE PATIENT IN THE EU
MORE ACTIVELY INVOLVED IN
TODAY?
THEIR HEALTHCARE?
Nowadays, patients are crucial
I strongly believe in the power
TUNITY FOR IMPROVING HEALTH-
policies, but also in their design.
needs and true experience. From
Within a Europe Union with 28 mem-
this standpoint it is very difficult for
cancer patients face are related to
ber states and growing harmonised
policymakers not to take our voice
the sharp decrease of resources al-
institutions, patients need strong,
into consideration. The European
located to healthcare. ECPC believes
CARE IN THE EU?
Many of the problems European
ties can play a crucial part in keeping
specialised and professional advo-
Parliament demonstrated to be a
that a sustainable solution would be
edge sharing within the EU holds
citizens healthy and these kinds of
cates to push on the crucial common
formidable partner in advocating pa-
to better integrate the promising
great promise in terms of addressing
efforts need to be scaled up. But
problems faced by all patients and
tients’ rights. The European Cancer
eHealth and mHealth technologies
some of the similar challenges we
just as with patient engagement,
raise awareness on the unbearable
Patient’s Bill of Rights, ECPC Call to
into European citizens’ lives, hence
are all facing.
it is essential that we don’t frame
national and local situations existing.
Action and several other advocacy
lowering the costs of several tradi-
community involvement as a way to
efforts are finally bearing practical
tional care services. We are actively
simply cut budgets or as a last resort
fruit. The European Commission has
working to demonstrate this through
demonstrated a high level of sensi-
eSMART, an EU funded project
tivity towards patients’ perspective,
investigating the use of mobiles to
establishing the Expert Group on
monitor cancer treatment.
HOW CAN PATIENTS TAKE PART
IN ENHANCING THE QUALITY OF
CARE IN THE EU?
to save ailing healthcare systems.
Companies also have an important
role to play. By encouraging and facilitating employees to live healthier
WHAT IS THE BIGGEST CHALLENGE FACING PATIENTS IN THE
EU TODAY?
to contribute more and be more ac-
lives, companies can also benefit
ities in the way EU’s 500 million
tients’ representatives in the CanCon
tive in the healthcare system of the
financially with greater employee
citizens access healthcare. Inequal-
Joint Action.
future. This could include measuring
satisfaction and fewer sick days.
ities in access to healthcare have
There are still unbearable inequal-
their own blood pressure or taking
different and varied faces: drugs
greater personal responsibility by
are not evenly priced in all member
living healthier lifestyles with better
states, and in several countries es-
diets and more physical activity. The
EU countries will essentially have
spending in all EU countries will
to develop healthcare systems that
hopefully help drive the develop-
empower patients to take control
ment of better treatments and
of their own health. This would also
increase the focus on prevention.
serve to involve patients more in the
This is a positive development
consequences of their own choices.
because the result is a clear focus
on how to enhance the quality of life
WHAT IS THE GREATEST OPPOR-
advocacy efforts are based on real
opportunity.
The efforts to lower healthcare
saving billions of euros.
tation and evaluation of healthcare
ly a challenge but it could also be an
IN THE EU?
therefore help our health systems
of patient’s advocacy. ECPC’s
I think patients are going to have
OPPORTUNITY FOR HEALTHCARE
reduce the incidence of cancer and
partners not only in the implemen-
of GDP in healthcare. This is certain-
HOW IS THE ECONOMIC CRISIS AN
90
for EU healthcare systems to focus
believe that collaboration and knowl-
Across the EU countries, I see two
overall challenges: aging popula-
Moreover, it is a great challenge
“it is unacceptable not
to grant access to the
best care available to
all European citizens”
EU healthcare systems will have
“I believe that collaboration and knowledge
sharing within the EU
holds great promise
in terms of addressing some of the similar
challenges we are all
facing”
sential drugs are not available at all.
Cancer Control and including pa-
WHAT ROLE DOES PREVENTATIVE CARE PLAY IN AN EFFECTIVE
HEALTHCARE SYSTEM?
Patients’ freedom to seek healthcare
The European Union has been
outside their country is declared by
very vocal on the role of prevention,
EU law, but cross-border health-
particularly through the promotion
care remains complex, bureaucratic
of healthy lifestyles. This is laudable
to obtain and in several cases too
and ECPC strongly encourages
expensive for the patient. Consid-
equilibrate nutrition, physical activity
ering the overall high standards
and screenings. However, preven-
and effectiveness in curing cancer
tion has many faces. In many cases,
in Europe, it is unacceptable not to
early diagnosis represents the most
grant access to the best care avail-
reliable weapon a cancer patient
for patients. By improving efforts
to become more focused on keeping
to prevent rather than treat illness,
patients out of the hospital, as this
Europeans will live better and longer.
benefits both patients and strained
able to all European citizens. The
has to successfully beat his/her
The economic crisis could therefore
national budgets. Unfortunately, the
Cross Border Healthcare Directive
disease. For a cancer patient, either
be seen as an advantage for patients
fact that these changes are framed
can provide a partial solution to the
in remission or facing the treatment,
and healthcare systems alike, even
as service cuts rather than oppor-
Dr. Francesco
De Lorenzo
President of The Italian
Federation of Cancer Patients
Organizations (FAVO)
Participant at the
Brussels roundtable
91
THE UNITED
STATES OF
AMERICA
BALANCING THE
SCALES
The United States’ healthcare system has been under increasing stress
in recent years. High spending costs, combined with the growing
burden of chronic and non-communicable diseases has created a
fractured and unsustainable healthcare model.
Seven of the top ten causes of death in 2010 were
but some progress has already been made –
chronic diseases, and by 2012 nearly half of all
namely in terms of lowering the uninsured rate
American adults – 117 million people – had one
through the implementation of the Affordable
or more chronic health conditions. This growth
Care Act. By the end of 2014, the uninsured rate
in chronic illnesses affects not only the country’s
among American adults was down to 12.9% –
health, but also its pocketbook, as these diseas-
compared to 17.1% just one year earlier.4
es cost individuals and the government a great
deal. In 2009, for example, 84% of all healthcare
This chapter offers a look at the American health-
spending went toward the treatment and man-
care system today, through the lens of the seven
agement of chronic conditions.3
dimensions of quality of care. By understanding
the challenges that exist in terms of equitable ac-
The structure of the American healthcare system,
cess, patient safety, appropriate use of treatment
particularly its fee for service model, is also
and medicine, and cost-efficient service, we can
important to consider when discussing how
develop solutions to address these weaknesses
In 2013, the USA spent $2.9 trillion on healthcare,
capita spent on healthcare.2 The costs are caused
healthcare delivery in the country can improve.
and create a more sustainable, person-centered
amounting to $9,255 per person and 17.4% of the
by multiple factors: insurance, specialist visits,
As it stands now, the country is unable to provide
system for the entire country.
GDP.1 The country outspends all others when
numerous expensive treatments, and overpriced
low cost, high quality care for all its citizens, even
it comes to healthcare and by a considerable
pharmaceutical drugs.
those unable or unwilling to purchase private
margin – the second highest-spending country is
the Netherlands with 12% of GDP and $4,710 per
insurance. Reaching this goal is a daunting task,
1 Centers for Medicaid and
Medicare Services. National Health
Expenditures 2013 Highlights. 2014.
2 OECD. StatExtracts – Health
expenditure and financing, main
indicators. 2013.
92
3 Robert Wood Johnson Foundation & Johns Hopkins Bloomberg
School of Public Health. Chronic
Care: Making the Case for Ongoing
Care. 2010.
4 Joszt L. Uninsured Rate Fell to
12.9% by the End of 2014. American
Journal of Managed Care. 2015.
93
USA
/
EQUITY
FIGURE 10.
RANKING SCORES (FROM 1-11 )
COSTS ARE KEEPING
PEOPLE AWAY FROM
HEALTHCARE
WATCH THE
ACCESS GAP
AUS
CAN
FRA
GER
NETH
NZ
NOR
SWE
SWIZ
UK
7
1
US
COST-RELATED ACCESS PROBLEMS
9
5
10
4
8
6
3
1
11
Access Measures
DID NOT FILL A PRESCRIPTION
More than one-third of the Americans went
Skipped recommended medical test, treatment, or follow-up; or had a medical
problem but did not visit doctor or clinic in the past year because of cost
without healthcare because of costs in 2014.
This puts the USA in the bottom in terms
7
4
8
6
10
9
3
2
4
1
11
9
1
11
cost-related access problems.
Equitable access to healthcare regardless of
income, race and ethnicity, gender, education, or
geographic location is an area in which the USA
still struggles.
In the report “Mirror mirror on the Wall: How
the U.S. Healthcare System Compares Internationally,” from 2014, the private foundation, The
Commonwealth Fund, found that the USA came
in last in terms of providing equitable care, when
compared with 10 other developed countries.5
Setting it apart from some of the other care
dimensions, the issue of inequality permeates all
sectors of American society, and healthcare is just
one of the areas it touches. It is therefore difficult
to separate inequality in healthcare from inequality in every other aspect of life. With that in mind,
rather than discussing the larger issue of socio-
QUALITY BY ZIP CODE...
An American’s place of residence plays an
integral role in the equity of access and quality
Source: Commonwealth Fund. Mirror, Mirror on the Wall:
How the Performance of the U.S. Health Care System
Compares Internationally. 2014. Page 21.
Patient’s insurance denied payment for medical
care or did not pay as much as expected
8
6
in certain states, such as Minnesota, receive
better care than higher income populations in
other states, like Louisiana.6 In Massachusetts,
9% of adults went without care last year because
of cost, while further south in Mississippi that
portion skyrocketed to 22%.7 This disparity exists
throughout the country and is often caused by
historic patterns of racial and ethnic discrimination.
economic disparity, this section will focus more
5
4
1
1
not expand coverage, however, only an average of
costs, putting them at risk of delaying or forgoing
31% of adults are Medicaid eligible, meaning huge
needed care and contributing to the disparity of
numbers of residents remain uninsured and with
healthcare access. As a nation, over 50% of people
little access to quality care.12 In these states, many
with low incomes and 20% of those with middle
now fall into what is known as a “coverage gap” in
incomes were either underinsured or uninsured in
which they earn too high an income to be eligible
2012.10
for Medicaid, but not high enough to qualify for tax
credits which would have made other insurance
plans affordable.13 In some states, such as Texas,
TRYING TO BRIDGE THE GAP
this gap is enormous, leaving about one million low
WITH MEDICAID AND MEDICARE
income people who could otherwise be covered,
Medicaid and Medicare are two government
uninsured.14 Thus, while some states move toward
funded insurance programs designed to provide
greater equity under this provision, others are
healthcare for low-income and elderly Americans,
widening the access gap between the haves and
respectively. Both are intended to ensure that
the have-nots.
vulnerable populations still receive quality medical
care. Medicare is operated at the national level, and
Medicaid is a state-run program. Both have been
affected by recent healthcare reforms, but the
narrowly on how entrenched inequality manifests
…AND BY PAYCHECK
changes to Medicaid coverage, in particular, have
in the healthcare system, particularly in terms of
37% of Americans went without care in 2013
an enormous impact on equitable care distribution
location, income, and insurance coverage.
because of cost, meaning that they did not visit
in the United States.
LEARNING FROM THE BEST
While the American healthcare system’s inequitable access is truly astounding on an international
a physician when sick, did not get a prescrip-
scale a great deal can be done to alleviate some
tion filled, or did not get a recommended test
On June 28, 2012, the USA Supreme Court issued
or treatment. See figure 10. Adults with lower
a ruling that states can decide whether or not to
socioeconomic status are more likely to experi-
expand Medicaid to cover individuals with incomes
ence high blood pressure, obesity, heart disease,
up to 138% of the poverty line.11 This ruling has had
meet the benchmarks of the highest performing
infectious diseases and mental illness.8 Due to the
a mixed effect on the alleviation of inequality of
American states, massive strides could be made
incredibly high cost of care, access is often de-
access to care for low-income individuals. At the
across the board. Over 30 million more low-in-
positive end, in states that chose to expand cover-
6 Commonwealth Fund. Healthcare
in the Two Americas. 2013.
10 Commonwealth Fund. America’s
Underinsured: A State-by-State
Look at Health Insurance Affordability Prior to the New Coverage
Expansions. 2014.
termined by whether or not someone is insured,
and it has been well-established that low income
age, an average of 77% of uninsured adults are now
adults are more likely to be uninsured than high-
eligible for Medicaid insurance. In states that did
7 Commonwealth Fund. Aiming
Higher: Results from a Scorecard
on State Health System Performance. 2014.
11 Kaiser Family Foundation. A
Guide to the Supreme Court’s
Decision on the ACA’s Medicaid
Expansion. 2012.
er-income individuals, leading to income-based
8 Weir K. “Closing the healthwealth gap.” American Psychological Association. 2013; 44(9): 36.
12 Kaiser Family Foundation.
Number of Uninsured Eligible for
Medicaid Under the ACA. 2015.
5 Commonwealth Fund. Mirror,
Mirror on the Wall: How the Performance of the U.S. Health Care
System Compares Internationally.
2014.
94
6
financial protection from out-of-pocket healthcare
of care they receive, as state by state disparities
are quite large. In fact, low income populations
10
9 Kaiser Family Foundation. Medicaid and the Uninsured. 2009.
“underinsured” with coverage that fails to provide
be found without leaving the country. As the
Commonwealth Fund reports, if all states could
come adults and children would have health
insurance – reducing the number of uninsured by
more than half. Additionally, an estimated 86,000
fewer people would die prematurely and about
21 million fewer low-income adults would go
without needed care because of cost.15
inequalities.9 In addition, when low-income people do have insurance, they are more likely to be
of these disparities, and many solutions can
Kaiser Family Foundation. The
Coverage Gap: Uninsured Poor
Adults in States that Do Not Expand Medicaid – An Update. 2014.
13, 14
15 Commonwealth Fund. Healthcare
in the Two Americas. 2013.
95
USA
/
SAFETY
HOSPITAL ACQUIRED INFECTIONS
ARE DECREASING
There is currently no system in place that can estimate
THE FIGHT TO
IMPROVE PATIENT
SAFETY
the extent of all types of hospital acquired infections
(HAIs) – but a prevalence study from the Center for
Disease Control provides an estimate of the overall challenge of HAIs in American hospitals. The latest survey
found that on any given day, about 1 in 25 hospital patients has at least one HAI.21 There were an estimated
722,000 HAIs in American acute care hospitals in 2011
budgets. HAIs alone are responsible for $28 billion to
In 2009 the USA Department of Health and Human
rors, healthcare acquired infections, and prevent-
each year due to preventable medical errors.16
able drug events.
lance resources and data to assess the health burden
and rates of ADEs.
2) Prevention—Share existing evidence-based prevention tools across Federal Agencies and with
non-Federal healthcare providers and patients.
3) Incentives and Oversight—Explore opportunities,
including financial incentives and oversight authorities, to promote ADE prevention.
HAIs: Road Map to Elimination” and each year the
progress towards this goal is measured and captured
in “The HAI Progress Report”. The Report shows that
4) Research—Identify current knowledge gaps and future research needs (unanswered questions) for ADE
prevention.
all infections. A main driver in this progress is, in part,
the third leading cause of death in America, behind heart disease and cancer. In 2008, medical
DIAGNOSTIC ERRORS POSE A SERIOUS
errors cost the United States $19.5 billion.17
THREAT
A correct diagnosis is a key element in increasing
Patient safety in the USA has improved in the
patient safety. Each year in the USA, approx-
last couple of years. According to the Agency for
imately 12 million adults who seek outpatient
Healthcare Research and Quality, hospital-ac-
medical care are misdiagnosed. This figure
quired conditions (HACs) in the USA have de-
amounts to 1 out of 20 adult patients, and in half
creased from 2010 to 2013 with 1.3 million fewer
of those cases, the diagnostic error has the po-
patient harms. As a result 50,000 fewer patients
tential to result in severe harm.19
in healthcare costs were saved.18 See figure 11.
the Medicare rule that took effect October 2008,
which prevents hospitals from receiving payment for
the costs of treating certain HAIs.25, 26
A study reporting results of a survey of 317 infection-control professionals published in The American
Journal of Infection Control in May 2012 shows that
Misdiagnosis also strains budgets with diagnos-
targeted under the Medicare rule.27
tic errors accounting for the largest fraction of
malpractice claim payouts, totaling $38.8 billion
PREVENTABLE MEDICATION ERRORS COST LIVES
the challenges that compromise patient safety in
between 1986 and 2010.20
AND MONEY
Each year in the USA, serious preventable medication
errors occur in 3.8 million inpatient admissions and
3.3 million outpatient visits. Inpatient and outpatient
preventable medication errors cost approximately $21
16
17%
12
billion annually.28 Medication errors typically occur
because of prescription error, fragmentation of care,
and lack of information technology infrastructure, such
8
as Electronic Medical Records and electronic prescrib-
9%
ing. Studies show that improved communication among
7%
4
physicians, pharmacists and nurses prevented 85% of
2%
Change in
HACs,
2010 to 2011
serious medication errors and that including a pharmaChange in
HACs,
2011 to 2012
Change in
HACs,
2012 to 2013
Change in
HACs,
2010 to 2013
document the same measurable results as the “National Action Plan to Prevent HAIs”, which was released in
2009 and showed measurable reductions by 2012.30
Results are not yet available for the ADE Action Plan.
for Medicare and Medicaid Services policy has led to
In the following section, we will look at some of
20
The ambition for the ADE Action Plan is that it will
more than 80% of the respondents believe the Centers
greater focus on the healthcare-associated infections
died in the hospital and approximately $12 billion
96
1) Surveillance—Coordinate existing Federal surveil-
significant reductions were reported in 2012 for nearly
The study places preventable medical errors as
0
prevention, incentives and oversight, and research:
Services set out the “National Action Plan to Prevent
Safety estimates that up to 400,000 people die
Source: AHRQ. Interim Update on 2013
Annual Hospital-Acquired Condition Rate
and Estimates of Cost Savings and Deaths
Averted from 2010 to 2013.
The four pillars in the ADE Action Plan are surveillance,
ditures annually.24
the American healthcare system: diagnostic er-
The national HAC rate declined by 9% from
2012 to 2013 and was 17% lower in 2013 than
in 2010
of Disease Prevention and Health Promotion.
$33 billion in potentially preventable healthcare expen-
A study released in 2013 by the Journal of Patient
Annual and cumulative decrease in
HACs, 2010-2013
the Department of Health and Human Services Office
died during their hospitalizations.22, 23 In addition to
The USA has made some notable progress in recent years in
regard to ensuring safer environments and safer treatment
for all patients, but is still lagging behind when compared
internationally.
HACS ARE DECREASING
SIGNIFICANTLY
prevention – “The ADE Action Plan“ – was released by
and approximately 75,000 hospital patients with HAIs
costing human lives, HAIs also put a strain on healthcare
FIGURE 11.
In August 2014, the first national action plan for ADE
cist on routine medical rounds led to a 78% reduction in
medication errors.29
16 James J. “A New, Evidence-Based
Estimate of Patient Harms Associated
with Hospital Care.” Journal of Patient
Safety. 2113; 9(3): 122-128.
17 Andel C, Davidow SL, Hollander
M & Moreno DA. “The economics of
health care quality and medical errors.”
Journal of Health Care Finance 2012;
39(1): 39-50.
18 AHRQ. Interim Update on 2013
Annual Hospital-Acquired Condition
Rate and Estimates of Cost Savings
and Deaths Averted from 2010 to
2013. 2013.
19 Singh H, Meyer A & Thomas E. “The
frequency of diagnostic errors in
outpatient care: estimations from three
large observational studies involving
US adult populations.” BMJ Quality and
Safety 2014; 23(9).
20 Johns Hopkins Medicine. Diagnostic
Errors More Common, Costly And
Harmful Than Treatment Mistakes. 2013.
Centers for Disease Control and
Prevention. Health-associated Infections (HAIs) – Data and Statistics. 2015.
24 Office of Disease Prevention and
Health Promotion. National Action Plan
to Prevent Health Care-Associated
Infections: Road Map to Elimination.
2013.
25 US Department of Health and Human
Services. Testimony on U.S. Efforts
to Reduce Healthcare-Associated
Infections. 2013.
26 Centers for Medicare & Medicaid
Services. Hospital-Acquired Conditions.
2014.
27 Lee G et al. “Perceived impact of
the Medicare policy to adjust payment
for health care-associated infections.”
American Journal of Infection Control
2012; 40(4): 314-319.
28,29 New England Health Institute. Preventing Medication Errors: A $21 Billion
Opportunity. 2010.
30 American Society of Health-System
Pharmacists. Federal Plan Aims to
Reduce Adverse Drug Events. 2014.
21,22
23 Magill S et al. ”Multistate Point-Prevalence Survey of Health Care-Associated Infections.” New England Journal of
Medicine. 2014; 370: 1198-1208.
97
USA
/
PERSON-CENTERED CARE
IMPROVING PERSONCENTERED CARE THROUGH
POLITICAL INITIATIVES
TOWARDS
HEALTHCARE OF,
BY AND FOR THE
PEOPLE
• An Accountable Care Organization is an entity
Poor continuity of care increases the risk of medication errors, unnecessary tests and emergency
room visits, and preventable hospital admissions,
all of which lead to costly and lower quality of
that consists of healthcare providers across
care.36 In 2011, the economic burden of inade-
the continuum of care (including acute care,
quate care coordination in the United States was
long-term care, and behavioral and mental
estimated to be between $25 billion and $45
healthcare) that agrees to be held accountable
billion.37
for improving the health of patients receiving
Medicare. If patients’ healthcare costs end up
Putting the patient at the center of care is not a new ambition
in the USA. Since the early 2000s the Institute of Medicine and
the Physician Charter have both defined person-centeredness
as an essential component of high-quality healthcare. While the
concept is well-known, its adoption into the overall healthcare
system remains less widespread.
CONTINUITY OF CARE IS A PROBLEM
being less than would otherwise be expected
According to The Agency for Healthcare Re-
while healthcare quality is maintained or
search and Quality (AHRQ) poor communica-
improved, the providers get to keep a share of
tion exchange between primary care physicians
that savings. Since passage of the Affordable
and specialists and information lost in referral
Care Act, more than 360 Medicare ACOs have
been established, serving over 5.6 million
Americans with Medicare.33
• A health home is a provider or group of
providers who coordinate care for all the
processes are two of the most crucial areas of
coordination to improve.38 These findings are
mirrored in the 2011 “Survey of Public Views of
the U.S. Health System” from the Commonwealth
medical and non-medical needs of Medicaid
Fund, where 47% of the respondents reported at
patients with two or more chronic conditions.
least one failure of care coordination.39
The Affordable Care Act created this option as
a way to allow states to use Medicaid funding
to better coordinate care for high-need,
high-risk populations.34 As of June 2014, 15
states have opened health homes and more
HEALTH INFORMATION TECHNOLOGY IS MOVING FORWARD
In its Declaration on Patient-Centred Healthcare
these issues are the Accountable Care Organi-
than one million Medicaid beneficiaries have
Health information technology has become a key
from 2006, The International Alliance of Patients'
zations (ACO) for Medicare recipients, health
been enrolled. Nearly a dozen other states are
element of person-centered care as it encom-
Organizations states that the essence of per-
homes for Medicaid recipients and a reward sys-
planning health home models.35
passes a wide range of products and services
son-centered healthcare is that the “healthcare
tem for person-centered care in hospitals.32 See
system is designed and delivered to address the
textbox on page 99.
healthcare needs and preferences of patients so
• The reward system for hospitals focuses on
designed to collect, store, and exchange patient
quality of care, and maintenance of high levels
data throughout the healthcare experience. The
of patient satisfaction. To measure how satisfied
core feature of health IT is electronic patient
patients are with the care they experienced,
that healthcare is appropriate and cost-effective.”
The following section discusses three elements of
The Declaration sets out five principles of per-
person-centered care in order to point to some of
about various aspects of their experience. In
forth legislation to make electronic health records
son-centered healthcare: respect; choice and em-
the challenges standing in the way of the scaling
October 2012, Medicare began rewarding the
a national goal.40 This could explain why the
powerment; patient involvement in health policy;
of person-centered care in the USA. These ele-
best performing hospitals with bonuses based
proportion of hospitals having electronic records
access and support; and information.31
ments are continuity of care, health information
on the evaluations.
has tripled since 2010 and why 38% of physicians
patients are surveyed randomly and asked
technology, and health literacy,
records. The USA federal government has put
report having adopted basic digitization in 2012.
American frontrunners such as Planetree, The
Institute of Medicine and Kaiser Permanente have
Although the numbers point towards an increase
focused on promoting and implementing per-
in the adoption of electronic records overall,
son-centered care, but still there is a long way to
there is still room for improvement. A study from
go for person-centered care to become common
practice in the USA.
The Patient Protection and Affordable Care Act
(ACA) repeatedly refers to patient centeredness,
patient satisfaction, patient experience of care,
patient engagement, and shared decision-making
in its provisions. Three initiatives that address
98
31 International Alliance of Patients’
Organizations. Declaration on
Patient-Centred Healthcare. 2006.
34 Families USA. The Promise of
Care Coordination: Transforming
Health Care Delivery. 2013.
32 Center for Health Care
Strategies, Inc. Health Literacy
Implications of the Affordable Care
Act. 2010.
35 Centers for Medicaid and
Medicare Services. Medicaid Health
Homes: An Overview. 2014.
33 Centers for Medicaid and
Medicare Services. Medicare ACOs
continue to succeed in improving
care, lowering cost growth. 2014.
36,37 Families USA. The Promise of
Care Coordination: Transforming
Health Care Delivery. 2013.
38 AHRQ. Care Coordination. 2014.
39 Commonwealth Fund. A Call for
Change: The 2011 Commonwealth
Fund Survey of Public Views of the
U.S. Health System. 2011.
40 Centers for Disease Control and
Prevention. Meaningful Use. 2012.
41 American Medical Association.
Quality of Patient Care Drives Physician Satisfaction; Doctors Have
Concerns About Electronic Health
Records, Study Finds. 2013.
42 George Washington University.
Low Health Literacy: Implications
for National Health Policy. 2007.
2013 found that digital recordkeeping negatively
affected physicians’ satisfaction. Those surveyed
expressed concern that current electronic health
record technology interferes with face-to-face
discussions with patients, requires too much clerical work, and degrades the accuracy of medical
records by encouraging template-generated
notes.41
99
USA
THE NATION SUFFERS FROM POOR
•GOAL 2: Promote changes in the healthcare
HEALTH LITERACY
delivery system that improve health informa-
When the health literacy of the American people
tion, communication, informed decision-mak-
was reviewed by the National Assessment of
ing, and access to health services
Adult Literacy, it showed that a mere 12% had
proficient health literacy. At the other end of the
•GOAL 3: Incorporate accurate, stan-
spectrum, 14% had below basic health literacy,
dards-based, and developmentally appropriate
and would not, for example, be able to recognize
health and science information and curricula in
a medical appointment on a hospital appoint-
child care and education through the university
ment form.42
level
Low health literacy is associated with reduced use
•GOAL 4: Support and expand local efforts
of preventive services and management of chron-
to provide adult education, English language
ic conditions, and higher mortality. Furthermore,
instruction, and culturally and linguistically
it also results in medication errors, misdiagnosis
appropriate health information services in the
due to poor communication between providers
community
and patients, low rates of treatment compliance,
hospital readmissions, unnecessary emergency
room visits, longer hospital stays, and poor re-
/
COST-EFFICIENCY
GETTING YOUR
MONEY'S WORTH?
Given the ever increasing cost of healthcare
throughout the world, maximizing efficiency
is of the utmost importance for every
country. Unfortunately in the USA, more
expensive healthcare does not translate to
better quality.
•GOAL 5: Build partnerships, develop guidance,
and change policies
sponsiveness to public health emergencies.
Since 1980, the USA has increased its health•GOAL 6: Increase basic research and the de-
care spending from around 9% of its GDP to
The economic repercussions of low health liter-
velopment, implementation, and evaluation of
17.7% in 2012.45 From 2007-2012, a period that
acy have been estimated to cost the American
practices and interventions to improve health
encompassed the Great Recession, health-
economy between $106 billion and $236 billion
literacy
care spending rose $491 billion, reaching $2.8
annually.43
trillion nationally according to government
•GOAL 7: Increase the dissemination and use of
estimates.46 Spending increased in all states
Several provisions in the Affordable Care Act
evidence-based health literacy practices and
on both a per capita basis and as a share of
directly acknowledge the need for greater atten-
interventions
total state income. And still, the Common-
tion to health literacy, and many others imply it.
wealth Fund’s 2014 “Scorecard on State
Moreover, the Plain Writing Act of 2010, requires
Health Performance” points to deteriorating
Furthermore, the Department of Health and Hu-
all new publications, forms, and publicly distrib-
access to care for adults, stagnant or worsen-
man Services developed the National Action Plan
uted documents from the federal government
ing performance on other key measures such
to Improve Health Literacy in 2010. The National
to be written in a “clear, concise, well-organized”
as preventive care for adults, and widespread
Action Plan provides a framework for consistent
manner.44
disparities in peoples’ healthcare experience
across and within states.47, 48, 49
action to address health literacy and proposes
coordinated societal action across seven different
The provisions in the ACA, in the national action
areas to improve systems, information communi-
plan to improve health literacy and the Plain
The American healthcare system therefore
cation and education.
Writing Act all point towards a positive focus on
provides the lowest quality of care at the
empowering the patients to become a more ac-
highest price tag – the definition of cost-inef-
tive part of their care. Whether they have helped
ficiency. Hence, gearing the system towards
produce positive results is too soon to tell.
providing better quality care for less money
The seven goals in the plan are listed below:
•GOAL 1: Develop and disseminate health and
is one of the great challenges that this region
safety information that is accurate, accessible,
and actionable
is up against. While the others sectors ex43 Center for Health Care Strategies. Health
Literacy Implications of the Affordable
Care Act. 2010.
44 Plain Writing Act. 5 U.S.C. 301. 2010.
plored the quality of the American healthcare
system, this section will look at some of the
features that makes this system so expensive.
COSTLY PAYMENT MODEL
With the fee-for-service (FFS) model, physicians are reimbursed for all services they
provide and pay is not necessarily linked to
outcomes.50 In 2008, 78% of employer-sponsored health insurance used this model.51
This means that there is little or no incentive
to discourage the delivery of unnecessary
services in this system.52
According to the American think-tank, Center
for American Progress, the FFS model has
multiple disadvantages: it encourages wasteful use, especially of high cost items and services, and it does not align financial incentives
between different providers.53
45 Commonwealth Fund. Mirror,
Mirror on the Wall: How the
Performance of the U.S. Health
Care System Compares Internationally. 2014.
46 Commonwealth Fund. Aiming
Higher: Results from a Scorecard on State Health System
Performance. 2014.
47 Center for Medicaid and
Medicare Services. National
Health Expenditures – Table 1.
Undated.
48 Center for Medicaid and
Medicare Services. Total All
Payers State Estimates by State
of Residence. 2011.
100
49 Commonwealth Fund. Aiming
Higher: Results from a Scorecard on State Health System
Performance. 2014.
50 National Commission on Physician Payment Reform. Report
on The National Commission
on Physician Payment Reform.
2013.
51 Center for American Progress.
Alternatives to Fee-for-Service
Payments in Health Care. 2012.
52 Barnes J. “Moving Away from
Fee-for Service.” The Atlantic.
2012.
101
USA
Furthermore, FFS does not encourage preven-
Administrative costs account for 25% of hospital
tive care and patient education, which results in
spending in the USA, and the 2014 Common-
conditions that could have been managed with
wealth Fund report, “A Comparison of Hospital
better preventive disease management being
Administrative Costs in Eight Nations,” found that
managed in acute care instead.54
there is no link between higher administrative
costs and better quality care.57 The study attri-
However, the need for alternative payment mod-
butes the high administrative costs in the USA to
els is well recognized and small shifts in payment
two factors:
models are emerging. In September 2013, the National Commission on Physician Payment Reform
EFFECTIVENESS
TOO MUCH AND
NOT ENOUGH
1) The complexity of billing a multiplicity of
issued its recommendations on how to reform the
insurers with varying payment rates, rules and
physician payment system. The first recommen-
documentation requirements;
dation reads: “Over time, payers should largely
eliminate stand-alone fee-for-service payment to
/
2) The imperative for hospitals to generate profits
medical practices because of its inherent ineffi-
or, for nonprofit hospitals, surpluses. The re-
ciencies and problematic financial incentives.”55
searchers found that within the USA, administrative costs were highest (27.2% of spending)
Other alternative payment models were intro-
at for-profit hospitals.
duced with the Affordable Care Act with the
aim of paying for quality instead of quantity of
Reducing USA per capita spending on hospital
care. These payment models include bundled
administration to Scottish or Canadian levels
payments, patient-centered medical homes and
would have saved more than $150 billion in 2011.58
The dual problem of over- and under-use use
of healthcare services is a significant concern in the USA. Overuse of medications and
tests puts a severe financial burden on the
system. However, underuse of certain services is still a great challenge, especially for
low-income groups.
accountable care organizations. See text box.
DOCTORS ON THE DEFENSIVE
Applying the appropriate measures based
This section will provide a status on the devel-
SKY HIGH ADMINISTRATIVE COSTS
In a 2009 national survey of physicians, 75% of
on science, and thus ensuring the effective-
opment of underuse and overuse of treat-
The money spent on healthcare administration
doctors said that they order more tests, proce-
ness of the healthcare system, has proven a
ment in the American healthcare system and
is more than twice the total spending on heart
dures and medicines than are medically nec-
difficult task.60 Appropriate measures refer
highlight key developments within promoting
disease and three times the spending on cancer.56
essary in an attempt to avoid lawsuits.59 About
to the avoidance of both underuse – like not
the use of evidence based medicine.
$650 billion are spent annually on defensive med-
receiving a vaccine despite its proven effec-
icine, which, aside from the high cost also results
tiveness – and overuse, e.g. treating a child’s
in other consequences:
simple ear infection with antibiotics.61
1) Limiting access to care for high-risk patients
Overuse and underuse of treatment are both
NEW PAYMENT MODELS TO
PROMOTE QUALITY CARE
far too common in the USA. Overuse has
2) Over- and under-treating patients with
life-threatening illnesses
•B
undled payments, which are fixed amounts
paid to healthcare providers for a bundle of
services or all the care a patient is expected to
need during a period of time
more on preventive care, patient education, and
care coordination between different healthcare
providers
•A
ccountable care organizations, which are
groups of healthcare providers who agree to
share responsibility for coordinating lower-cost,
higher-quality care for a group of patients
‘healthcare for all’ discussion. A trend away
physicians, which has resulted in lowered
from employing evidence based medicine
physician morale and manpower
also contributes to improper and ineffective
treatment.
53 Center for American Progress.
Alternatives to Fee-for-Service
Payments in Health Care. 2012.
and Improving the Health Care
System.” New England Journal of
Medicine 2012; 367: 1875-1878.
54 Gillies S & Gretch S. “Coping with
Medicare Advantage fee-for-service plans.” American Academy of
Orthopaedic Surgeons. 2008.
57,58
55 National Commission on Physician Payment Reform. Report on
The National Commission on Physician Payment Reform. 2013.
56 Cutler D, Wikler E & Basch P.
“Reducing Administrative Costs
102
the skyrocketing healthcare expenses, and
underuse remains a challenge feeding into the
3) F
ostering distrust among patients and their
•P
atient-centered medical homes, which are
redesigned primary care practices that focus
been named one of the main contributors to
Himmelstein D et al. ”A Comparison Of Hospital Administrative
Costs In Eight Nations: US Costs
Exceed All Others By Far.” Health
Affairs 2014; 33(9): 1586-1594.
Page 1586
59 Jackson Healthcare. Quantifying
the Cost of Defensive Medicine.
2010.
60 Institute for Healthcare Improvement. Across the Chasm: Six Aims
for Changing the Health Care
System. 2015.
61 Commonwealth Fund. Mirror,
Mirror on the Wall: How the Performance of the U.S. Health Care
System Compares Internationally.
2014.
103
STATUS QUO OF OVERUSE
UNDERUSE STEMS FROM INEQUALITY
Overuse in America’s healthcare system is a sub-
A 2007 study by the National Committee for
stantial problem that may account for as much as
Quality Assurance reports that 91,000 Americans
30% of healthcare spending.62 Antibiotic overuse
die each year because they don’t receive the
EVIDENCE VS. EXPERIENCE
is perhaps the most well-known issue, and it is
right evidence-based care for chronic conditions
In the USA, the lack of integration of evidence
This is in part due to evidence-based med-
particularly apparent in the USA. For instance,
like high blood pressure, diabetes and heart
based medicine (EMB) into the healthcare
icine being derived from averaged global
60-90% of patients with acute bronchitis who
disease.69
system has had severe impacts with as many
evidence gathered from exogenous popu-
as 57,000 Americans dying each year due to
lations, which may not be relevant to local
seek care are given antibiotics, despite the fact
that they will recover without them.63, 64, 65 Some
An important indicator of effectiveness in terms
care not being based on the best available
circumstances. As Trish Greenhalgh explains,
positive news on this front has emerged recently,
of underuse is the degree to which a healthcare
evidence.73 Thus the USA will, in the coming
there are some additional crises in the EMB
though; the NCQA's 2014 “State of Healthcare
system manages the care of patients with chronic
years, be forced to reflect on how to better
movement, namely:
Quality Report” found that avoidance of antibi-
illnesses and prevents future illnesses through
integrate EBM as a way to develop more
otic treatment in adults with acute bronchitis had
targeted interventions.70 The 2014 “Mirror Mirror
scientifically valid and smart ways to care for
its first gain in the measure's seven-year history.
on the Wall” report from the Commonwealth Fund
patients.
This is a substantial development, since aside
places the USA in third place on effective care
from being harmful to individual and communal
overall – performing relatively well on prevention
Not surprisingly, a lack of EBM – and health-
• The volume of evidence, especially clinical
health, antibiotic-resistant bacteria costs ap-
but average in comparison to other Western coun-
care professionals’ reliance on tradition and
guidelines, has become unmanageable
proximately $55 billion in health services and lost
tries on quality of chronic care management.71
anecdotal personal experience when making
productivity.66
been misappropriated by vested interests
decisions – contributes to the aforementioned
• Statistically significant benefits may be
Underuse in the American healthcare system
problems of inappropriately- and over-used
The overuse of tests and procedures is also a
has traditionally been linked to equity with many
medical services.74 It has been estimated that
problem. The NCQA's 2014 State of Healthcare
patients not getting the care they need due to
about half of all physicians rely on clinical ex-
Quality Report concludes that the USA is either
lack of insurance or ability to pay out of pocket.
perience rather than evidence to make deci-
en prompts may produce care that is
stagnant in or overusing a range of medical
By expanding access to insurance, the Affordable
sions. This happens despite physicians rarely
management driven rather than patient
procedures. More than a quarter of all wasteful
Care Act has the potential to address underuse
seeing enough cases of the same conditions
centered
spending in healthcare— $210 billion out of the
due to lack of insurance and ensure that more
to draw scientifically valid conclusions about
estimated $765 billion in wasteful spending in
Americans get the appropriate treatment.72
treatment.75
marginal in clinical practice
• Inflexible rules and technology driv-
• Evidence based guidelines often map
2009—is attributed to overuse of services.67
poorly to complex multimobidity77
This is due, in large part, to the fact healthcare
On the flip side, though, the evidence based
providers are paid in a way that rewards doing
medicine movement is struggling to narrow
more, rather than being efficient. Alternative
the gap between EBM and physician clinical
Greenhalgh continues that these problems
payment models exist, such as prior authorization
practice.76
don’t signify the end of EBM, but rather point
for approval to run certain tests; episode-based
payments; and value-based benefit design. These
alternatives, however, present three respective
challenges, namely increasing excessive bureaucratic steps, incentivizing numerous doctors’
visits, and the fact that most services are not uniformly appropriate or inappropriate.68 Therefore,
more research must be conducted to identify
the best possible way to structure payments that
reduce the incentive to overuse medical services.
104
• The evidence based “quality mark” has
toward a need to return to “real” evidence
62 Overuse Accounts for Up to 30%
of Healthcare Spending. Medscape.
2012.
66 Smith R & Coast J. “The True
Cost of Antimicrobial Resistance.”
BMJ 2013; 346.
63 WebMD. Acute Bronchitis—Topic
Overview. 2015.
67,68
64 Kroening-Roche JC, Soroudi A,
Castillo EM, Vilke GM. “Antibiotic
and bronchodilator prescribing for
acute bronchitis in the emergency
department.” The Journal of Emergency Medicine 2012; 43:221.
65 Evertsen J, Baumgardner DJ,
Regnery A, Banerjee I. “Diagnosis
and management of pneumonia
and bronchitis in outpatient primary care practices.” Primary Care
Respiratory Journal 2010; 19:237.
based medicine, that values individual patient
care and sound, supported judgment rather
than strict rules.78
Robert Wood Johnson Foundation. Doing Better by Doing Less:
Approaches to Tackle Overuse of
Services. 2013.
69 National Committee for Quality
Assurance. The Essential Guide to
Healthcare Quality. 2007.
1 Commonwealth Fund. Mirror,
Mirror on the Wall: How the Performance of the U.S. Health Care
System Compares Internationally.
2014.
70,7
72 Patient Protection and Affordable Care Act, 42 U.S.C. § 18001.
2010.
73 National Committee of
Quality Assurance. The State
of Healthcare Quality: 2003.
2003.
74 Institute for Healthcare Improvement. Across the Chasm
Aim #2: Health Care Must Be
Effective. 2015.
Hay MC et al. ”Harnessing
experience: exploring the
gap between evidence-based
medicine and clinical practice.”
Journal of Evaluation in Clinical
Practice 2008; 14(5): 707-713.
75, 76
Greenhalgh T. “Evidence
based medicine: a movement
in crisis?” BMJ 2014; 348.
77,78
105
USA
/
TIMELINESS
HEALTHCARE ON
TIME... SOMETIMES
The timeliness of healthcare delivery in the USA is
highly dependent on the type of care being sought.
While specialist visits are typically quick and easy to
schedule, primary care visits tend to come with long
waiting times.
INCREASINGLY CROWDED EMERGENCY
ROOMS
Waiting times in emergency departments are
often used as central indicators of timeliness in
healthcare systems. In 2003, American patients
arriving at emergency departments had to wait
for an average of 46 minutes before receiving
A SOLUTION: OPEN ACCESS
SCHEDULING
One way to better manage waiting times in
healthcare is through smarter appointment
scheduling. In an open access schedule – also
treatment. Six years later, this increased by 25%
known as advanced access and same-day
to almost an hour.86 This development is due,
schedule – almost all patients are seen on the
in part, to the fact that there has been a 32%
day they call for an appointment regardless of
increase in visits to emergency departments from
1999 to 2009.87
the reason for their visit. Instead of booking a
physician’s time weeks in advance, this model
leaves a specific number of appointments
kept open in each clinic session. Open access
The overuse of EDs for conditions that could be
scheduling has proven able to eliminate
seen in a non-emergency setting is one of several
backlogs of appointments in many healthcare
contributors to ED overcrowding and delays in
care and is often caused by a lack of primary care
organizations – covering primary care facilities,
medical centers and specialists clinics. At the
Kaiser Permanente facility in Roseville, California,
It has been shown that a lack of timely
GREAT VARIATION IN TIMELINESS
utilization. For instance, the WHO’s European Ob-
where the open access strategy originated,
treatment may result in emotional dis-
FOR PRIMARY CARE AND SPECIALISTS
servatory on Health Systems and Policies found
average waiting times for routine appointments
that in 2008, a regular doctor could have handled
were lowered from 55 days to one day in less
tress, physical harm, frustration for service
users and professionals alike and higher
treatment costs.79, 80 If all American states
improved their performance to the level of
the best-performing state in terms of timely
care delivery, the benefits would mean a
reduction in premature deaths by as much
as 84,777 per year from causes that are potentially treatable or preventable.81 Additionally, timely outpatient care has the potential
to reduce admissions for pediatric asthma,
which costs $1.25 billion in hospitalization
charges annually.82, 83
When compared internationally, the USA
performs poorly on waiting times for primary care, as the Commonwealth Fund’s
“Mirror Mirror on the Wall” survey from
2014 ranks the USA 8th of 11 high-income
nations.84 This picture changes when examining how the USA performs on specialist
and elective surgery waiting times. Here the
19% of ED visits, had one been available.88
care, specialists and emergency wards are
discussed as primary indicators for the state
implementation of open access scheduling
include e.g. The Mayo Clinic’s Primary Care
A survey of emergency department users in Cal-
Pediatric and Adolescent Medicine Team and The
ifornia shows that 46% of the users themselves
Alaska Native Medical Center.90,91
indicated that their problem could have been
handled by a primary care physician. See
figure 12.
country ranks 3rd and 6th, respectively, on
questions regarding waiting.
1%
FIGURE 12.
The results correspond with the fact that
IS THIS AN EMERGENCY?
the healthcare system in the USA puts less
In the following, waiting times for primary
than a year. Other examples of successful
emphasis than most countries on primary
27%
Urgency of emergency room visits
care and has a greater proportion of specialists than general physicians.85
of timeliness in the American healthcare
Recent ED users’ responses to whether
their problem could have been handled by a
primary care physician
sector.
Yes
No
N/A (Visit Was Prearranged)
Not Sure
46%
25%
Source: California Health Care Foundation. Overuse of Emergency Departments Among Insured Californians. 2006.
79 Boudreau RM et al. “Improving the timeliness of written
patient notification of mammography results by mammography centers.” The Breast
Journal 2004;10(1):10-9.
80 Institute for Healthcare Improvement. Across the Chasm:
Six Aims for changing the
Health Care System. 2015.
106
81 Commonwealth Fund.
Aiming Higher: Results from
a Scorecard on State Health
System Performance. 2014.
82 Schatz M, Rachelefsky G,
Krishnan JA. “Follow-up after
acute asthma episodes: what
improves future outcomes?”
Proceedings of the American
Thoracic Society 2009;6:
386-93.
83 Agency for Healthcare Research and Quality. Calculated
from Healthcare Cost and Utilization Project. Kids’ Inpatient
Database. Undated.
84 Commonwealth Fund. Mirror,
Mirror on the Wall: How the
Performance of the U.S. Health
Care System Compares Internationally. 2014.
85 WHO European Observatory of
Health Systems and Policies. Health
Systems in Transition: United
States. 2013.
88 WHO European Observatory of
Health Systems and Policies. Health
Systems in Transition: United
States. 2013.
90 Murray M and Tantau C. “Must
patients wait?” Joint Commission
Journal on Quality Improvement
1998; 24(8): 423-5.
Centers for Disease Control
and Prevention. Wait Time for
Treatment in Hospital Emergency
Departments: 2009. 2012.
89 California Health Care Foundation. Overuse of Emergency
Departments Among Insured
Californians. 2006.
91 Agency for Healthcare Research
and Quality. Open Access Scheduling for Routine and Urgent
Appointments. Undated.
86,87
107
USA
/
ENVIRONMENTAL SUSTAINABILITY
GREENING THE
HEALTHCARE
AGENDA
...AND RESOURCES
The majority of the materials procured by a hospital ultimately become waste, resulting in nearly
7,000 tons of waste every day and $10 billion
annually in disposal costs across the healthcare
industry.93 Most of that waste—as much as 8085%—consists of materials that typically end
up in ordinary landfills: paper files, cardboard
packing materials, glass, plastics, and other types
GREEN FRONTRUNNERS ARE
LEADING THE WAY
of commercial trash.94 The potential for reducing
In December 2014, the Obama administration declared
climate change a public health hazard, highlighting the
shared challenges of healthcare and environmental
sustainability. These challenges are framing the ‘green’
healthcare agenda in the coming years.
materials used and handling waste smarter could
improve the environmental footprint of health-
Kaiser Permanente has become widely
care in the USA substantially.
recognized as an environmental leader in the
healthcare sector and over the past decade
But healthcare waste is complex not only be-
they have initiated a line of green initiatives.
cause of its sheer volume, but also because a
Among other implementations, they have
small but significant amount of that waste, about
created an Environmental Preference Program
15–20%, must be regulated by multiple agencies,
and a Sustainability Scorecard for medical
products, which helps the company evaluate
including U.S. Environmental Protection Agency,
and select products without harmful chemicals.
Occupational Safety and Health Administration,
One month after hurricane Sandy hit New York
City, four hospitals – together receiving 1.5 million
patient visits per year – were still partially closed.
Adapting healthcare practices and infrastructure to new conditions caused by climatic and
environmental changes is a key element in a
sustainable healthcare system. But sustainable
healthcare should also reflect the environmental
footprint of healthcare providers. In relation to
environmental footprint, the substantial amounts
of waste generated in the healthcare system is a
major challenge.
The following sheds light on the two main agendas within sustainability affecting the healthcare
sector in the coming years: how climate change
affects healthcare and how the healthcare sector
in general responds to the fact that they have to
work towards becoming more sustainable.
A WASTE OF ENERGY...
Energy consumption is another environmental
and economic challenge for American healthcare
systems. Currently, American healthcare facilities
This Scorecard was the first of its kind in the
Drug Enforcement Administration, and others.95
healthcare sector, and it helps encourage its
The ever-growing healthcare industry in the USA
suppliers to provide more sustainable products.
means that the medical waste industry is also
These dual benefits are estimated to save the
company $26 million annually.
growing rapidly, expected to reach $3.2 billion by
2017.96
spend $8.8 billion per year on energy. In 2013,
USA Department of Energy's "Advanced Energy
Retrofit Guide for Healthcare Facilities" outlined
the opportunities of retrofitting healthcare facilities in order to improve energy efficiency. Along
with reduced energy consumption, retrofitting
also yields other benefits, ranging from improved
equipment longevity to decreased patient recovery times to a more attractive brand.
An example of the benefits of energy retrofitting is Connecticut's Greenwich Hospital. On the
American government's 1-100 rating scale for
Energy Star, Greenwich Hospital scored only 47,
falling far short of the 75 required to garner an
Energy Star designation. The hospital implement-
EXTREME WEATHER WREAKS HAVOC ON
HEALTHCARE
Extreme weather events are associated with a
The growing focus on how extreme weather
range of health impacts, from immediate injuries
impacts healthcare is a response to the USA
and deaths, to chronic depression and post-trau-
experiencing as much or more severe weather
matic stress disorders seen in weather-related
than any other country on Earth.99 Each year,
disaster survivors.97
nearly 12,000 people are hospitalized as a result
of extreme temperature conditions.100 This calls
In the 2014 report "Primary Protection: Enhancing
for adapting the healthcare infrastructure in the
Healthcare Resilience for a Changing Climate," the
country to mitigate new risk factors and enable
Obama administration provides a guide and tool
healthcare providers to tackle events such as hurri-
kit that is designed to help healthcare providers
canes, heat waves, droughts and floods.
ensure quality care before, during and after extreme weather events.98
ed a deep energy retrofit, saving more than 1.7
million kWh and $303,000 of electricity per year.
The hospital also doubled its Energy Star rating
by 2010 to 88 in only six months, and reduced its
overall energy consumption by 35% with a lessthan-six-month payback on the effort.92
108
92 Connecticut Energy Efficiency
Fund. Energy Efficiency At Work –
Case Study: Greenwich Hospital.
93 Sustainability Roadmap for
Hospitals. Waste. 2015.
94 Ganju N & Walsh M. “Sustainable
Computing: How Digital Healthcare
can Help the Environment, Reduce
Costs, and Improve Patient Service.” TechNet Magazine. 2009.
95 Sustainability Roadmap for
Hospitals. Waste. 2015.
96 BCC Research. U.S. Market For
Medical Waste Treatment, Containment, Management, and Disposal
To Reach Nearly $3.2 Billion In
2017. 2012.
U.S. Department of Health
and Human Services. Primary
Protection: Enhancing Health Care
Resilience for a Changing Climate.
2014.
97,98
American Meteorological
Society Policy Program. Under The
Weather: Environmental Extremes
and Health Care Delivery. 2010.
99,100
109
WASHINGTON DC
ROUNDTABLE
The Washington DC roundtable was the final destination on our global journey to co-create better
healthcare systems. The keynote speaker, Ms.
Susan Sheridan (profiled in an interview on page
144), became a passionate patient engagement
advocate after her family suffered from no less
than two major healthcare system failures.
CHALLENGES FOR HEALTHCARE IN THE USA
OPPORTUNITIES FOR CHANGE
The quality of care varies greatly across the
system
Introduce a patient safety liaison outside the
care team who can interact with patients and
address concerns
The current payment model is not cost-efficient
There is a lack of involvement of patients and
recognition of patient expertise as a valuable
resource in treatment
Use open health records to bring down waiting
times
Communication between professionals and
patients is challenged by overly complex healthcare information
Create strong, courageous leadership that can
lay out common goals to change the healthcare
culture
Education and training of health professionals
does not have a sufficient focus on patient engagement
Break the “10 minute rule” to give physicians
time for more meaningful conversations with
patients
Include patient centeredness in the training of
healthcare professionals
She is now Director of Patient Engagement at the Patient-Centered Outcomes Research Institute, fighting for the creation of a safer healthcare
system. Her story greatly influenced discussions at the roundtable with
all participants engaging actively in developing new ways to overcome
the known challenges of the healthcare system in the USA and identify
the opportunities at hand.
THREE GLOBAL ROUNDTABLES
110
In late 2014 and early 2015, DNV GL and Monday Morning Sustainia traveled to
The roundtables were in the format of one-day interactive workshops that gathered key
Shanghai, Brussels, and Washington DC to gain insights for this publication and start
stakeholders from across the healthcare system, including patients, professionals, providers,
a conversation on challenges and opportunities for improving the quality of care in
policy makers and researchers, with the aim of identifying possible trajectories for change
the healthcare systems of China, the EU and the USA. The guiding question for the
by spurring dialogue and discussions based on the various perspectives from the different
roundtables was: HOW DO WE IMPROVE THE QUALITY OF CARE?
stakeholders.
111
USA
/
EXPERT INSIGHT
The idea was that psychiatry will
to someone discovering a drug that
take care of the mental health prob-
cures 50% of people with depres-
lems but it never worked because
sion. The inventor of such a drug
there have never been enough psy-
would win the Nobel Prize, for sure.
chiatrists. Mental health issues are
Training for patient-centeredness
the most common problem a doctor
would be the equivalent of five or
will see in their clinic every day.
ten Nobel prizes in terms of the im-
Therefore, doctors need to know
pact it would have on mental health.
more about mental health.
Robert Smith
Professor of Medicine
and Psychiatry at
Michigan State University
Participant at
Washington DC roundtable
WHAT MAIN CHALLENG-
ES DO YOU SEE FOR HEALTHCARE
SYSTEMS IN THE USA?
The biggest challenge is to take
care of the most common, most
WHAT MAIN CHALLENG-
ES DO YOU SEE FOR HEALTHCARE
SYSTEM IN THE USA?
As a whole for the US healthcare
WHAT ARE SOME TANGIBLE WAYS
WHAT’S THE BIGGEST OPPORTU-
OF IMPROVING PATIENT-CEN-
NITY FOR IMPROVING THE QUALI-
TERED CARE IN THE USA?
TY OF CARE IN THE USA?
“We really have the opportunity to change the
way the US healthcare system is run.”
government has capped graduate
medical education funding since
1997, but the number of medical
system, the fact that not every per-
schools has grown since that time.
son has access to quality healthcare
The consequence is that we are
is a great challenge. In the US we
facing a bottleneck shortage. Today
have a healthcare system that is
we have around 26,000 residency
reactionary instead of preventative
positions available for first year
– where we focus on treating people
trainees and that will not be enough
sionals a generic, patient-centered
are negotiated. When faced with the
instead of preventing people from
to provide training for the students
approach that includes a greater fo-
difficult decisions regarding their
getting sick. We do not focus on
graduating from medical schools as
cus on mental healthcare. Students
healthcare, patients need assistance
primary care, but on the myriad of
early as 2016.
and residents need to be trained
in understanding what is happening
sub-specialties. We usually try to
intensively in the psychological and
to them. This is a negotiated process
shuffle patients off to those instead
social dimensions of medicine as
that is, in essence, bilateral between
of allowing ourselves to really focus
well as basic principles of doctor-pa-
the healthcare professional and the
on the patient and their needs.
tient relationships where the patient
patient.
leads the way in their own treatment.
Getting that done is the key
However, patients can also learn
to take a more active part in their
HOW IS THE MINDSET OF THE FUTURE GENERATION OF DOCTORS
DIFFERENT FROM THE CURRENT
GENERATION?
WHAT’S THE BIGGEST OPPORTUNITY FOR IMPROVING THE QUALI-
Britani Kessler
National President of the
American Medical Student
Association
Participant at
Washington DC roundtable
take part in the delivery of healthcare. For them, providing healthcare
is a dialogue with the patient and not
just one way communication from the
professional to the patient.
We have a generation of young
disabling and most ignored problem,
task in solving the biggest problem
treatment. In one study, patients in
which is mental healthcare. It is more
facing healthcare in the US. We have
clinic waiting rooms were coached
common than cancer and heart
estimated that training students in
on several factors in relation to com-
disease combined. Psychiatrists see
every medical school and residency
municating with the doctor before
time of change in the US healthcare
for the status quo, but want to be a
only 15% of the mentally ill, which
in mental healthcare will cost some-
they went in to their consultation.
system. Politically the healthcare
strong voice in improving the state
We are fighting the status quo
means that the remaining 85% are
thing in the range of $300 million
This was a randomized, controlled
system is up for debate and political
of the healthcare system. They are
at the moment. We have a history
seen entirely by medical doctors.
over 10 years. That sounds like a lot
trial and it was quite effective in
initiatives such as the Affordable
focused on patients, patient safety
where care has been very paternal-
Care is very poor because medical
of money but we are losing more
improving the dialogue between
Care Act are changing the health-
and on improving the quality of the
istic. A majority of the older gen-
doctors are not sufficiently trained in
than that every year due to poor
patients and doctors.
care system. For the new generation
healthcare system – both at hospitals
eration are used to a culture where
mental health. It is such an obvious
mental healthcare.
of professionals, but also for the
but also at a political level.
the doctor has the final say. This
problem but nothing is being done
about it.
WHY DO YOU THINK THAT IS?
The impact of teaching with a
TY OF CARE IN THE USA?
We are currently in a tremendous
tion that this time of change gives
ness would be dramatic. It would
them the opportunity to make things
take twenty years to train everyone
better. We really have the opportunity
but the impact would be comparable
to change the way the US healthcare
system is run.
entirely on physical disease and
omits anything to do with psychological or social factors. Medicine
education has not changed for well
over a hundred years in the US.
physicians that really want to be active and to make things better in the
healthcare system. They won’t settle
patients, there is currently a realiza-
greater focus on patient-centered-
Medical education focuses almost
“Doctors need to realize that treatments are not
prescribed, they are negotiated.”
WHAT IS THE BIGGEST CONCERN
FOR MEDICAL STUDENTS AND
RESIDENTS IN THE USA?
age of more than 130,000 physicians
WHAT ARE SOME OF THE OBSTACLES PREVENTING CARE FROM
BEING MORE PATIENT CENTERED?
means that moving towards a more
DO YOU SEE THE MINDSET OF
THE FUTURE GENERATION OF
DOCTORS AS MORE ACCEPTING
OF PATIENT-CENTERED CARE?
The new generation is more
We are facing a physician short-
112
medical education funding. The US
treatments are not prescribed, they
In short: teaching health profes-
Doctors need to realize that
by the year 2025 – due to graduate
patient centered healthcare system
will demand a cultural change. This
is not something that is done overnight. Also there are currently no
real incentives for professionals to
include patients. On the contrary, we
patient centered. They are taught to
are faced with great time constraints
listen to patients and to make sure
and pressure for fast delivery of
that the patient is involved through-
diagnoses, plans and treatments,
out their training at medical schools.
which makes it difficult to provide
They learn that patients have an
care that is truly patient centered.
active voice and expect patients to
113
ROADMAP
TO CHANGING
HEALTHCARE
ON OUR JOURNEY THROUGH THIS PUBLICATION,
WE HAVE NOW REACHED THE DESTINATION
OF CHANGE.
WHILE OUR PREVIOUS CHAPTERS HAVE DEALT WITH
THE CHALLENGES THAT HEALTHCARE SYSTEMS
AROUND THE WORLD ARE FORCED TO DEAL WITH,
WE NOW WISH TO UNFOLD THE OPPORTUNITIES
THAT EXIST AS DISRUPTIVE ELEMENTS IN OTHERWISE STATIC HEALTHCARE SYSTEMS.
114
115
QU
AN
A JOURNEY
TOWARDS
OPPORTUNITIES
LEARN ABOUT...
do it, at what price and with
Measuring the impact of
what specific outcome is vital
Page 131
information that can help reduce the costs – and not the
ensuring long-lasting and
Page 128
quality – of healthcare.
profound improvements to
the effectiveness of healthcare delivery.
Formalized patient in-
From improving timeliness in China to value-based healthcare at the Schön Klinik in Germany to patients leading the way in improving
patient safety in the USA – examples of new
opportunities, new ways of thinking, and new
models of healthcare are flourishing as tangible
responses to the growing challenges that the
healthcare sector faces.
Knowing what we do, why we
from the best are vital in
...PATIENT
ENGAGEMENT
PROGRAMS IN THE
USA
Y
IT Y
...MEASURING
HEALTHCARE’S TRUE
VALUE IN GERMANY
...KNOWLEDGE
SHARING IN THE UK
healthcare and learning
TIT
AL
QU
volvement and creating
a culture where tapping
into patients’ thoughts,
worries and experiences is the ‘new normal’
opens the door to
effective improvements
in patient safety.
...DIGITAL APPOINTMENT
SCHEDULING IN CHINA
Page 122
Technology targeted at improving the communication ‘gap’ can
help bridge some of the main
obstacles standing in the way of
quality, timely healthcare. These
innovations lay the groundwork
for a more convenient, quicker
and more person-centered interaction between patients and the
Seven opportunities – each paired with a case that highlights how to
move from idea to action – serve as examples of how to improve the
healthcare sector.
quality of healthcare in practice. They are framed around each of the
Page 134
seven dimensions of healthcare quality: equity, safety, person-centered
care, cost-efficiency, effectiveness, timeliness, and environmental sustainability and act as a roadmap for others who wish to effect change
in healthcare from small to large-scale.
These inspiring examples are not yet the new normal, but they tell
the story that the current healthcare challenges can be turned into
sector does not have to wait until tomorrow – it can and it does, in fact,
...SUSTAINABLE
HOSPITAL
PRACTICES IN THE
USA
happen today.
The power of role
...MOBIL HEALTH APP
IN KENYA
model clusters and
Convenient, accessible and
opportunities – with the right mind-set. They are leading the way
and can inspire us to see that changing and improving the healthcare
specific guides on how
to achieve change can
spearhead new agendas
and promote behavioral
shifts throughout the
healthcare sector.
Page 125
Page 137
...HEALTHCARE
ALLIANCES IN NEW
ZEELAND
user-friendly technology
A clear and binding con-
can pave the way for more
tract committing healthcare
equitable and high quality
healthcare – not just for the
few, but for the masses.
Page 119
providers to work towards
a common goal – instead of
working on the basis of individual interests – is crucial in
creating a healthcare system
that is person-centered.
116
117
FROM OPPORTUNITY...
Mobile health apps open
the door to universal
healthcare
Additionally the new technologies have also prov-
through technological platforms opening the
en to be a vehicle for reducing healthcare costs,
door to new possibilities and new solutions in
optimizing asset utilization and efficiency, deliver-
healthcare provision.
ing higher quality care, and improving the patient
The challenge: 40 million people, but only 7,000 doctors. The solution:
... TO ACTION IN KENYA
Healthcare is online and provided increasingly
A doctor to the masses
experience.
This changing tide is not a small wave, but a
tsunami of new communication platforms trans-
the mHealth app, MedAfrica. In a country where doctors are in high
demand, healthcare services are fragmented and the vast majority of
healthcare consumers are poor. Additionally, access to healthcare is
far from universal and there is a widespread need for services that can
help bridge the gap between the supply of and demand for healthcare
services. This is where the mHealth app, MedAfrica, steps in. MedAfrica was launched in 2011 by the Kenyan based mobile design and development company, Shimba Technologies. It is a free app that allows
healthcare consumers to access relevant medical information and find
reputable doctors and hospitals in their local area. 2
MedAfrica takes advantage of the fact that 25 million Kenyans have
forming healthcare systems today and in the
mobile phone subscriptions and makes it possible for all Kenyans with
coming years. In terms of revenue, the mobile
a mobile phone get access to healthcare and health information. 3 This
health market is expected to grow to $21.5 billion
allows for a whole new type of healthcare – one that is much more
by 2018 with a compound annual growth rate of
accessible for everyone. It helps dissolve the barriers between the rich
54.9%, according to a report from the market
and poor, well educated and uneducated, and rural and urban – and
research company, BCC Research.1
thus helps achieve a more equitable Kenya.
The growth and innovation of new mobile
The Kenyan healthcare system consists of a large number of fragment-
healthcare technologies is a positive addition to
ed and also fraudulent healthcare services, making it very difficult for
the world of healthcare – as these innovations
consumers to access and identify quality care.
can lead to new services and higher quality of
care. The application of mobile technologies, also
called mHealth, has already sparked a revolution
in the way healthcare is delivered – especially in
developing regions such as Africa. It is currently
becoming a key factor in democratizing healthcare, opening up the possibility to gain access to
healthcare services on the individual level – and
EQUITY
thus helping to break down barriers of income,
MEDAFRICA MHEALTH APP IN KENYA
race, ethnicity, geographic location and educa-
INITIATOR
PRIMARY DRIVER
tion.
Private company with support from leading
Mobile technology
healthcare institutions
SCALE
INVOLVED ACTORS
Kenya
Primarily potential and current healthcare users,
2
BCC Research. Wireless Electronic
Health Records: Technologies and
Global Markets. 2014.
1
118
but also involves professionals and healthcare
TYPE OF CHANGE
institutions
Increased access to healthcare
Shimba Mobile. Medafrica. 2014.
World Wide Web Foundation. Problem: 7,000 Doctors Serve a
Nation of 40 Million People. Solution: MedAfrica. 2012.
3
119
The country struggles not only with scarce resources and insufficient
4
healthcare professionals, but also with providing safe and quality-
5
based healthcare. The MedAfrica app tries to respond to exactly this
challenge by providing detailed contact information for 7,200 qualified
doctors and 8,076 quality assured health facilities - all freely accessible
for the app’s users.
Medafrica. 2012.
Pivot25 is an mlab initiative to bring focus
on the Mobile developer and entrepreneur
community in East Africa. mlab East Africa
is a consortium of four organizations aiming to be a leader in identifying, nurturing
and helping to build sustainable enterprises
in the knowledge economy.
Ericsson. Health care and painting apps
win top prizes in 2012 Ericsson Application
Awards. 2012.
6
The development and structure of the app are based on the idea of
FROM OPPORTUNITY...
The patient as the expert
involving the individual patient as an active consumer of healthcare.
Besides allowing the user to locate qualified healthcare providers,
Since the 2000 Institute of Medicine report, “To
The patient role in improving patient safety is
MedAfrica also provides a diagnostic tool to identify the potential
err is human – building a safer health system,” pa-
widely recognized by the WHO.
cause of illness and then link patients to specialists who can treat
tient safety has gained an increasingly prominent
them.4 Furthermore, it offers information on recommended drugs and
place on the international health policy agenda.7
A main part of their “Patient Safety Program” and
diets for specific medical conditions. By providing this kind of informa-
Fifteen years on, the quest continues to find new
work for promoting patient safety throughout the
tion, the app is taking a great step towards closing the gap between
models and new systems that can help improve
world is initiatives that include and incorporate
the supply of professionals and demand of the Kenyan people. It helps
patient safety in healthcare. 8
patients as active players in this process. 9
remove some of the pressure on the healthcare system by serving as
a first point of entry to the healthcare sector – helping to focus and
One example from the WHO is the “Patients for
guide healthcare consumers in the right direction.
Safety” initiative that was launched in 2004.
The app was developed in partnership between Samsung, Nokia, the
The initiative aims to build a global network that
Kenya Open Data Initiative, and others. The app is not publicly funded,
champions patients as key change makers when
but is rather a product based on a clear underlying business model.
it comes to improving safety in the healthcare
Thus, Shimba Technologies receive revenues for the free app through
sector. Through the initiative, the WHO works ac-
targeted ads and extended subscription services.
tively for “a world in which patients are treated as
partners in efforts to prevent all avoidable harm
in healthcare.” 10
Since its launch in 2011, MedAfrica has been growing quickly. Today
the app has more than 200,000 downloads, about 60% of which are
active users and the app is currently one of the top 10 apps in Kenya.
Looking to the future, patient involvement and
These numbers clearly indicate that the app is an accessible and nec-
engagement as a means of improving the culture
essary tool for the average Kenyan; it’s a spot-on solution for meeting
of safety are recognized as key components of
the country’s healthcare demands.
creating much safer healthcare systems. 11,12
The company behind the app is now focused on scaling and extending
its reach. They are currently working on cross-border partnerships
that will open the door for spreading the app to other countries. At the
same time they are adding more user services, and listing more doctors by collaborating with one of the country’s doctors organizations.
They are also developing a Ministry of Health feed with real-time information on disease outbreaks. The potential for this app is substantial
TAKE AWAY
because it offers a solution to a great healthcare problem – not only in
Convenient, accessible
and user-friendly technology can pave the way for
more equitable and high
quality healthcare – not
just for the few, but for the
masses.
Kenya, but in many developing countries: safe and quality healthcare is
not a commodity for all, but still reserved the few.
The success of and future potential for the app has been widely recognized. In its short history, the app has won the Pivot25 award5 and
the Ericsson Award, the latter “for the potential to bring important
information to many people and give them the power and knowledge
to take better care of their communities.”6
WHO. Exploring patient participation in reducing health-care-related safety risks. 2013.
7, 8, 9
WHO. Patients for Patient Safety.
2015.
10
120
AHRQ. The Role of Patients in
Safety. 2015.
11
The bmj spotlight. Patient
Centred Care. 2015.
12
121
Bringing the patient voice
to the world of patient
safety
A key word in the patient involvement movement is “transparency,”
meaning that patients are integrated into the system and have access
to relevant information on their safety. They are even members of
major committees across the Dana-Farber organization, ranging from
Patient safety improvements do not happen to patients – but with
board level committees to committees on quality improvement and
... TO ACTION IN THE USA
them. Partnerships with patients and families are thus an essential
risk management. One example is the Patient and Family Advisory
SAFTEY
aspect of improving patient safety and healthcare quality. But patients
Council that serves as an important part of the organizational struc-
and their families are not always engaged, and they do not automati-
ture for quality improvement. Another is the Adult Oncology Clinical
cally take on an active role in ensuring their own safety. They need to
Services Quality Improvement Committee, where patients review pa-
learn and become equipped to take on this role.
tient falls and accidents, medication errors, and patient survey results.
At the Dana-Farber Cancer Institute in Boston, USA, this is a primary
Another initiative aimed at involving the patients at the Dana-Farber
DANA-FARBER CANCER
INSTITUTE IN THE USA
goal. Dana-Farber/Harvard Cancer Center is the largest cancer center
in the world and is funded by the National Cancer Institute, USA. The
Cancer Institute is Patient Safety Rounds, which was implemented in
2004. Patient Safety Rounds help the institute identify and eliminate
institute has incorporated patient-centered care as a key element of
INITIATOR
patient safety risks through two methods: internal staff communi-
their healthcare services – and has used this approach to create a
Healthcare provider
cation about actual and potential safety problems,17 and interviews
stronger culture of patient safety. They focus on collaboration, com-
between former and current patients and families about their percepINVOLVED ACTORS
munication, and engagement with the patients and their families in
tion of safe care, with the ultimate goal of improving patient safety at
Management, patients,
a range of aspects in order to improve the quality and safety of their
the institute.18,19
professionals
care.13
Their work began in 1994 due to a heartbreaking incident. Betsy
PRIMARY DRIVER
Now, more than 20 years after the death of Betsy Lehman, the Da-
Patient Involvement
na-Farber Cancer Institute offers a free toolkit for other healthcare
Lehman, a 39 year-old Boston Globe health reporter suffering from
providers to become inspired and learn how to implement Patient
SCALE
breast cancer died at the Dana-Farber Cancer Institute because of
Safety Rounds. The Institute has received a line of recognitions for its
Dana-Farber Cancer Institute
four overdoses of chemotherapy. Doctors apparently refused to hear
work of improving patient safety through patient involvement. The
her warnings that something was drastically wrong and ignored the
TYPE OF CHANGE
Leapfrog Group, for instance, recently named Dana-Farber Cancer
results of tests indicating heart damage.14,15 This incident prompted the
Improving patient safety by
Institute to its annual list of Top Hospitals. The Leapfrog Top Hospi-
hospital to engage in self-examination of the state of patient safety at
involving patients
tal Award is given to less than seven percent of all eligible hospitals
the Institute.
nationwide – based on their demonstration of excellence in hospital
safety and quality. Additional recognition comes from News & World
Setting out on this journey, the patients were given a pivotal role. In
Report’s Best Hospitals 2010 Guide, which ranked Dana-Farber Cancer
the Institute’s mission statement they state that patients and their fam-
Institute the top Cancer Center in New England and 5th overall in the
ilies have “experience; expertise; insights; and perspectives that can
USA. 20
be invaluable to bringing about transformational change in healthcare
and enhancing quality and safety.” 16
To walk the talk, the Institute has named patients and their family
members “experts in quality improvement” and, as such, they are
regarded as equals with hospitals management, doctors and nurses
in terms of improving the safety of every patient. One of the specific
tools used by the Dana-Farber Cancer Institute is education of patients on their role as key players on the healthcare team. Patients are
encouraged to check their medication, ask providers to disinfect their
hands and notify clinicians of last minute changes in their treatment.
Institute for Patient- and
Family-Centered Care.
Partnering with Patients
and Families to Design a
Patient and Family-Centered Health Care System.
2008.
13
Aspden P, Wolcott J,
Bootman JL, Cronenwett
LR (eds.). The Betsy
Lehman Case. Preventing
Medication Errors: Quality
Chasm Series. 2007.
14
Altman LK. Big Doses of
Chemotherapy Drug Killed
Patient, Hurt 2d. New York
Times. 1995.
15
Dignified Person Centred
Care - Learning from the
USA. 2013.
16
This model has been positively evaluated
both at the Schwartz Center for Compassionate Healthcare in Boston, USA and a
pilot project at two UK hospitals. The Kings
Fund. Evaluation of the UK Pilots. 2011.
17
AHRQ. Organizational Change in the
Face of Highly Public Errors. The Dana-Farber Cancer Institute Experience. 2005.
18
Institute for Patient- and Family-Centered
Care. Partnering with Patients and Families
to Design a Patient and Family-Centered
Health Care System. 2008.
19
TAKE AWAY
Formalized patient involvement and
creating a culture where tapping into patients’ thoughts, worries and experiences
is the ‘new normal’ opens the door to
effective improvements in patient safety.
The Dana-Farber Cancer Institute. Paths
of Progress Volume 2011; 20(2).
20
122
123
FROM OPPORTUNITY...
Healthcare:
more than the sum
of its parts
This approach can help break down borders and
decision making are the headlines for healthcare
bridge the gap between healthcare partners –and
in the coming years. Today, person-centered
thus facilitate a far more person-centered healthcare
care is championed by the WHO and Healthcare
system. 22
What can the healthcare sector learn from the world of construction?
Looking at healthcare systems that are defined by fragmentation and
authorities from the USA to the UK, Denmark to
China, and Sweden to Singapore are supporting
and exploring it as a precondition for delivering
safe and quality healthcare.
Despite the broad endorsement, the reality is
that a transition to healthcare systems that are
much more person-centered than those we know
today is far from easily done. It demands radical
change, where new partnerships and collaborations are valued over the status quo – and where
each healthcare system is seen as a whole, rather
than as individual and fragmented parts. 21
Creating more integrated and collaborative
healthcare systems could be made possible by
Ministry of Health. NZ Health Systems,
Key Organizations, Health alliances. 2011.
23
Gauld R. NHS can learn a lot from New
Zealand’s healthcare system. The Guardian.
2014.
24
Ministry of Health. Better, Sooner, More
Convenient Health Care in the Community.
2011.
25
DNV GL and Monday Morning Sustainia.
Guide to Person-Centred Care. 2014.
26
... TO ACTION IN NEW ZEALAND
Integrated care, patient involvement, and shared
Strong alliances create
integrated healthcare
a lack of collaboration, the short answer is actually a great deal. In
New Zealand the aim of improving the quality of the healthcare system
has led to a new “alliancing” model based on how construction work
is managed. The model is specifically inspired by the way in which
contractors on large projects work collaboratively and share resources
needed to get the job done on time and on budget.
The primary objective of these new healthcare alliances is to get all
actors in the healthcare sector to work toward a common, shared goal.
Through these alliances and their joint incentive structure, healthcare
stakeholders in New Zealand are encouraged to engage in new partnerships and cross-sector collaborations. This ensures that everyone is
working towards the same goal. 23,24
Today the alliance model is a vital part of the government’s ‘Better,
Sooner, More Convenient’ care initiative that aims to improve the quality and person-centeredness of the healthcare sector in New Zealand. 25
The motivation for working with and developing the alliance model is
the conviction that strong collaborations between healthcare stakeholders are crucial in improving the quality of healthcare in areas such
as equity, access, integration and prevention. 26
taking on a ‘whole system approach’. A healthcare system based on the whole system approach is one that recognizes and understands
the wider system within which services are
embedded, and any and all service improvements
must take place within this broader context. Such
a model values the contribution of all partners –
including the patients – in ensuring the delivery
of high quality care.
PERSONCENTERED CARE
THE ALLIANCE INITIATIVE IN NEW ZEALAND
INITIATOR
SCALE
Policy makers
New Zealand
INVOLVED ACTORS
TYPE OF CHANGE
Professionals
Creating more integrated and collaborative
care for the patient
PRIMARY DRIVER
Whole system approach
DNV GL and Monday Morning
Sustainia. Person-Centred Care.
2014.
21
The bmj Spotlight. Patient Centred Care. 2014.
22
124
125
FROM OPPORTUNITY...
Knowing the value of
healthcare is key
In 2013 the dream of having at least one alliance in each of New Zealand’s 20 healthcare districts became reality. This decision was based
on the evaluation of nine alliancing pilots, which were initiated in 2010.
The evaluation concluded that the alliance model had improved the
position of primary care and increased opportunities for achieving
integrated care in the nine piloted districts. 27,28
More specifically, the alliance model requires providers in each of the
Rising costs, distorted incentive structures and errors
The need for forward thinking and innovative mind-
20 healthcare districts to work collaboratively within a whole system
in diagnosing and providing care are all great challeng-
sets has never been greater, as new ideas are vital for
approach to ensure that services are designed with what is best for
es for healthcare systems across the globe. These chal-
meeting the demands of more cost-efficient health-
patients and the public in mind. Each alliance is a way to bring togeth-
lenges threaten not only patient safety and well-be-
care sectors of the future. This is precisely what the
er a range of providers from across a healthcare district and encour-
ing, but also the cost-efficiency and sustainability of
concept of value based healthcare entails. Value based
age them to work collaboratively on what the system should look like
healthcare models. Overcoming these challenges and
healthcare has emerged as a strategy for delivering
from a patient perspective. 29 Alliance members are healthcare leaders
making healthcare systems more cost-efficient is vital,
healthcare at lower costs. It has been championed by
from different service areas, such as GPs, nurses, and professionals
as the demand of providing more healthcare for less
Professor Micheal Porter 32, who believes value should
in aged care, ambulance services, public health and different hospital
money is projected to become a major challenge for
define the framework for performance improvement in
specialties.
healthcare systems throughout the world.
healthcare. As Porter notes, “rigorous, disciplined mea-
Each alliance member signs a charter which binds them to work to-
Cost-efficiency often is associated with layoffs, fund-
gether and build trust in one another. The charter stipulates that they
ing cuts and increasing the speed of operations. But
focus on the whole system, and not the specific interests of the sector
making a healthcare system more cost-efficient need
Yet value in healthcare remains largely unmeasured
they may work for, and that they agree to help one another to achieve
not come at the expense of quality. On the contrary,
and misunderstood. Value should always be de-
the alliance’s goals. These goals include a wide range of elements
it can lead to improved healthcare services, a much
fined around the customer, and in a well-functioning
focused on improving and redesigning healthcare services, such as
needed freeing up of resources and new means of
healthcare system, the creation of value for patients
integrated services for older people with chronic care needs, or access
delivering care.
should determine the rewards for all other actors in the
surement and improvement of value is the best way to
drive system progress.”
system. 33 A value based approach to healthcare has
to GP-referred specialist service. 30
The evaluation of the first nine alliance model pilot projects indicates
that one of the positive outcomes was that the alliances helped drive
new initiatives to provide better support for patients with complex
needs in primary care settings by enabling general practitioners to
work together with hospital specialists and other providers. Furthermore there was also evidence of reductions in emergency department
admissions and of more services traditionally provided in hospital
settings now being delivered in the community, such as specialist outpatient consultations, older people’s health, and emergency response
services that might otherwise require a hospital visit. Furthermore, the
TAKE AWAY
A clear and binding
contract committing
healthcare providers to
work towards a common goal – instead of
working on the basis of
individual interests – is
crucial in creating a
healthcare system that
is person-centered.
This demands that healthcare systems make a change,
been implemented by a few pioneering providers, such
and focus on being leaner and smarter rather than just
as Kaiser Permanente and Cleveland Clinic in the USA,
slashing budgets.
Martini-Klinik and Schön Klinik in Germany—discussed
below—and Terveystalo, the largest private healthcare
provider in Finland.
QU
AN
TIT
healthcare stakeholders that took part in the alliances considered it to
be a model that helps steer the health system and service design in an
important new direction. 31
Y
Y
T
I
L
A
QU
In the future, the concept could very
well become a common standard in
healthcare systems throughout the
world. The prospects of improving the
costs of healthcare through the value based
approach are substantial. According to Boston
Consulting Group, a value-based approach to hospital
operations could improve performance by up to 30%. 34
Porter ME. A Strategy for Health
Care Reform — Toward a Value-Based
System. The New England Journal of
Medicine 2009; 361: 109-112.
32
Cumming J. Integrated care in New
Zealand. International Journal of Integrated Care Special 10th Anniversary
Edition 2011 e138.
27
Gauld R. What should governance
for integrated care look like? New
Zealand’s alliances provide some
pointers. The Medical Journal of
Australia. 2014.
28
126
Gauld R. New Zealand’s ‘integrated
performance and incentive framework’: Will it drive a ‘whole of system’
approach to health service design?
University of Birmingham. 2014.
29
Cumming J. Integrated care in New
Zealand, International Journal of Integrated Care Special 10th Anniversary
Edition: e138. 2011.
30
Gauld R. What should governance
for integrated care look like? New
Zealand’s alliances provide some
pointers. The Medical Journal of
Australia. 2014.
31
Porter ME. What Is Value in Health
Care? The New England Journal of
Medicine 2010; 363: 2477-2481.
33
Budryk Z. Value-based model could
improve hospital performance 30%.
Fierce Pharma. 2014.
34
127
Improving quality by
measuring the true value of
care
“Measurable. Tangible. Better“. This is the motto for the Schön Klinik
At that time the Schön Klinik, like other hospitals in Germany, had re-
... TO ACTION IN GERMANY
– a hospital group consisting of 17 hospitals across Germany, special-
duced the capacity of its knee replacement rehabilitation units in part
COST-EFFICIENCY
ized in orthopedics, neurology, and psychosomatic medicine. Over
because the existing cost system portrayed them as less profitable
the past years, the clinic has become one of the leading international
than acute-care units. But during the Schön Klinik’s value based cost
pioneers in value based healthcare as a new approach to healthcare. 35
measurement of the knee replacement process, they discovered that
The Schön Klinik has made the approach standard in their healthcare
the existing cost system allocated support-department costs largely
delivery and services.
on the basis of length of patient stay, not on the patient’s use of support resources. Since knee replacement patients at the Schön Klinik’s
THE SCHÖN KLINIK IN
GERMANY
Their work is based on the idea that the direct costs of patient care,
such as nurses, physicians, and consumable supplies can be assigned
hospital units spent 75% of their stay in the rehab facility, rehab had
been allocated about 75% of support department costs.
INITIATOR
directly to the individual patients – and that knowledge of the value
Healthcare provider
and costs of each step of a patient’s treatment and care is crucial to
The analysis showed, however, that the demand for many support-unit
continuous improvement of the clinic’s efficiency and performance
INVOLVED ACTORS
services, such as medical billing, is far higher during the days a patient
in delivering healthcare. The basic idea is to know the value of their
Management, professionals
spends in the acute-care facility than during rehab days. With support
healthcare – what they deliver, and at what costs. Therefore, the Schön
costs properly assigned, the rehab facility showed improved profitPRIMARY DRIVER
Klinik focuses intensely on measuring health outcomes of specific
ability. Based on the value analysis, the Schön Klinik thus began to
Measuring the price and quality
patient groups and understanding resource requirements and costs in
contemplate the expansion of its rehabilitation capacity—a complete
of healthcare
the context of these outcomes.
The Schön Klinik’s goal is that the combination of accurate outcome
reversal of common standard in Germany— and shifted its focus more
SCALE
intensively on reducing support costs incurred during the acute-care
Schön Klinik’s 17 hospital units
stay. 37
and cost measurements will empower the local personnel – physicians,
TYPE OF CHANGE
nurses, and administrators – at the Schön Klinik’s different sites to
The Schön Klinik has received international recognition for the value
Knowledge of specific value
improve the value of care they deliver, but also to open the door to
benchmarking across the 17 different hospitals in order to identify and
improve the cost-efficiency of
based approach to patient care – from, among others, Harvard Busi-
healthcare
ness School.
share best practices. This focus has led the Klinik to develop 1,500 value indicators – a mixture of outcome and process measures as well as
patient evaluations. The data is collected with a focus on the medical
condition and not the department – underlining the idea of focusing
on the direct costs of care. 36
One specific example of how the Schön Klinik’s is taking on the
value based cost and outcome approach is an improvement initiative
focused on the knee replacement process, which was implemented
TAKE AWAY
throughout the Klinik’s hospitals in 2009.
Kaplan RS, Witkowski ML, & Hohman JA.
“Schön Klinik: Measuring Cost and Value.”
Harvard Business School Case 112-085,
2012. (Revised December 2014.)
35
Porter ME & Guth C. Redefining German
Healthcare: Moving to a Value-Based
System. 2012.
36
128
Kaplan RS & Porter ME. The
Big Idea: How to Solve the
Cost Crisis in Health Care.
Harvard Business Review.
2011.
37
Knowing what we do, why we do
it, at what price and with what
specific outcome is vital information that can help reduce the
costs – and not the quality – of
healthcare.
129
FROM OPPORTUNITY...
How do we ensure the right level of treatment
Thus, relevant and effective models that can help
and the right level of medication? How do we
measure the quality of treatment procedures, patient
measure and improve healthcare performance?
experiences and operational performance are in high
Simply put, how do we best ensure that health-
demand within the healthcare sector. Such initiatives
care systems do their job: provide the appropri-
can help limit over- and under-use of services and
ate care to the appropriate patients? These are
realign incentive structures to best meet the needs
some of the big questions countries around the
of patients.
improving and ensuring high quality standards in
Innovative ways to ensure increased effectiveness by
the healthcare sector. Answering these questions
measuring and comparing performance mark a new
will become an increasingly pressing concern in
era in the delivery of healthcare.
reforms through the National Healthcare System – the
NHS. This has led to heated debate and negative cri-
INITIATOR
Policy makers and publicly
tique of some of the resolutions. The report “The NHS
funded healthcare system
under the coalition government” from the UK-based
INVOLVED ACTORS
The Clinical Commissioning
Groups
PRIMARY DRIVER
Measuring the value of health-
world must ask themselves when it comes to
Since 2010, the UK government has pushed a line of
COMMISSIONING FOR
VALUE IN THE UK’S NHS
care – benchmarking the performance with the best
SCALE
England
TYPE OF CHANGE
Using performance measurement as a vehicle for improving
healthcare
... TO ACTION IN ENGLAND
Knowledge sharing helps
healthcare do its job
the years to come.
Commissioning for
Value increases
effectiveness
EFFECTIVENESS
King’ Fund, published this year, concludes that the
reforms “have resulted in top-down reorganization of
the NHS and this has been distracting and damaging”
and “new systems of governance and accountability
resulting from the reforms are complex and confusing.” 38
Despite the clear downsides of the reforms, it is not
all bad. The development of the NHS over the past
few years also entails stories of success and improvements. One such story is the “Commissioning for
Value Initiative,” in which knowledge about performance and the identification of specific possibilities
for improvements are used as drivers for creating
better outcomes, higher quality and more efficient
healthcare.
The Commissioning for Value initiative is a collaboration between NHS Right Care, NHS England and
Public Health England. It is aimed directly at the 211
Clinical Commissioning Groups (CCG) in the NHS –
which are groups of primarily general practitioners
that work together to plan and design local health
services throughout England.
The initiative gathers and shares a series of information on each CCG’s performance and identifies a
series of different areas and healthcare services that
have unexploited potential in terms of improving the
delivered healthcare. These results help each local
CCG decide ‘where to look’ and ‘what to do’ in order
to improve outcomes and increase the quality of their
healthcare service.
The King’s Fund. The NHS under the coalition government. 2015.
38
130
131
FROM OPPORTUNITY...
Bridging time lags with better
communication
An important element in the initiative is the “Commissioning for Value
Packs,” initiated with the goal of identifying “local opportunities for improvement in health outcomes, patient experience, or finance.” In 2013
the first packs were distributed, which triangulated data on spending,
outcome, and quality and identified value opportunities where each
of the specific CCG was an outlier compared to equivalent CCGs. A
year later, a second round of packs provided in-depth data for the 13
patient conditions with the greatest potential for improvement.
In recent years, a myriad of technologies has become
Technology opens the door to a much more direct and
vital in the delivery of healthcare. These technologies
easy communication between healthcare providers
There are a number of examples of CCGs that have used the numbers
are currently transforming how healthcare is provided
and patients, including, for instance, booking appoint-
and recommendations from Commissioning for Value initiative to
in regions all over the world – opening healthcare sys-
ments online, communication on estimated waiting
improve their performance and quality of healthcare. One example is
tems up to new possibilities in healthcare services, new
time in doctors’ offices and information on the interval
the CCG in Warrington where the Commissioning for Value approach
types of treatments, new healthcare monitoring, and
between referrals and treatment. It also allows for
was used to identify where savings could be made to help overcome
ensuring new and improved communication channels.
much more widespread, proactive and timely communication between healthcare providers, including
a $38.3 million funding shortfall in 2011-12. 39 In the Commissioning for
Value Packs, “respiratory services” were identified as one of the main
The development and adaptation of technology can
communication between departments or booking new
improvement opportunities, but at the time, Warrington was spending
not only improve the standard of healthcare, but can
appointments with specialists. 41
$2.3 million more on these conditions than equivalent CCGs.
also serve as an important driver for augmenting
patient-provider relationships and supporting human
As a response, the respiratory service in Warrington was redesigned.
needs throughout the healthcare journey. Electronic
The primary changes included:
medical records and mHealth apps are two well-known
examples of how technology is improving the speed
• Extending the pul-
• Targeting patients
• Commissioning
monary rehabili-
with acute epi-
consultant-led
tation service to
sodes of illness
multi-disciplinary
include a home-
teams to carry out
based program
Hospital at Home
visits
Following the changes, quality, patient outcomes and pathway management all improved. Warrington also reduced its spending on respiratory services significantly, now spending $600,000 less than other
TAKE AWAY
Measuring the impact
of healthcare and
learning from the best
are vital in ensuring
long-lasting and profound improvements
to the effectiveness of
healthcare delivery.
and ease of healthcare delivery, all while prioritizing
patient needs.
Nhavoto JA & Grönlund Å. Mobile
Technologies and Geographic Information
Systems to Improve Health Care Systems:
A Literature Review. JMIR mHealth and
uHealth 2014; 2(2).
41
CCGs providing the same service. 40
NHS Warrington CCG. Commissioning for Value Insight Pack. 2013.
39
Wellards. What is commissioning
for value? 2014.
40
132
133
It’s time for a change
in healthcare provision
... TO ACTION IN CHINA
In recent years online healthcare platforms have become very popular
Imagine a Chinese woman, 55 years old and suffering from a severe
with Chinese consumers, allowing services like Gauhao to revolutionize
case of osteoporosis. Her pains are worsening, so her family urges
the interaction between users and providers and improve the quality
her to go to the nearest hospital to see a specialist. Sick, tired and
and timeliness of healthcare immensely. This type of online reservation
in pain, she has to get up at one o’clock in the morning, drive three
service also opens the door to a much more person-centered ap-
hours by car to reach the nearest hospital, and then stand in a line
proach to healthcare delivery. Furthermore, online scheduling provides
in front of the hospital entrance. Eight hours later, she reaches the
healthcare providers with the ability to better predict patient flow and
reception desk and gets her appointment to see a specialist – in
more efficiently allocate resources. 43
two weeks.
Guahao was founded in Shanghai in 2010 as a collaboration between
This kind of story is far from rare in China. On the contrary, long
the Chinese Health Education Network, Fudan Hospital and Health-
waiting times just to book an appointment are commonplace.42
care Management Co., and the Chinese Hospital Association, and later
expanded nationally. Today the online platform has spread to all of
Fortunately, this kind of healthcare experience could soon be in
the country’s 23 provinces and boasts over 37 million verified users,
China’s past, thanks to blossoming technological healthcare plat-
around 120,000 registered doctors and covers more than 900 major
forms, like Guahao. Guahao means scheduling a patient appoint-
hospitals in China.44 The site has a team of 3,000 personnel that helps
ment in Chinese, and this is exactly what the platform enables the
patients who are new to internet usage make appointments with doc-
Chinese healthcare consumer to do. Through Guahao, healthcare
tors. Guanhao also launched a mobile phone app in 2013, making its
consumers are able to schedule appointments with doctors online
services even more convenient and user-friendly.
based on location, medical specialties and other criteria. The
Guahao platform lets patients assess their personal calendars,
In late 2014, China’s internet giant, Tencent, invested $120 million in
local hospitals, and physicians to make an appointment one day to
the platform. The Tencent investment is expected to expand Guahao’s
two weeks in advance. In addition, the healthcare consumers can
user base as the health platform seeks to upgrade its WeChat payment
read medical advice and suggestions for different kinds of medical
service. WeChat is a mobile text and voice messaging communication
treatments.
service developed by Tencent.45
Hoath, B. Guahao: VC Fantasy. Online Appointment Registration System for China’s
700 Million Internet Users. The Health Care
Blog. 2013.
43
44
Guahao. 2014. www.Guahao.com
Asia First. Health platform Guahao gets
USD120m Tencent investment. 2014.
45
TIMELINESS
THE GAUHAO HEALTH TECHNOLOGY PLATFORM IN CHINA
INITIATOR
SCALE
Providers, policy makers and private
China
TAKE AWAY
company
TYPE OF CHANGE
INVOLVED ACTORS
Improving timeliness through
Patients, professionals
communication technology
PRIMARY DRIVER
Communication technology
See Health Systems in Focus –
China chapter page 46.
42
134
Technology targeted at improving the communication ‘gap’ can help bridge some of the main
obstacles standing in the way of quality, timely
healthcare. These innovations lay the groundwork
for a more convenient, quicker and more person-centered interaction between patients and the
healthcare sector.
135
Hospitals are leading
the green battle
FROM OPPORTUNITY...
Green thinking is
becoming the new
normal
This tells a story of a healthcare system where
for healthcare systems across the globe. Increas-
sustainability is no longer an afterthought, but is
ing pressure from rising costs in energy, water and
becoming a necessary and integrated aspect of
carbon are currently leading many governments
the healthcare sector.
group of progressive healthcare stakeholders in the USA are trying
to make sustainability a reality in the American healthcare system. 12
healthcare providers are leading this charge and inspiring others to
follow suit, with the ultimate goal of catapulting the nation into a future
where green is the new black for the healthcare industry.
... TO ACTION IN THE USA
Environmental sustainability is becoming reality
A sustainable healthcare system – within reach or a distant utopia? A
and healthcare providers to focus on the value of
sustainability within the health system.
Energy is a particularly difficult challenge; American hospitals spend roughly $8.5 billion per
year on energy costs and consume almost twice
the energy per square foot as traditional office
Launched in 2012, the Healthier Hospitals Initiative (HHI) is a threeyear, national campaign that advocates for the improvement of
environmental sustainability within the healthcare sector. This call-toaction to the entire healthcare sector was born out of a partnership
between 12 of the largest, most influential American health organizations, comprising approximately 500 hospitals with more than
$20 billion in purchasing power. These organizations, including many
well-known healthcare institutions, such as Dignity Health, Kaiser Permanente and the Cleveland Clinic, collaborated with three leading environmental organizations focused on ‘greening’ healthcare to create
HHI as a guide for hospitals to reduce energy and waste, choose safer
and less toxic products, and purchase and serve healthier foods.
space.46 Brazil’s hospitals are reported to account
for 10.6% of the country’s commercial energy
The goal of the initiative is to prove that implementing strategies to re-
use.47 There is also a growing recognition of the
duce costs, improve environmental performance and meet broad envi-
effects of climate change on health and the fact
ronmental health goals is, in fact, possible for hospitals and healthcare
that these effects will continue to drive up the
providers. The 12 healthcare providers are working to actively pool
cost and the demand for health services around
their collective sustainability experience, purchasing power and indus-
the world. Among others, the National Institute
try representation in order to accelerate the process of greening the
of Environmental Health Sciences in the USA
has concluded that climate change “stresses our
healthcare infrastructure and delivery systems.” 48
entire healthcare system. Consequently, the initiative is not limited to
Healthier Hospitals
Initiative. What we do.
2012.
50
the 12 founding members, but invites healthcare organizations across
the country to join and to become an active part of the initiative. 50
Environmental sustainability is quickly moving up
the agenda of healthcare providers. A 2013 poll
that surveyed top American and global representatives from hospitals and healthcare systems
shows that more than 87% of American hospitals
ENVIRONMENTAL
SUSTAINABILITY
HEALTHIER HOSPITALS INITIATIVE IN THE USA
are incorporating sustainability into their decision-making processes and operations. 49
INITIATOR
SCALE
12 healthcare systems
The HHI campaign had more than 1,000
total enrollees nationally in 2014
INVOLVED ACTORS
The American healthcare sector
TYPE OF CHANGE
Promoting sustainable healthcare care for
PRIMARY DRIVER
KPMG. Trends, risks and opportunities in healthcare. 2012.
46, 47
the patient
Advocacy and campaigning
National Institute of Environmental Health Sciences. Climate
Change & Human Health. 2014.
48
Greenbiz. Kaiser, Metro Health
bet big on sustainability. 2013.
49
136
137
THE CHANGE
MAKERS
Two years into the initiative, one of the main outcomes has been the
creation of six specific guides for hospitals and providers to reference
when aiming to improve their sustainability. These how-to guides
include strategies for handling six particular challenges: engaged
leadership, healthier foods, leaner energy, less waste, safer chemicals,
and smarter purchasing. When joining the HHI, hospitals and hospital
systems are encouraged to adopt at least two of the above challenges
in their commitment to sustainability.
In this publication, we have journeyed from challenges to opportunities hoping that you will feel
inspired to meet the challenges that are holding the
quality of care back in your part of the world.
Other than these guides, the HHI has also developed a range of different tools intended to make the fulfilment of this mission as easy as
possible. These are:
• Easy-to-use mechanisms
• Interactive, content-focused
for identifying metrics and
webinars
collecting data
• Insight into how others have
• Access to a broad-based
achieved success – case
We have established that healthcare systems are complex organisms.
community through the HHI
studies, success stories,
They consist of various fields of expertise, a multitude of stakeholders
network
leadership insights 51
with different objectives and numerous terms for the same concept. However, the complexity of healthcare systems shouldn’t hold us back from
• Hospital-to-hospital mentor-
trying to change them for the better.
ship programs
To move from great ambitions to real change takes leadership, examples
of success and people who dare to defy the norm. Therefore, we present
The initiative has already had an impressive impact. In 2012, The
White House Council on Environmental Quality hosted a discussion
on “Greening America’s Hospitals” highlighting the importance of the
HHI. 52
Evidence from the HHI’s 2013 Milestone Report backs up this recognition. The national HHI campaign has reached more than 1,000 total
hospital enrollees in 2014. More than $45 million was saved as a result
of single-use medical device reprocessing, a 33% increase from 2012.
Additionally, the majority of the hospitals reported spending more
to you three change makers in healthcare, from China, Europe and the
TAKE AWAY
The power of role model clusters and specific
guides on how to achieve
change can spearhead
new agendas and promote behavioral shifts
throughout the healthcare
sector.
USA, who dared to challenge the status quo and succeeded in creating a
better tomorrow.
than 15% of their food budget on local and sustainable food – amounting to $23.7 million. 53 These figures represent an increase of more than
350% in local and sustainable spending from the previous year.
The aim of the HHI is to enroll at least 2,000 hospitals by the end of
the three-year initiative.
Healthier Hospitals Initiative. What
we do. 2012.
51
The White House. Greening America’s Hospitals Part 1. 2012.
52
138
Health Care Without Harm. Healthier Hospitals Initiative’s 2013 Milestone
Report Shows Sustainability Trends
Catching on Among U.S. Hospitals.
2014.
53
139
CHANGE MAKER IN EUROPE
JEFFREY V. LAZARUS
CLOSING THE
“KNOWING-DOING” GAP
IS KEY TO IMPROVING
THE STATE OF HEALTHCARE
INTERVIEW
WHAT SPARKED YOUR
INVOLVEMENT WITH THE HIV IN
EUROPE INITIATIVE?
I am very much driven by the
research-to-action gap. We know
so much, the evidence is there, yet
too often people remain unaware
of this evidence and ‘what we know
works’ does not get translated into
healthcare standards. This was
what led me to join four experts
One of the greatest challenges within healthcare systems
today is the “knowing-doing gap”: often we know what to
do, but fail to do it. Overcoming this challenge is the primary
driver for Jeffrey Lazarus, a leading figure in the fight against
HIV in Europe.
140
and start the HIV in Europe Initiaactivities took place on the streets, in clinics, at universities, in
gay clubs and saunas, and at other venues in 52 countries.
tive, while I was at WHO.
Back in the mid-2000s we
had made immense progress in
Another example of how the HIV in Europe Initiative has
terms of treating HIV. We finally
contributed to growing awareness of HIV testing is the 2012
had the biomedical tools to really
publication, “HIV Indicator Conditions: Guidance for Imple-
reduce the staggering number of
menting HIV Testing in Adults in Healthcare Settings,” which
HIV-related deaths in Europe and
For years Jeffrey Lazarus has been on a quest
lion people infected with HIV in the European
translates scientific evidence into a practical approach to iden-
around the world. But what kept
to bridge the knowing-doing gap in HIV test-
Region, one in three remains undiagnosed.
tifying HIV-positive people who might not otherwise be tested.
us from seizing this great opportu-
ing and care through a series of research proj-
This situation is resulting in significant levels
The guide is targeted at healthcare providers in all relevant
nity was the fact that not enough
ects, initiatives and collaborations. This quest
of late diagnosis, ill health, and HIV trans-
specialties and settings, as well as at administrators and pol-
people were testing for HIV. And
is what motivated him to co-found the HIV in
mission across the region. Furthermore, the
icy-makers responsible for overseeing HIV testing programs
not enough of those who did learn
Europe Initiative – a platform for increasing
region is characterized by large variations in
at the national and local levels. Today it is increasingly used in
they were HIV-positive went on to
early diagnosis and timely care for people
HIV testing recommendations and in access
healthcare systems across the region.
initiate treatment.
living with HIV across Europe.
to prevention, testing, care and treatment.
Since its founding in 2007, the initiative has
During its first eight years, the HIV in Europe
brought together an independent group of
Initiative has had a great impact. It has proven
experts representing civil society, policy-mak-
to be an effective vehicle for putting the issue
ers, health professionals and European public
of earlier diagnosis of HIV on the political
health institutions – all working to create
agenda at the highest levels in Europe. It also
awareness of and improve the evidence base
BIOGRAPHY
Jeffrey V. Lazarus is a Senior
at WHO’s Regional Office for Europe
Researcher based at CHIP, the Centre
was followed by a stint at the Global
has promoted the sharing of knowledge and
for Health and Infectious Disease
Fund to Fight AIDS, Tuberculosis
around the importance of providing earlier
best practices across different European re-
Research and WHO Collaborating
and Malaria, where he led knowledge
HIV testing and care. Considering the course
gions and institutions – ultimately broadening
Centre on HIV and Viral Hepatitis at
translation and oversaw publication
of the HIV epidemic in Europe over the last
HIV awareness. A prominent example of this
the University of Copenhagen. He
of the Fund’s global and regional
decade, this work is very much needed.
is the European HIV testing week, initiated in
is also a Professor at the Lithuanian
impact reports. Upon his return to
University of Health Sciences, Medical
Copenhagen in 2012, he became the
Despite the fact that there is now widespread
2013. The second European HIV testing week
Academy, and an Affiliated Professor
co-founding Secretariat Director of
knowledge of preventive tools such as con-
was held in November 2014 with more than
at the Institute of Public Health,
Health Systems Global, an international
doms and access to life-saving antiretroviral
700 organizations across Europe hosting ac-
University of Porto.
health systems membership society.
therapy in most European countries, the situ-
tivities intended to make more people aware
ation is still gloomy: of the estimated 2.5 mil-
of their HIV status. HIV testing and awareness
JEFFREY V. LAZARUS
DIRECTOR OF HEALTH
SYSTEMS GLOBAL
His ten-year career as a health systems
and communicable diseases expert
141
It was estimated that almost half
WHAT WERE THE MAIN BAR-
of all people living with HIV in Eu-
RIERS AND HOW DID YOU OVER-
rope were unaware of their status – a
COME THEM?
totally unacceptable figure, from my
is being widely used by professionals
think that we are successfully evolv-
and specialists – this is clear proof
ing in a way that will incorporate a
that what we do is driving change
focus on hepatitis into the HIV in
and having an impact. I truly believe
perspective, especially in a region
The first barrier we faced was
Europe Initiative’s long-term vision.
that the guide was a major European
with so many well-functioning and
getting people involved. That was
Several hepatitis experts have joined
action to co-create healthcare. It
well-resourced healthcare systems.
actually a barrier that we were able
our Steering Committee since the
encompassed the key stakeholders,
This was the impetus for founding
to overcome quickly because the
conference.
including physicians, researchers,
the HIV in Europe Initiative.
people whom we were approaching
were, in one way or another, already
involved in the fight against HIV and
WHAT WAS YOUR FIRST STEP?
could clearly see the relevance of
We started as five people who
our initiative.
came together from different fields.
Our second barrier was funding.
NGOs and the affected communities.
HOW HAVE YOU MEASURED THE
IMPACT OF THE HIV IN EUROPE
INITIATIVE? CAN YOU ELABORATE
ON THE POSITIVE CHANGES THAT
IT HAS HAD?
This is why it has gained prominence
in healthcare systems across the
region.
Through the years we had a payoff in terms of Europeans’ growing
In addition to myself there were
This also proved to be surmountable
two clinician-researchers and two
thanks to support from the man-
We have been measuring the
situation has improved considerably
representatives of HIV community
ufacturers of HIV diagnostics and
effects of our work since the begin-
since the Initiative was launched, and
medicines as well as from the Euro-
ning. We evaluate our conferences
I am excited to see what else we can
pean Commission, which understood
by getting feedback from attendees.
accomplish as the HIV-related needs
the added value of European-wide
We also evaluate our project activ-
of European populations continue to
activities.
ities and research activities on an
evolve and as we engage in the field
ongoing basis.
of viral hepatitis.
and nongovernmental organizations.
at the highest political and expert
At that time I was working for the
technical levels in the region. One of
WHO Regional Office for Europe.
the primary outcomes of the confer-
Our first step was to invite 15 experts
ence was a call to action regarding
and key stakeholders within the field
what to do next. Since then we have
of HIV in Europe to be part of the
been arranging these conferences
initiative. We also invited some 10
every two years – each with a man-
organizations including WHO to join.
ifesto for the coming years as an
They all became part of the steering
important take-away.
committee, some as observers, guiding the initiative forward, identifying
and launching new projects, and
involving a broader constituency in
the fight against HIV.
HOW DID YOU GET RESOURCES
TO CREATE THE CHANGE YOU
WANTED?
“We know so much,
the evidence is there,
yet too often people
remain unaware of the
evidence and ‘what
we know works’ does
not get translated into
healthcare treatment
standards.”
Now, almost ten years later, we
are confronted by other types of
barriers. We are working on main-
was the development of a consensus
taining momentum and making sure
on the definition of a ‘late presenter’
that we continue to be relevant. For
for HIV treatment. This definition has
instance, we are currently working
been adopted across Europe. Also,
on integrating viral hepatitis issues
the response to HIV Testing Week
into our work. Hepatitis looks like
in 2013 and 2014 has confirmed that
HIV did when we started: there is a
our work has a positive impact on
– whether it is our conferences,
huge gap between knowledge and
society. We received a lot of support
We started with funding from
advocacy activities, research or the
action across Europe. We are clearly
and made more people aware of
increase awareness of our work, we
industry. We also applied for and
European HIV testing week. We do
failing in terms of seeing that knowl-
the Initiative. From the first to the
arranged a major conference on
received grants from the Europe-
not just focus on reaching one type
edge about testing and treating
second year, the number of partners
earlier diagnosis of HIV. It was held in
an Commission. For example, we
of stakeholder – we are trying to
hepatitis is actually reflected in the
and the number of people who got
Brussels in 2007 and had more than
recently initiated “Optimizing Testing
engage everyone who is or should
care Europeans receive. This is par-
tested increased greatly. Here it is
300 participants from 27 countries
and Linkage to Care for HIV across
be invested in this issue. From the
ticularly concerning now that there
important to stress that the Initiative
– including the European Commis-
Europe,” where I sit on the advisory
beginning, we have worked as a
is an effective cure for hepatitis C.
often functions as an umbrella
sioner for Health and Consumer
board. And there is a lot of volunteer
multidisciplinary team because we
Incorporating a focus on hepatitis
organization that adds value to
Protection.
time from the Steering Committee,
are convinced that broad action
brings about some challenges for
work already happening. For Testing
not least from our co-chairs.
is needed to meet this challenge.
the HIV in Europe Initiative in terms
Week there were thousands of
to create a common understanding
Participants at our conferences, for
of our identity, which is very much
people, including many people who
of the role of HIV testing and coun-
example, have diverse backgrounds.
linked to our experience of working
volunteered their time to provide
on HIV for all of this time.
on-the-ground testing and raise
seling in optimizing diagnosis and of
the need for earlier care. We chose
Brussels as our kick-off location in
HOW DID YOU INVOLVE OTHER
PEOPLE, AND WHOM DID YOU
INVITE?
They include clinicians, researchers, policy-makers, community
We made the first effort to put
representatives, and NGO advocates
hepatitis squarely on our agenda at
awareness of their HIV status. The
An early result of the initiative
To introduce the initiative and
With the conference we wanted
142
subsequent evaluation leads me to
“Now, almost ten
years later, we are
confronted by other
types of barriers. We
are working on maintaining momentum
and making sure that
we continue to be relevant.”
awareness.
Also, we can see that our 2012
order to be close to the political
We always have put a great deal
– all in the same room to talk about
the Initiative’s 2014 conference in
guide, “HIV Indicator Conditions:
epicenter of Europe, and we were
of effort into involving a wide range
how they can play an important part
Barcelona. Interest from conference
Guidance for Implementing HIV Test-
successful in engaging stakeholders
of people through our activities
in overcoming this challenge.
participants and feedback from the
ing in Adults in Healthcare Settings,”
143
CHANGE MAKER IN USA
SUSAN SHERIDAN
defined as the “kind of mistake that should never
occur” in the field of medical treatment.
IMPROVING
PATIENT SAFETY
THROUGH ADVOCACY
– A FIGHT TO RECTIFY
A SYSTEM FAILURE
From personal tragedy to national advocacy,
Susan Sheridan’s story is one of patient empowerment.
She and her organization, PICK, are tirelessly working to improve the awareness of kernicterus and elevate patient safety
higher on the national healthcare agenda.
In 2001 , PICK played an important role in getting
the Center for Disease Control and the Joint
Commission to issue alerts to all accredited hospitals and public health professionals in the USA
saying that all healthy infants are at potential risk
of kernicterus if their newborn jaundice is not
monitored and not adequately treated. Furthermore, Susan Sheridan and the other mothers of
PICK have played an important role spreading
awareness of the risks of kernicterus among
healthcare consumers. One of their initiatives was
the parent education campaign, “Did you know
that jaundice can sometimes lead to brain damto healthcare. PICK’s focus in these partnerships
age in newborns?,” which was initiated in 2006.
is to actively involve healthcare professionals as
key players in the change process – working for
The effect and significance in PICK in the fight for
a system change to improve the monitoring and
eradicating kernicterus has been widely recog-
treatment of jaundice.
nized. Susan Sheridan and the six other mothers
of PICK were honored at the national Patient
Through this work, Susan Sheridan and the six
Safety Partnership Symposium as a success
other moms have managed to put kernicterus on
story of partnership between consumers and the
the healthcare agenda and to push forward more
healthcare system to initiate system-wide im-
research and increased awareness of the prob-
provements. And in 2009, Sheridan was named
lem. In 2002, they successfully advocated for the
to Modern Healthcare’s list of the Top 25 Women
classification of kernicterus as a “Never Event” by
in Healthcare.
the National Quality Forum. ”Never Events” are
No one is born with kernicterus. It is a brain
cated to research, education, prevention and
injury that occurs when jaundice is misman-
outreach for individuals with kernicterus and
aged in the first days and weeks of a baby’s
their families, PICK’s mission is “passionately
life. This happened to Susan Sheridan’s son,
pursuing ways to make the future of individu-
Cal. He suffered severe brain damage five
als with kernicterus brighter.”
BIOGRAPHY
days after his birth in 1995 because his neo-
organization that seeks a safe,
in patient safety after her family
compassionate and just healthcare
experienced two serious medical
system through proactive partnerships
natal jaundice was untreated. A one dollar
The story of PICK is a story of success built
system failures. Her son, Cal, suffered
between consumers and providers of
bilirubin test could have prevented it. This
upon Susan Sheridan’s and the six other
severe brain damage called kernicterus
care. Sheridan served at President of
led Susan Sheridan to leave behind a career
moms’ personal tragedies. Since its founding,
five days after his birth in 1995 when
CAPS from 2003-2010.
as a banker in trade finance and to become a
PICK has managed to mobilize great support
leading activist in the patient advocacy battle
and expand its activities in order to create
his diagnosis of spinal cancer failed to
– a battle to put the awareness and improve-
awareness about kernicterus and strategies
be communicated.
ment of patient safety at the forefront of the
for putting an end to this easily preventable
healthcare agenda.
patient injury. Throughout the last 15 years,
many families and medical professionals have
144
Susan Sheridan became involved
his neonatal jaundice was untreated.
Her husband, Pat, died in 2002 after
SUSAN SHERIDAN
DIRECTOR OF
PATIENT ENGAGEMENT
FOR THE PATIENT-
From 2004-2011 Sheridan lead the
World Health Organization’s Patients
for Patient Safety initiative, a program
under the WHO Patient Safety
Sheridan, MIM, MBA, DHL is currently
Program that embraces the collective
the Director of Patient Engagement
wisdom of patients, and values patient
for the Patient-Centered Outcomes
empowerment and patient centered
Research Institute. She is also
care.
One of her first steps was to found the
become involved with PICK, forming a strong
non-profit organization, Parents of Infants
community of support. With Susan Sheridan
and Children with Kernicterus, PICK, together
as one of its leaders, PICK has also succeeded
with six other moms and dedicated research-
in developing strong partnerships with federal
co-founded Consumers Advancing
ers in October 2000. An organization dedi-
and non-governmental organizations related
Patient Safety (CAPS), a non-profit
CENTERED OUTCOMES
co-founder and past President of
RESEARCH INSTITUTE
Parents of Infants and Children with
(PCORI)
Kernicterus (PICK), and in 2003, she
Sheridan received her BA from
Albion College and her MIM and MBA
from Thunderbird School of Global
Management.
145
INTERVIEW
WHAT SPARKED YOUR
INVOLVEMENT WITH PICK?
For me it was personally motivated. I – as the other moms who
co-founded PICK – had a baby who
ington. This led to a front page
article in USA Today on kernicterus
– where I got to share my story nationally. It got a lot of reactions from
other families with similar stories.
Ultimately this led to a meeting in
“It was personal, it was
passion and it was
very healing for me
to feel that my story
could become part of
a greater system-wide
change.”
HOW DID YOU INVOLVE OTHER
PEOPLE, AND WHOM DID YOU
INVITE?
From day one we built our work
ago, having moms setting this kind
of agenda was almost unheard of in
the healthcare sector. The healthcare
system was not used to listening
to patients – especially not those
HOW DID YOU MEASURE THE EFFECT OF THE CHANGE?
HOW DO YOU KNOW IT WORKED?
The implementation the biliru-
on a partnership strategy. We
demanding radical change. This is
bin test nationally has really been a
did not want to leave anyone out,
very different from today, where the
great victory. We helped change the
because the backing from all actors
patient voice has become standard
standards of care. I am not saying
was crucial if we were to make this
in our healthcare system.
that it is perfect, but research shows
suffered brain damage because of
Chicago, where we – seven mothers
newborn jaundice, which is prevent-
to babies with kernicterus along with
able. I wanted to prevent this from
dedicated researchers – decided to
happening to other babies and fam-
form PICK as an NGO. We started
ilies. It was personal, it was passion
out by developing a structure, an
and it was very healing for me to feel
objective and a timeline for our ini-
happening. Leading up to this, the
for bringing the partners together.
that my story could become part of
tiative. One of our first decisions was
mothers formulated a to-do-list for
In terms of getting the right
a greater system-wide change.
to go big and to focus on the entire
the healthcare system, researching
people to attend our first round-
there was will. We were complete-
both in the healthcare system, where
healthcare system. We did not want
and identifying the responsibilities
table, we had opened some doors
ly mission driven – focused on our
the previous misinformation about
risks and consequences of the
to stay local, because the mistreating
and roles for each stakeholder in
when I testified in Washington. At
north star. We just had to look at our
the seriousness of jaundice has been
current protocol and improve the
of newborn jaundice was happen-
the healthcare system. We created a
that summit there were a number of
children, as they were a constant re-
replaced by more fact-based discus-
guidelines for practicing pedia-
ing across the country. This also
security blanket showing what could
leading figures within the healthcare
minder of the importance of pushing
sions on the risks of not getting your
tricians. I wanted to contribute to
meant that our mission and what we
and should be done to prevent this
system, including the Joint Commis-
through and making kernicterus a
baby tested, as well as in families,
getting kernicterus on the radar for
worked for was a nationwide system
from happening again.
sion, who I reached out to when we
phenomenon of the past.
where parents now demand that
the US healthcare authorities, which
change. We wanted to implement a
decided to have the first roundtable.
it was not at that time. There was
universal bilirubin test for the entire
I picked up the phone and talked to
We focused on consistency and a
a perception that this disease was
healthcare system for all newborns,
their CEO, and he agreed to come to
clear message that was not attack-
based on the anecdotes we hear.
simply not happening in the USA.
to create awareness of the problem
our event – the first one to step up.
ing, but trying to engage and involve
We get many personal stories from
Thus, we parents needed to get
and to push forward education of
This opened the door to get other
the system. This helped us get
moms and dads that have just had a
involved and to tell the story – that
parents and professionals.
At the beginning all we had was
stakeholders involved, because we
through and make a difference. We
baby that had jaundice and was test-
our own time, so we used a lot of our
could say that the Joint Commission
focused on speaking the healthcare
ed with bilirubin. Those letters really
was supporting it.
language, being informed, know-
matter and make us confident that
we really made a difference.
I wanted to tell the story of the
this was a preventable patient injury
Our basic idea was then, and still
kind of radical change throughout
the entire healthcare system. We
saw our own role as being catalytic
HOW DID YOU GET RESOURCES
TO CREATE THE CHANGE YOU
WANTED?
that once the test was made a
HOW DID YOU OVERCOME THESE
BARRIERS?
There was no silver bullet, but
We were very true to our mission.
that was, in fact, a reality in the USA.
is, that if you want to drive change,
time and resources. As the initia-
We were the only ones who had
you have to work in partnerships.
tive grew, we also began working
ing our partners as means of being
the knowledge of what happened,
So in the forming of PICK we
more actively on getting funds for
considered a serious and important
we knew the history of healthcare
reached out to nationally well-known
research and specific activities.
failures that led to our babies’ brain
researchers, doctors and safety
The Academic Institute helped
damage. There was a profound goal
experts and asked them to become
fund some of the first steps. The
healthcare professionals. So at first,
by making the concept of partner-
of making the patient voice count.
a part of the initiative. Based on this,
researchers that we partnered with
in terms of eradicating Kenicterus,
ships a very important aspect of our
We wanted to advocate for the
our first big step was to work with
also received money from govern-
we did not see the barriers, but
work. We did not know it was a great
importance of bringing patients,
our lead researchers to organize
ment agencies to conduct research.
only the possibilities. But one of the
strategy at first, but it was key for
patient advocates and family mem-
the roundtable, “Strategies for a
One grant came from The Centers
challenges when we started was
our success as a vehicle for bridging
bers to the table to help redesign the
System-wide Change in the Manage-
for Disease Control and Prevention
that they asked us: where is the
patients and professionals. In regard
healthcare system and to improve
ment of Neonatal Hyperbilirubinemia
to conduct more research on a
evidence? We lacked evidence of the
to this, we also had immense help
patient safety.
to Prevent Kernicterus,” in February
database of children with kernicter-
extent of kernicterus and the treat-
from some remarkable partners
2001. At this roundtable we brought
us, and to create a public education
ment failures. We had to take on the
within the system. They were bold
basically the entire healthcare sys-
campaign. We also got some funding
task of uncovering and making this
and progressive enough to support
tem to the table. Accreditors, regula-
from parents through our fundrais-
research available.
us even though this meant support-
tors, researchers, payers, healthcare
ing events and advocacy. It was kind
happened to my son at an Agency
systems and government represen-
of a grassroots effort.
for Healthcare Quality & Research
tatives sat down to discuss what was
WHAT WAS YOUR FIRST STEP?
In 2000, I testified about what
146
summit on patient safety in Wash-
WHAT WERE THE MAIN BARRIERS
First of all, we moms were not
Another great barrier was to
national standard, newborn readmissions decreased by 30%.
We have also managed to change
the way people talk about jaundice –
their babies be tested.
Success, for us, is also very much
voice.
We overcame a lot of the barriers
ing a radical change.
“We overcame a lot of
the barriers by making
the concept of partnerships a very important aspect of our
work.”
create a patient voice and make it
count. When we started 16 years
147
CHANGE MAKER IN CHINA
STEPHEN MACMAHON
LIFESEEDS’ TWO PRIMARY ACTIVITIES:
• Training of “village doctors” through the Healthcare
BRIDGING THE GAP:
LIFESEEDS AND CHRONIC
DISEASE MANAGEMENT
IN RURAL CHINA
Steven MacMahon’s spearheading efforts at LifeSeeds are
training village doctors and improving the treatment of
cardiovascular disease in China’s “stroke belt”.
Provider Program – a primary care-based program
seeking to build up the capacity of village doctors
in cardiovascular prevention and management and
thus enhance the identification and medical management of individuals at high cardiovascular risk.
• Educating the people through a Community Education Program seeking to improve blood pressure
control in those already affected, and to prevent
hypertension and reduce overall salt consumption
in the population and provide recommendations of
salt substitutes.
A recent meta-study on hypertension in rural China
This dual focus is motivated by the fact that the chal-
deemed the overall hypertension prevalence rate to be
lenge lies not only in the behavior of the people, but also
22.81%.1 Even more worrisome, a 2015 study in rural
in the healthcare system. Rural China is characterized
Northeast China concluded that 51% of the population
by low awareness, poor disease management, limited
was hypertensive. 31.2% were taking medication to ad-
resources and a healthcare service without well estab-
dress the problem but only 6% had their blood pressure
lished evidence-based clinical guidelines for the man-
under control. 2 These gloomy numbers are due both to
agement of hypertension and cardiovascular disease.
On the 2nd of June, 2011, the Salt Reduction
and doctors, LifeSeeds is introducing effec-
a lack of knowledge of healthy living among the Chinese
and Health Education Campaign launched in
tive, low-cost and sustainable interventions
people, and to a healthcare system that is currently
So far the success has been great. An evaluation of the
Lianghu– a small village in the Shanxi prov-
for cardiovascular disease that will enable
not properly managing these health challenges. The
first part of the project showed that the people in rural
ince of Northern China. The launch was or-
widespread prevention and management
campaign launched in Lianghu marks a new beginning –
northern China reduced their salt intake after participat-
chestrated as a village celebration equipped
programs to be implemented in rural China.
confronting the lack of knowledge and action from both
ing in a community-based sodium reduction program.
with drummers and dancing. Healthcare
LifeSeeds is thus addressing a greater health
the healthcare consumers and providers.
120 villages from five of the Northern provinces of China
experts gave inspirational speeches explain-
challenge in China, one in which chronic
ing the risk of high salt intake and told people
diseases are growing by the minute and cur-
how to reduce their salt consumption. As in
rently account for more than three-quarters
many other villages and towns in Northern
of all deaths.
- Hebei, Liaoning, Ningxia, Shanxi, and Shaanxi – are parChen X, Li L, Zhou T, Li Z. Prevalence
of Hypertension in Rural Areas of China:
A Meta-Analysis of Published Studies.
PLOS One 2014; 9(12): e115462.
1
Li Z, Guo X, Zheng L, Yang H, Sun Y.
Grim status of hypertension in rural
China: Results from Northeast China
Rural Cardiovascular Health Study 2013.
Journal of the American Society of
Hypertension 2015.
2
ticipating in and benefitting from the various elements
of implementation of LifeSeeds.
China, in Lianghu it is common to use a large
amount of salt in everyday cooking. This high
Cardiovascular diseases are, at present, the
salt consumption is becoming a health risk
leading cause of death in China, responsible
and these small communities are seeing a
for about 2.6 million deaths annually. And
steady rise of hypertension and other cardio-
predictions for the future assess that this
vascular diseases.
number will only grow in the coming years,
BIOGRAPHY
likely to reach 4 million deaths per year by
The campaign is part of The China Rural
2020. In rural China, where access to basic
Health Initiative – also called LifeSeeds – and
health services is difficult, these problems are
is a flagship project of the George Institute for
particularly significant.
Global Health. The project is designed to improve healthcare in China’s rural areas, home
Cases of heart disease, stroke and diabe-
to more than 700 million people. It involves
tes are rising rapidly in rural China and the
120 townships in five provinces in Northern
control and treatment of diseases are lagging
China and is supported by the Ministry of
behind.
Health. By working with local governments
148
STEPHEN MACMAHON
PRINCIPAL DIRECTOR OF
Stephen MacMahon is one of the founders
As Principal Director of The George
of The George Institute for Global Health
Institute, Professor MacMahon is
and is currently its Principal Director. He
responsible for more than 500 staff at
is Professor of Medicine at the University
Institute research facilities in Australia,
of Oxford and is an international authority
China, India and the UK. In 2008, he
on the causes, prevention and treatment
received the Australian Government’s
of common cardiovascular diseases.
highest award for achievement in medical
His special interest is the management
research and in 2012, he was elected as
of chronic and complex conditions in
Fellow to both the Australian Academy
resource-poor settings, particularly in the
of Science and the Academy of Medical
Asia-Pacific region.
Sciences.
THE GEORGE INSTITUTE FOR
GLOBAL HEALTH
149
INTERVIEW
WHAT SPARKED THE
CREATION OF LIFESEEDS?
We’ve had a long term interest
ultimately the whole project has
been designed and run by our team
in Beijing – all of whom are Chinese
and several have joint appointments
in the treatment and prevention of
with Peking University. Therefore, it
heart disease and stroke in Asia. One
wasn’t an Australian or British study.
of the lessons we learned early on is
Fundamentally, it was run, as is ap-
that a large majority of patients who
propriate, by people who understand
either had already experienced a
the Chinese health system, politics
heart attack or stroke – or those who
and culture, all which are critical in
are at very high risk – weren’t getting
any shift in healthcare.
“the West has so much
experience in the
management of these
chronic conditions,
that we have something to offer China
and other emerging
markets”
any care at all, and those who were
getting care were usually getting
suboptimal care. That was the scenario we faced, and clearly the status
quo of healthcare services was far
short of what was required.
ilarly, once we had a plan for action,
referral, treatment and follow-up.
Health and Family Planning Commis-
we identified the key stakeholders
We believe that these personalized
sion) has not had access to research
including the Ministry of Health and
instructions for clinical management,
funds, so it was not in a position to
provincial health bureaus, and we
together with continuous monitoring
contribute financially but it has acted
worked closely with them as well as
of practice quality, have the potential
as strategic partner. Additionally,
a range of others, like the Chinese
to greatly improve the quality of
the regional health bureaus in the
Center for Disease Control and Pre-
care provided. That said, without the
provinces contributed by providing
vention. So we made a deliberate
extension of the human resource,
access to facilities and staff. But we
effort to identify and engage all the
there will always be limitations.
had to raise all the research funds
key stakeholders, and take account
We’ve shown that we can improve
outside of the country, which is –
of their views as to how best to
the care provided by what are effec-
today - unsustainable. China has
achieve our goals.
tively non-medical workers, and if
an enormous economy and thereWHAT WERE YOUR FIRST STEPS IN
STARTING LIFESEEDS?
We didn’t have many models to
follow, because at the time we start-
by building technology systems to
we not focus on the most or least
fore the days of the United States,
developed provinces, but rather
Australia, the UK and other Western
find provinces in the middle, where
countries providing research funds
there was the greatest potential for
to China are over. We’d like to get
change and scale-up.
China more directly involved with
the village doctors were already
care workers because they are, of
healthcare research funding in the
overwhelmed with work, so ex-
course, very inexpensive compared
So we focused on what is basical-
WHAT WERE THE MAIN BARRIERS
IN STARTING LIFESEEDS?
The major barrier was that that
support them we can substantially
improve the quality of care, then
it will be very cost effective to hire
more of these non-medical health-
Therefore, we commissioned a
ed working with China in this area,
small pilot study in China working
there wasn’t much focus on stroke
ly the “stroke belt” of China, which
future. To do so, we’re focusing on
tending their reach, even to cover
to regular doctors. As long as we
with the Ministry of Health to look at
and heart disease. Most of the global
runs from the middle of China above
closer engagement with the Ministry
something as important as stroke
can ensure safe, effective care, this is
a few clinical centers in some rural
interest in healthcare in China had
Beijing to the east coast. Here stroke
of Science and Technology.
prevention and treatment, was not
potentially a very scalable solution.
areas to see what was going on, par-
focused on issues like SARs, which
rates are very high, and while there
ticularly in terms of stroke preven-
were seen as possible threats to the
are major limitations in the level of
organization, and not a techni-
very modest level of training of
and have shown that a very basic
tion, as stroke is the leading cause
West. So ailments that weren’t a
care provided, the health systems
cally Chinese organization, so we
doctors was an issue. So while the
prototype technology has the ca-
of death and disability in China.
threat to the West, like heart disease
are strong enough to support the
cannot seek resources directly from
stroke prevention program clearly
pacity to improve outcomes. What
And the results were pretty grim in
or stroke, weren’t on the Western
implementation of new programs.
the government, as only Chinese
improved the quality of the care that
we now need is a bespoke Chinese
terms of the treatments people were
agenda. Part of the rationale for es-
And as it has turned out, the Minis-
organizations can apply for funding
was delivered, the impact was still
version and a completely new phase
receiving if they’d had a stroke, and
tablishing The George Institute was
ter’s advice was extremely helpful
from the Chinese government. That
well short of what we had hoped for.
of LifeSeeds, targeting the same
the absence of anything being done
that the West has so much experi-
and the provinces we chose to be
said, we need to find other ways to
for those at risk.
ence in the management of these
great places to run this project.
work with the government through
On that basis, we put together
The George Institute is a global
chronic conditions, that we have
partnerships or joint venture with
a partnership with Peking Universi-
something to offer China and other
Chinese organizations with interests
ty – it also involved the Ministry of
emerging markets, experientially and
Health and Bureaus of Health in rural
financially.
provinces. We developed a program
At the outset, we knew there
HOW DID YOU GET RESOURCES TO CREATE THE CHANGE YOU
in improving healthcare for the poor.
WANTED?
HOW DID YOU INVOLVE OTHER
a straightforward task. Also, the
HOW WILL YOU OVERCOME THESE
BARRIERS? AND WHAT ARE THE
CHALLENGES TO OVERCOME IN
THE FUTURE?
The next phase of this project will
was a big difference in the quality
After identifying the provinces
healthcare workers with very modest
of healthcare in the cities and rural
with which to work, we sought fund-
training. The program was very
areas in China. I had previously had
ing from the US National Institutes of
simple and aimed to enable them to
the opportunity to host the Chinese
Health, which had a specific program
identify people at high risk of stroke
Minister of Health, Mr. Gao Qiang, on
devoted to improving healthcare for
When we first established our
or who had had a stroke, and provide
a visit to Sydney and he emphasized
heart disease and stroke in low and
Institute in China, we developed it as
gram, we will provide mobile internet
low-cost evidence based treatment.
that the most important challenge
middle income countries. We suc-
a partnership with Peking University.
based programs, which provide
The program ran for 2 years and
was to improve care in Chinese rural
ceeded in gaining their support, and
We chose Peking University because
instructions directly to the doctor
then we assessed the outcomes.
communities. We discussed with
they funded the project for the best
it’s the leading university in China,
about how to manage the patient
him the selection of provinces for
part of 5 years.
so in that sense it was a carefully
in front of him or her. This includes
planned strategic partnership. Sim-
instructions about risk assessment,
cial support for this project, but
LifeSeeds and he suggested that
Until very recently, the Chinese
PEOPLE AND ORGANIZATIONS
AND HOW DID YOU CHOOSE WHO
TO INVITE?
We’ve begun some work on this,
or similar populations, to assess
to train “village doctors,” who are
I was involved in raising finan-
150
Ministry of Health (now the National
whether this approach to care works.
We do not yet have funds for this,
but it is something we will continue
to seek.
There is also a need to extend the
reach of the program to urban com-
use new IT technology to commu-
munities. If you are wealthy in China,
nicate with the village doctors. So
you can get 5 star medical service in
rather than training the doctors
and leaving it to them to follow the
guidelines and implement the pro-
“As long as we can
ensure safe, effective
care, this is potentially
a very scalable solution.”
151
any of the major cities, but if you’re
the national level. If we can achieve
of 2 generic drugs that cost about
poor, and particularly if you’re a
the results we are aiming for in terms
10 cents a day. If we could show
migrant, then there are big challeng-
of stroke prevention, then we could
widespread uptake and persistence
es in accessing quality care. There is
take a similar approach to other
in that sort of care, we would know
therefore a demand for accessible,
major health problems in China such
we are on track to make a major
affordable care in urban areas, as
as lung disease, cancer, and mental
difference in clinical outcomes for
well as in rural areas.
health.
this very large patient population.
Of course, the actual implemenHOW DO YOU ENGAGE ALL THE
ACTORS INVOLVED WITH LIFESEEDS?
work is that there is a clear currency:
the provincial or national levels is
death or hospitalization. It’s the type
the responsibility of governments,
of thing you can easily count.
unless – and this is possible – China
But, of course, it’s not only
There has been very a good engage-
opens up the healthcare sector to
counting the bodies that matters.
ment with the village doctors and
foreign ownership and operation.
We need to make sure treatments
this is demonstrated by the improve-
I think that’s in the cards. Already,
and initiatives are cost effective. You
ment in care we have observed.
the planned free trade agreement
could spend a fortune and only save
We’ve also had great support from
between Australia and China will
a few lives, or you could spend much
the Chinese bureaus of Health,
allow Australians to own and operate
less and save many lives. And in all
Peking University and the Ministry of
healthcare facilities in China. This
resource poor environments, you
Health, so I don’t think engagement
could be the start of much more
need to veer on the side of the latter
has been a major challenge.
global engagement with China in
– and do things that are affordable
the development of solutions for its
as well as accessible. That said, the
greatest health challenges.
resources that are currently available
The bigger challenge will come
when it comes to scale up. Translating evidence from projects such
as LifeSeeds directly into national
programs is extremely challenging. What we have learned is that
a better option may be to first try
in rural China are not adequate, so
H0W DO YOU MEASURE THE EFFECT OF LIFESEEDS? HOW WILL
YOU KNOW IT WORKED?
any sort of implementation of better
quality care is going to require greater resources. Our hope is that if we
can show the LifeSeeds programs
to achieve scale up in a provincial
There are national and interna-
are cost effective, this will result in
program. A successful provincial
tional guidelines about how patients
resource allocation that will allow
program could then provide a model
with certain conditions should be
these programs to be scaled up.
for a national program. Our view
treated and their recommenda-
at the moment is that although we
tions are based on strategies that
have improved the care provided in
have been shown, unequivocally,
these villages, we don’t yet have the
to reduce the risk of death, stroke
solution that we should be scaling
and other diseases. Therefore, if
up. We’ve proven the principle that
we can show there are meaningful
you can change the care provided
improvements in the application of
by village doctors, but we still need a
those strategies in the populations
more powerful intervention that will
served by LifeSeeds we can make a
deliver larger improvements. If we
precise estimate of the effect these
can achieve this in the next phase of
programs will have on death and
LifeSeeds then I think we will really
disease. For instance, if a patient has
have something we could promote
had one stroke then that person’s
at a provincial level.
risk of a second stroke is high (say,
From there, we’d have a model of
success that we could then bring to
152
The great thing about this kind of
tation of any such programs at either
20% over 5 years). We know that this
risk can be halved by a combination
“The great thing about
this kind of work is
that there is a clear
currency: death or
hospitalization. It’s the
type of thing you can
easily count.”
153
INSPIRATION
FOR FURTHER READING
WHO’S BEHIND
SUSTAINIA is an innovation platform where companies,
The objective of strategic research is to enable long-
NGOs, foundations and thought leaders come together
term innovation and business growth in support of the
in creating tangible approaches to sustainability. With a
overall strategy of DNV GL through new knowledge and
focus on readily available solutions, Sustainia’s mission
services. Such research is carried out in selected areas
is to mature markets and sectors for sustainable models,
that are believed to be of particular significance for DNV
products, and services. The work of Sustainia equips
GL in the future. DNV GL will seek out the best practices
decision makers, CEOs, and citizens with the solu-
in risk thinking to support the further development of
tions, arguments, visions, facts, and networks needed
high quality, person-centered care. We welcome the
to accelerate a sustainable transformation in sectors,
opportunity to work with others to make this vision a
BMJ SPOTLIGHT: PATIENT CENTRED CARE, 2015
industries, and our everyday lives.
reality for all. To learn more about our work to establish
Healthcare faces serious threats to its sustainability. Ageing populations, the rise
a collaboration, please visit us at: www.dnvgl.com/pa-
of co-morbid chronic conditions, an unenviable safety record and the impact of
tientsafety
austerity collectively mean that health systems around the world have to change
The concept of Sustainia was developed by Scandina-
if they are to achieve improved well-being for individuals and populations. Such
vian think tank, Monday Morning, in a collaborative ef-
change is possible if we join the power of systems thinking with the engagement
fort with global companies, foundations, organizations,
and experts. Since 1989, Monday Morning has addressed
megatrends in our society: sustainability, healthcare,
welfare, and financial systems, to name but a few. On a
DNV GL and Sustainia have created multiple publications on the
subjects of healthcare and health. We hope State of Healthcare
has inspired you to keep reading and exploring our work. We have
listed a selection of reading material below:
of service users as equal and active partners alongside practitioners, provider
organizations and policy makers. This is the message of the new publication on
Erik Rasmussen
Founder of Sustainia and CEO of Monday Morning
person-centred care from the BMJ and DNV GL.
national and international level, Monday Morning works
Stephen Leyshon
for an innovative society where old barriers between
Deputy Programme Director - Principal Advisor in Patient Safety
MIXED METHODS: IMPROVING THE ASSESSMENT OF SAFETY CULTURE IN
sectors, institutions, and leaders are torn down in an ef-
DNV GL - Healthcare | Strategic Research and Innovation
HEALTHCARE, 2014
fort to locate common challenges and shared solutions.
To find out more, visit: www.sustainia.me
Safety culture is the way in which organizations live and breathe safety. If there is
Eva Turk
to be improvement in the quality of healthcare, the assessment of safety culture is
Senior Researcher
DNV GL - Healthcare | Strategic Research and Innovation
DNV GL is driven by its purpose of safeguarding life,
property, and the environment, DNV GL enables organizations to advance the safety and sustainability of their
business. DNV GL provides classification and technical
Global Technical Director for Healthcare
DNV GL - Healthcare | Business Assurance
Fabijana Popovic
advisory services to the maritime, oil and gas, and
Project Manager, Monday Morning Sustainia
to customers across a wide range of industries. Combining leading technical and operational expertise, risk
THE GUIDE TO CO-CREATING HEALTH, 2014
Guide to Co-Creating Health describes a not-too-distant future society in which
different arenas work together to create a health-empowering society. The guide
Esben Alslund-Lanthén
looks at schools, workplaces, the food sector, healthcare and communities and
Research Analyst, Monday Morning Sustainia
examines their roles in creating a society that truly values health. By using clear
language and easily read illustrations, the book portrays the healthy society we
methodology and in-depth industry knowledge, DNV
Monica Keaney
GL empowers its customers’ decisions and actions with
Project Coordinator, Monday Morning Sustainia
trust and confidence.
The company continuously invests in research and col-
in which quantitative and qualitative methods are combined to improve the accuracy
of results in the assessment of a healthcare organization’s safety culture.
Stephen McAdam
assurance along with software and independent expert
energy industries. It also provides certification services
paramount. This position paper makes the case for using a mixed methods approach,
could live in ten years from now based on solutions available today.
Anna Fenger Schefte
Journalist, Monday Morning
THE GUIDE TO PERSON-CENTRED CARE, 2014
While the current healthcare systems of the world are unsustainable, their challenges
laborative innovation to provide customers and society
Lisa Haglund
at large with operational and technological foresight.
Head of Design, Monday Morning Sustainia
also present the greatest opportunities to co-create healthier societies. In PersonCentred Care, we set forth a bold vision for what healthcare could look like if person-
DNV GL, whose origins date back to 1864, operates
centered care is made a reality for all. The guide features interviews with world
globally in more than 100 countries, with its 16,000
leaders in person-centered care, 10 illuminating case studies from around the world,
professionals dedicated to helping their customers make
the world safer, smarter, and greener. Always looking
a review of the challenges and obstacles to person-centered care and an accessible
SUSTAINIA
and engaging review of the evidence.
to the future, the company undertakes a great deal of
research on coming trends, as part of the DNV GL Strategic Research and Innovation program.
154
a part of
MONDAY MORNING
155
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167
THE STATE OF
HEALTHCARE
From Challenges To Opportunities
To be sustainable, people and societies
need to be healthy and to be healthy
we need to be able to rely on quality
healthcare. This publication offers a look at
the current state of global healthcare and
points towards solutions, technologies
and people that inspire a new and
brighter future.
DNV GL and Sustainia joined forces with
key stakeholders from healthcare systems
all around the world in order to start the
discussion about the future of healthcare.
Our ambition is to help change the
conversation from only focusing
on challenges to an approach that
highlights opportunities and
co-creates positive change.
SUSTAINIA
a part of
MONDAY MORNING
168