The State of Healthcare: From Challenges to Opportunities by Sustainia

FROM CHALLENGES TO OPPORTUNITIES

SUSTAINIA

a part of

MONDAY MORNING

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. ÂŠ DNV GL and Monday Morning Sustainia 2015 Print: Rosendahls ISBN: 978-87-93038-30-1

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FROM CHALLENGES TO OPPORTUNITIES

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. I propose that we need a new scientific approach to understanding the role of the patient.

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 â&#x20AC;&#x201C; in healthcare as well as any other matter â&#x20AC;&#x201C; 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 worldâ&#x20AC;&#x2122;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 â&#x20AC;&#x192;

By e-Patient Dave deBronkart, healthcare expert, author and cancer survivor dedicated to patient engagement and advocacy

Table of Contents 8

INTRODUCTION

10 EXECUTIVE SUMMARY

13 WHAT WE DID AND WHY 14

MAPPING THE STATE OF HEALTHCARE

ROUNDTABLES WITH KEY STAKEHOLDERS

HIGHLIGHTING OPPORTUNITIES, INSPIRING CHANGE

WHAT YOU SHOULD KEEP IN MIND WHEN READING THIS PUBLICATION

25 GLOBAL HEALTHCARE OUTLOOK 28 AFRICA 30

THE AMERICAS

43 HEALTH SYSTEMS IN FOCUS 44

FROM EAST TO WEST

CHINA – RECALIBRATING A SYSTEM FOR NEW DISEASE PATTERNS

32 EASTERN MEDITERRANEAN

48 Physical and social inequalities

34 EUROPE

SOUTH-EAST ASIA

WESTERN PACIFIC

GLOBAL OVERVIEW

CO-CREATING HEALTHCARE

SEEING THE WHOLE SYSTEM

STANDARDS FOR COCREATION

The patient is a resource The economic burden of no gatekeeping

19 SYSTEMS THINKING AND CO-CREATION

Safety is a challenge for patients and professionals

Effectiveness is improving but not incentivized

Worth the wait?

In need of a breath of fresh air

Shanghai roundtable

Expert insight

EUROPE– SHARING A HEALTHCARE GOAL

Protecting universal care

Creating a patient safety culture

Towards co-creation at different speeds

Growing demand and shrinking budgets

EU guides the way to more effective care

Timing is everything

A healthy environment

Brussels roundtable

115 ROADMAP TO CHANGING HEALTHCARE 116

118

A JOURNEY TOWARDS OPPORTUNITIES

Case in Kenya: A doctor to the masses

121 122

Case in USA: Bringing the patient safety

Expert insight

Healthcare: more than the

Case in Australia: Strong alliances create integrated healthcare

94 96

THE UNITED STATES OF AMERICA – BALANCING THE SCALES Watch the access gap

103 106

108

128

Case in Germany: Improving quality by measuring the

130

131

133

134

154 WHO’S BEHIND THIS PUBLICATION 155 FURTHER READING 156 REFERENCES

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

– Steven MacMahon, China

better communication

Healthcare on time…

112

Chronic disease management in rural China

Knowledge sharing helps

increases effectiveness

Washington DC roundtable

148

healthcare do its job

worth?

110

– Susan Sheridan, USA

true value of care

Commissioning for Value

sometimes

Improving patient safety through advocacy

Knowing the value of

Getting your money’s

Too much and not enough

144

healthcare is key

Towards healthcare of, by and for the people

101

127

The fight to improve patient safety

– Jeffrey V. Lazarus, Europe

sum of its parts 125

Bridging the “Knowing-Doing” Gap

The patient as the expert

patient voice to the world of

125

140

Mobile health apps open the door to universal healthcare

119

139 THE CHANGE MAKERS

136

Green thinking is becoming the new normal

137

Case in USA: Hospitals are leading the green battle

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 worldâ&#x20AC;&#x2122;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.

HENRIK O. MADSEN

ERIK RASMUSSEN

President & CEO DNV GL Group

Founder of Sustainia and CEO of Monday Morning

Executive Summary â&#x20AC;&#x153;We cannot solve our problems with the same thinking we used when we created them.â&#x20AC;? This quote from Albert Einstein hits the nail on the head when it comes to the publication you hold in your hands.

The aim of this publication and the

On the following pages, we take a

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. This publication is the result of a 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 reoc-

regions. The data offer insight into the challenges faced in different regions. For instance, NCDs cause 87% of deaths in Europe, but only 28% in Africa. However, developing countries struggle with a lack of healthcare resources compared to more industrialized regions.

health problems in due time.

ing co-creation between different stakeholders. 3

placing it in the context of the WHO

regions hoping to avoid the same

the underlying system and promot-

Greenhalgh T et al. Evidence Based Medicine: A Movement in Crisis? BMJ 2014; 348: 1-7.

of healthcare. We frame this by

be seen as warning signs for other

understanding and strengthening

around the world to give a snapshot

ing figures from one region can

their immediate causes rather than

Dixon-Woods M et al. Explaining Matching Michigan: An Ethnographic Study of a Patient Safety Initiative. Implementation Science 2013; 8(70):1-13.

today. In this section we synthe-

Importantly, when compared, alarm-

currence of particular ailments and

we need to know where we stand size data on health systems from

smarter pathways towards the healthcare systems of tomorrow.

Before making an improvement,

World Health Organization. Systems Thinking for Health Systems Strengthening. 2009. 3

HEALTH SYSTEMS IN FOCUS This section of the publication

ROADMAP TO CHANGING HEALTHCARE

And we hear the story of Stephen MacMahon and Lifeseeds, a pro-

sets out to examine the healthcare

Challenges in healthcare systems

gram tackling the challenge of NCDs

systems in China, Europe and the

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

care systems offers valuable insight

will form the healthcare systems of

into changing healthcare dynamics

tomorrow are popping up all around

in the world today.

the world to address the specific

of care. These three regions were

needs of specific locations. China, Europe and the USA are examined through seven dimensions

Finally, revolutions need leaders, and

of healthcare quality: equity, safety,

healthcare is no exception. To guide

person-centered care, effective-

the reader from learning about the

ness, cost-efficiency, timeliness

inspirational performances of others

and environmental sustainability.

towards creating change in their

Healthcare in China is challenged by

own system of healthcare, three

its extreme urban and rural divide,

change makers tell the story of how

while in the USA, historical social

they saw a need and created a solu-

inequalities continue to have an

tion to meet it.

– 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.

impact on the healthcare systems of today. Europe, meanwhile, is

We learn how Susan Sheridan, after

performing a balancing act between

her family experienced two serious

leaving health issues to the nations

medical system failures, succeed-

and consolidating policymaking at

ed in changing the standards of

an EU level.

care. We meet Jeffrey Lazarus, who co-founded the HIV in Europe

But despite the differences, all three

Initiative as a way of closing the gap

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.

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.

1) Mapping The

State Of Healthcare

The challenges that healthcare systems around the

HEALTH SYSTEMS IN FOCUS

world are facing are known â&#x20AC;&#x201C; they are documented and

Here, we present the reader with an examination of

communicated in various indices, reports and fore-

healthcare systems in China, Europe and the USA

casts. A key element in our work has been to gather

by using 7 quality dimensions of healthcare as an

the newest information on the challenges, select the

analytical framework, outlined on page 15. The health

relevant data and present them in an easy to under-

systems profiled in this section are chosen due to

stand and engaging way that enables comparison

their importance and impact on the global economy,

between regions.

the sheer size of their populations, and their different 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. Weâ&#x20AC;&#x2122;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.

Outlook gives the reader a quick overview of the healthcare system and health in society for each region.

The following data has been used for the global healthcare outlook:

DATA USED FOR THE HEALTHCARE SYSTEM OVERVIEW

Physicians

Hospital beds

Total

General

Out-of-pocket

Per capita total

per 10,000

expenditure

Government

expenditure

people

on health as %

Expenditure

as % of private

on health

of GDP

of total

expenditure on

at average

expenditure on

health

exchange rate

health

DATA USED FOR THE HEALTH IN SOCIETY OVERVIEW

Life expectancy

Under-five

Deaths

HIV

Obesity

Alcohol

mortality rate

caused by

mortality rate

rate

consumption

NCDs

and tobacco use

THE 7 QUALITY DIMENSIONS OF HEALTHCARE

By adding it to the existing quality dimensions, we

We have adapted the six quality dimensions of

provide a framework for identifying priority areas

the Institute of Medicine by adding sustainabili-

that, if improved, would increase healthcareâ&#x20AC;&#x2122;s abili-

ty. The impact of healthcare on the environment

ty to meet the needs of service users and commu-

and the environment on healthcare is increasingly

nities today and tomorrow.

recognized as an important factor in the ability of healthcare to deliver services that meet the needs of individuals and populations.1

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.

as equal partners in co-creating care.

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, climate change) on the healthcare sector2

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

WASHINGTON DC 9TH OF FEBRUARY 2015

BRUSSELS 18TH OF NOVEMBER 2014

SHANGHAI 28TH OF OCTOBER 2014

2) Roundtables With Key Healthcare Stakeholders Although gathering and analyzing existing knowl-

The roundtable participants were selected by com-

edge gives the publication a strong foundation,

bining DNV GL and Monday Morning Sustainiaâ&#x20AC;&#x2122;s

we also wanted to listen to key stakeholders in our

networks, and reaching out to experts in each loca-

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

ties for healthcare in their region. The roundtable

makers and researchers.

locations were chosen to match the policy epicenters of each of our three Health Systems in Focus:

After the roundtables, we conducted interviews

Shanghai, Brussels and Washington DC.

with two participants from each region in order to harvest even more of their knowledge within the

The roundtables were in the format of one-day

field, giving the reader a more in-depth under-

interactive workshops. Each roundtable included

standing of the different healthcare systems.

an inspirational talk from an expert participant, followed by structured group-work and discussions.

3) Highlighting Opportunities, Inspiring Change 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 solutions which demonstrate that opportunities are

The change makers, and the initiatives for which

created all around the world and come in different

they are responsible, correspond to the three loca-

shapes and sizes.

tions of the Health Systems in Focus: China, Europe and the USA. An interview was conducted with

The seven inspirational performances reflect our

each change maker using core questions in order

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

Some are multi-million dollar, large scale initiatives,

the world.

while others are home grown and locally supported campaigns. They also differ in terms of where they are in the implementation process. This breadth of coverage is important in order to stress that solutions to healthcare issues exist at every level of operation.

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 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 Financeâ&#x20AC;&#x2122;s currency exchange system. The figures express the exchange rates from 2 March 2015.

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 healthcare for the better.

SYSTEMS THINKING AND COCREATION 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.

CO-CREATING SAFER, SMARTER 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 Yet, as the regional analyses in the following chapters show, all countries are currently struggling to deliver safe and sustainable healthcare. Ageing populations, the pandemic of non-communicable diseases, rising costs, disparities in access between rich and poor and unacceptably high rates of patient harm are clear and significant threats to sustainable healthcare around the world. The growing complexity of healthcare, with care becoming ever more sub-specialized, poses an additional challenge. Increasing numbers of health and social care professionals are involved in each patientâ&#x20AC;&#x2122;s journey through the system, particularly those with multiple co-morbidities. Within this complexity the patient is in danger of becoming lost as different parts of the health and social care system struggle to coordinate with one another. 2 Too often services are fractured and fragmented: reflecting the evolution of abstract political ambitions rather than a purposeful and coherent system design based on what patients need or want. Attempts to improve healthcare have relied on narrowly defined, technocratic approaches with inadequate attention to context and engagement of local providers, practitioners and patients as co-creators of health systems. 3 There is, therefore, a clear need to look for ways that build on the knowledge of quality improvement and evidence based practice by involving stakeholders in strengthening health systems as a whole. 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.

Co-Creating Healthcare Co-creation means delivering services “… in an equal and reciprocal relationship between professionals, people using services, their families and their [communities … so that both services and communities] become far more effective agents of change”.4 Engaging patients as active partners in the design and delivery of services is a powerful tool for transformational change, resulting in:

1) IMPROVED COSTS Patients who are actively engaged have better health outcomes at lower costs compared with less activated patients. For example, patients with the lowest activation scores (i.e. people with the least skills and confidence to participate in their own healthcare) can cost 8 to 21% more than patients with the highest activation levels, even after adjusting for health status and other factors. 5

2) IMPROVED OUTCOMES Working with patients and their family members to co-create person-centered care is proven to have a positive impact on outcomes in low, middle, and high income countries, including: health status6, knowledge7, adherence 8 , and patient and practitioner satisfaction. 9, 10 But to achieve this requires an understanding of how systems and their different components work together to produce results.

WHO. World Health Statistics. 2014.

Donaldson L in Monday Morning Sustainia & DNV GL. Person-Centred Care. 2014. 2

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

Leyshon S & McAdam S. The importance of taking a systems approach to person-centred care. BMJ Spotlight Supplement on Patient Centred Care. 2015.

Boyle D & Harris M. The challenge of co-production: How equal partnerships between professionals and the public are crucial to improving public services. 2009.

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.

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:

“… 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

Standards for co-creation 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

with pre-established performance standards that

quality components of a healthcare system, offering

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.

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.

SYSTEMS-THINKING IN HEALTHCARE, AS WELL AS OTHER SAFETY CRITICAL AND COMPLEX ADAPTIVE SECTORS, FOCUSES ON:

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)

Identifying and assessing risks to human, technologiContinuously improving

cal and organizational safety

through the analysis of

and performance (including

performance and the

how these are distributed

adoption of necessary

within and across organiza-

process changes to

tions and who owns them)

achieve results Mapping processes and identifying indicators to monitor those processes (including Measuring process performance and

how they connect within and between organizations)

monitoring the efficacy of controls

Leyshon S & McAdam S. The importance of taking a systems approach to person-centred care. BMJ Spotlight Supplement on Patient Centred Care. 2015. 11

World Health Organization. Systems Thinking for Health Systems Strengthening. 2009. 12

Adam T. Advancing the application of systems thinking in health. Health Research Policy and Systems 2014; 12(50): 1-5. 13

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

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.

Global Healthcare Outlook In this chapter, we map out the state of healthcare throughout the world, using the six WHO regions as guides, in order to give a broad, global overview before diving into our three health systems in the next 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 general overview of healthcare in each region, but lack a local context. 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 complexities of healthcare in every region.

Algeria Angola

AFRICA

Benin Botswana Burkina Faso Burundi Cabo Verde Cameroon

Central African Republic Chad Comoros Congo Côte d’Ivoire Democratic Republic of the Congo

EUROPE

EASTERN MEDITERRANEAN

THE AMERICAS

Equatorial

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

Dominican Republic

Haiti

Peru

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

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

Estonia 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

Zambia Zimbabwe

South Africa

Canada

Belize

Tanzania

Sierra Leone

Brazil

Bosnia and Herzegovina

SOUTH EAST ASIA

Lesotho

Antigua and Barbuda

Belgium

WESTERN PACIFIC

Guinea

Trinidad and Tobago United States of America Uruguay Venezuela

United Arab Emirates 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

Vanuatu

Singapore Tonga

AFRICA 10 facts about healthcare in the region

The removal of user fees for children’s healthcare in 12 districts in Burkina Faso led to an average increase of 2,000 visits per year per center – a 110% spike. 3

In Ghana, 92% of caregivers of sick children sought treatment from community-based agents trained to manage pneumonia and malaria and most sought care for their children within 24 hours of the onset of fever. 5

eHealth Africa, WE CARE SOLAR

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

Studies on hospital-wide healthcare associated infections from African countries report high infection rates e.g. Mali 18.9%, the Tanzania 14.8% and Algeria 9.8%. 8

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

The World Bank. Results Based Financing at the World Bank: Burundi’s National Performance Based Financing (PBF) Program. 2011. 11

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

2 1 – 63 Mali – Ethiopia, Gabon

deaths per 1,000 live births in 2000 to 77 in 2011.7

Rwanda has mandatory health insurance (even for visitors staying less than 15 days). Currently 92% of the population is covered. 2

THE HEALTHCARE SYSTEM

under –five mortality from 139 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)

90% of births in the richest quintile in Madagascar were attended by skilled health personnel, while this was only the case in 22% of births in the poorest quintile. 4

OUT-OF-POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH

A study in Zambia found that

$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

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

Only five countries: Botswana, Madagascar, Rwanda, Togo and Zambia, have been able to achieve the target set in the Abuja Declaration – dedicating more than 15% of general government expenditure to healthcare.10

HEALTH IN SOCIETY

LIFE EXPECTANCY AT BIRTH IN YEARS (2012)

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)

13 – 182 Seychelles – Sierra Leone

THE AMERICAS 10 facts about healthcare in the region

By staggering start-times for surgery and standardizing surgical equipment, wait times dropped 75% and the number of surgeries completed increased by 136% in some Canadian hospitals. 9

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% in 2010. 8

While 97% of Colombians are

Ecuador has introduced price

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

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

PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)

2.1 – 67.2 Guyana – Cuba

The economic repercussions of low health literacy are estimated

HOSPITAL BEDS PER 10,000 PEOPLE (2006 – 2013)

to cost the United States economy between $106 billion and $236

pitals in Cuba found the overall prevalence rate of device-associated healthcare-associated infections (DA-HCA) to be 22.4%. 6

Partners in Health’s mobile clinics in Haiti have helped more than

THE HEALTHCARE SYSTEM

billion annually. 4

A 3-year study of two ICU hos-

20.8

33,000 patients since 2013, and

PER CAPITA TOTAL EXPENDITURE ON HEALTH AT AVERAGE EXCHANGE RATE (US$) (2011)

who tested HIV+ to receive further care.7

TOTAL EXPENDITURE ON HEALTH AS % OF GDP (2011)

OUT-OF-POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH

In Brazil, it is estimated that 76% of towns dispose of medical and

6 – 62 Guatemala – Barbados

$3,482

$62 – $8,467 Haiti – USA

GENERAL GOVERNMENT EXPENDITURE OF TOTAL EXPENDITURE ON HEALTH (2011)

have referred over 450 people

municipal wastes together at the

14.1%

4.5% – 17.7% Venezuela – USA

49.5% 21.5% – 94.7% Haiti – Cuba

30.1%

3.5% – 100% Haiti– Barbados, Cuba, Saint Vincent and the Grenadines

municipal landfills.11

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

Center for Health Care Strategies Inc. Health Literacy Implications of the Affordable Care Act. 2010. 4

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

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

HEALTH IN SOCIETY

Pfizer. The Global Burden of Noncommunicable Diseases. 2011. 1

LIFE EXPECTANCY AT BIRTH IN YEARS (2012)

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

EASTERN MEDITERRANEAN 10 facts about healthcare in the region

Palestine generates about 512.6 tons of medical waste every month.10

King Faisal Specialist Hospital & 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

highest in the Region, and 4% in the Saudi Arabia, the Region’s In urban areas of Morocco, 100%

lowest. 9

of the population live less than 5 km from a healthcare facility,

The rate of antiretroviral

whereas in rural areas, this number is only 30%.

treatment (ART) coverage for

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

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

PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)

Due to instability caused by war,

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,

11.4 0.4–77.4 Somalia–Qatar

8 1– 37 Iran – Libya

Jordan, Iran and Turkey to receive

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.

THE HEALTHCARE SYSTEM

healthcare. 6

A study of 4,350 patients at 8 7

OUT OF POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH

For 55% of Qatari women, their husband decides whether contraception is used or not. 2

100% of the population in the

Al-Khatib I. “Medical waste management in healthcare centres in the occupied Palestinian territory.” Eastern Mediterranean Health Journal 2007; 113(3): 694-705.

HEALTH IN SOCIETY

to local health services, while this

$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

LIFE EXPECTANCY AT BIRTH IN YEARS (2012)

United Arab Emirates has access figure is only 57% in Afghanistan. 3

TOTAL EXPENDITURE ON HEALTH AS % OF GDP (2011)

GENERAL GOVERNMENT EXPENDITURE OF TOTAL EXPENDITURE ON HEALTH (2011)

hospitals in Iran determined the HAI prevalence rate to be 9.4%.

PER CAPITA TOTAL EXPENDITURE ON HEALTH AT AVERAGE EXCHANGE RATE (US$) (2011)

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

EUROPE 10 facts about healthcare in the region

In 2011 administrative costs in Scotland accounted for 12% of total hospital expenditures while in the Netherlands this figure was 19.8%.7

Scotland, which has been a test bed for telehealth innovation since 2006, currently has approximately 180,000 people signed up to its telecare services, delivered through 32 local partnerships. 5

100,000 people waited over 12 months for an outpatient appointment at public hospitals in Ireland during April of 2013. 9

In the Netherlands, almost 70% of the population return their unused medicines to the pharmacy or a hazardous waste collection point. 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.

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

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.

Healthcare Information and

The cost of unnecessary Caesarean sections in Italy was $101 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.

WHO Regional Office for Europe. Regional Pharmaceutical Situation Report. 2013.

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.

PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)

33.1

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.

In Georgia, pharmacies and doctors are incentivized to dispense brand name drugs in preference to generics. By contrast, studies in Kyrgyzstan and Tajikistan show a high level of generic prescription, about 70% in both countries. 8

THE HEALTHCARE SYSTEM

25 – 138 Andorra, Turkey – Monaco

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)

Hospital in-patient medicines, all

OUT OF POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH

cancer medicines, and medicines prescribed by family doctors are free of charge to patients in Turkey.

21%. 3

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 Europe, and lowest is Austria at

$48 – $9,908 Tajikistan – Norway

2.1% – 11.9% Turkmenistan – Netherlands

73.9% 18.1% – 88.6% Georgia – Monaco

68.8% 32.1% – 100% France – The former Yugoslav Republic of Macedonia, Turkmenistan

LIFE EXPECTANCY AT BIRTH IN YEARS (2012)

The perceived likelihood of being is 82% in Cyprus – the highest in

$2,370

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

SOUTHEAST ASIA 10 facts about healthcare in the region

A project at the cardiology outpatient department of a large university hospital in India was able to significantly reduce waiting times. In 2011, 64% of patients waited 3 hours or more for their consultation, while after the project’s completion, in 2013, this number had dropped to just 8%. 9

510 tons of medical waste is produced in the Maldives each year.11

67% of pregnant women and 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

WHO Regional Office for SouthEast Asia. Health in South-East Asia. 2013.

OECD. Structural Policy Country Notes: Thailand. 2013.

WHO Regional Office for SouthEast Asia. eHealth in South East Asia Region of WHO. 2013. 4

birth practices. 17% even forewent these payments. 2

funds to cover the cost of safe essential food in order to cover

developing country.7

Pfizer. The Global Burden of Noncommunicable Diseases. 2011.

new mothers in Myanmar had difficulties in raising necessary

Mobile Monday. Mobile Southeast Asia Report 2012: Crossroads of Innovation. 2012.

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

Amnesty International. The Crumbling State of Health Care in North Korea. 2010. 8

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). 9

PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)

5.9

0.7 – 14.2 Timor-Leste – Maldives

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 coun-

29% of Indonesians have mobile internet access, making them prime candidates for mobile health apps. 5

THE HEALTHCARE SYSTEM

try in the world. 8

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)

About 10% of hospitalized patients in Indonesia suffer an adverse event and 5–10% acquire a healthcare associated infection. 6

OUT-OF-POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH

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

84.3% 15.4% – 96.6% Timor-Leste – Bangladesh

While Bangkok has about 1 doctor per 1,000 people, the poorer northeast region of Thailand has only 1 doctor per 8,000 people. 3

Village Health Volunteers in Thailand provide essential basic healthcare services to 65 million Thai villagers, all free of charge.10

WHO Regional Office of South-East Asia. A Decade of Public Health Achievements in WHO’s South-East Asia Region. 2013. 10

The World Bank. Climate Change in the Maldives. 2010. 11

HEALTH IN SOCIETY

LIFE EXPECTANCY AT BIRTH IN YEARS (2012)

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)

10 – 57 Sri-Lanka – Timor-Leste

WESTERN PACIFIC 10 facts about healthcare in the region

40% of the 7 million people killed by air pollution globally in 2012 lived in the Western Pacific Region. It is estimated that air pollution caused 350,000 to 400,000 premature deaths in China alone.11,12,13

Initiatives to address financial barriers to accessing care in Cambodia include Health Equity Funds which now cover 80% of the poorest people in the country. 3

77.2% 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

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

Pfizer. The Global Burden of Noncommunicable Diseases. 2011.

WHO. Health System Financing Country Profile: Philippines. 2012.

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.

Ministry of Health, Singapore. Patient Satisfaction Survey 2013. 2013.

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

PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)

About 65% of Japanese patients with chronic conditions can be expected to secure same-day access

15.3 0.5 – 32.7 Papua New Guinea – Australia

to a healthcare provider.7 HOSPITAL BEDS PER 10,000 PEOPLE (2006 – 2013)

5 – 137 Philippines – Japan

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

Lower rates of hospital-acquired MRSA (methicillin-resistant Staphylococcus aureus )were reported in the Philippines

THE HEALTHCARE SYSTEM

The levels of out-of-pocket

(38.1%) compared to the Republic

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 had very high prevalence rates of 77.6% and 74.1%, respectively. 8

OUT-OF-POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH

6.3% of admissions into Ministry

$679

$35 – $5,991 Lao PDR – Australia

6.6%

2.2% – 17.6% Brunei – Tuvalu Darussalam

65%

22.6% – 99.9% Cambodia – Tuvalu

78.4% 0.5% – 100% Kiribati – Cook Islands, Niue, Tuvalu

of Health non-specialist hospitals in Malaysia had an adverse event (AE) and 78.8% of the AEs were due to errors. 5

A skilled birth attendant was present at only 37% of births in Lao PDR. The number is 100% for Fiji. 4

Chen C & Bennett S. “China Smog at Center of Air Pollution Deaths Cited by WHO.” Bloomberg Business. 2014. 11

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

AFRICA

THE AMERICAS

EASTERN MEDITERRANEAN

EUROPE

SOUTHEAST ASIA

WESTERN PACIFIC

2.6

20.8

11.4

33.1

5.9

15.3

$99

$3,482

$195

$2,370

$69

$679

6.2%

14.1%

4.2%

3.7%

6.6%

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%

PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)

HOSPITAL BEDS PER 10,000 PEOPLE (2006 – 2013)

PER CAPITA TOTAL EXPENDITURE ON HEALTH AT AVERAGE EXCHANGE RATE (US$) (2011)

TOTAL EXPENDITURE ON HEALTH AS % OF GDP (2011)

AFRICA

THE AMERICAS

EASTERN MEDITERRANEAN

EUROPE

SOUTHEAST ASIA

WESTERN PACIFIC

28%

79%

52%

87%

55%

80%

377

5.5

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)

HIV MORTALITY RATE DEATHS PER 100,000 PEOPLE (2012)

OBESITY RATE AMONG ADULTS OVER 20 YEARS OLD (2008)

11.1%

women

ALCOHOL

USE AMONG ADULTS OVER 15 YEARS OLD (2011)

men

women

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

22%

16%

26%

38%

19%

38%

34%

47%

women

men

women

men

women

men

women

men

women

men

women

men

HEALTH SYSTEMS IN FOCUS TAKING THE TEMPERATURE OF HEALTHCARE IN CHINA, EUROPE AND THE USA.

FROM EAST TO WEST From China over Europe to the United States of America, healthcare systems are under pressure to fulfill their task of delivering quality healthcare. This chapter gives three of the largest and most prominent healthcare systems in the world a check-up in order to describe some of the systemic challenges that are holding them back from becoming safer, smarter and more sustainable. By giving an objective diagnosis of the healthcare systems 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 – measure up with the reality on the ground.

THE SEVEN DIMENSIONS OF HEALTHCARE QUALITY ARE: EQUITY

EFFECTIVENESS

SAFETY

TIMELINESS

PERSON-CENTERED CARE

ENVIRONMENTAL SUSTAINABILITY

COST-EFFICIENCY

The analysis is coupled with insights from the three roundtables conducted in the regions, where professionals, patients, policy makers and researchers discussed the future of healthcare and pointed us towards challenges and opportunities.

CHINA 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 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 are significant, certain bright spots, such as hospital coordination improvements and the Essential Drug List, could have the potential to help transform China’s healthcare system into one that is more equitable, person-centered and sustainable.

PAGES 46-65

EUROPE 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 UNITED STATES OF AMERICA The healthcare system of the United States is 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 far outpace any other industrialized nation.

Social factors such as aging populations and the growing burden of NCDs have only exacerbated these challenges. Despite national autonomy, the region’s countries are intertwined and deeply connected. Citizens have an increasing choice in where to live, work and seek healthcare.

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, lowering healthcare spending, and cultivating an all around more sustainable and efficient

PAGES 66-91

healthcare system.

PAGES 92-113

U.S. Department of Health and Human Services. The Affordable Care Act is Working. 2015. 1

Patient Protection and Affordable Care Act, 42 U.S.C. § 18001. 2010. 2

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. The reforms underline the fact that the health-

are more likely to live longer. In 2010, people

care sector has become an economic and

aged 60 and over accounted for 13% of the total

strategic priority for China. Healthcare spending

population and it is expected that this will further

in China is expected to near $890 billion a year

increase to 24% by 2030. 2

by 2017, growing by an average rate of 13.8% annually in local currency terms from 2013-2017.

As the countryâ&#x20AC;&#x2122;s demographics and citizen

Total spending is forecast to reach the equivalent

lifestyles have changed, so have the diseases

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 China, and today more than 85% of the countryâ&#x20AC;&#x2122;s

China has made impressive strides since the mid-

mortality is attributed to NCDs. While NCDs have

20th century in terms of healthcare. Notably, life

become the primary disease burden, communi-

expectancy at birth rose from 35 years before

cable diseases remain a problem in some western

1949 to 75 years in 2010. This increase has also

provinces, illustrating the often extreme divide

resulted in a rapidly aging population, as people

between urban and rural livelihoods in China. 3

While China has made remarkable progress in

There are also some positive developments, as

recent decades, serious challenges remain in

programs are seeking to help balance healthcare

the country’s approach to healthcare delivery.

resources between rural and urban populations6,

As explained in the analysis below, the divide

and new reforms like the redesign of the Essen-

between wealthier urban residents and poor-

tial Drug List have the potential to provide more

er rural citizens is apparent in their respective

equitable and safer access to pharmaceuticals.7

healthcare access. Corruption is a serious issue and person-centered care, while gaining traction,

remains almost entirely absent in some regions.4 Deloitte. Global healthcare outlook: Shared challenges, shared opportunities. 2014. 1

Due to major structural problems, safety for both patients and doctors alike is a concern. 5 The healthcare sector is growing at a rapid pace, consuming more economic resources, but the allocation and use of such funds is, at times, wasteful and inefficient.

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

Hesketh T et al. “Violence against doctors in China.” BMJ 2012; 345. 5

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.

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.

tals that exist in a given region. Chinese hospitals are divided into three classification schemes 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.

Ministry of Health, China. “Counterpart Technical Support between Urban Tertiary Hospitals and Rural Hospitals in China.” WHO – Global Health Workforce Alliance. 2011.

Yip W & Hsiao W. “The Chinese Health System At A Crossroads.” Health Affairs 2008; 460-468.

Lua W. “Universal Rural healthcare in China? Not So Fast.” The Atlantic. 2013. 10

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

HIMA Research. Untitled.2013.

Swedish Agency for Growth Policy and Analysis. China’s Healthcare System – Overview and Quality Improvements. 2013. 16

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 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

The Chinese government’s 2009 reforms 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 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 cor-

Wharton – University of Pennsylvania. Healthcare in China: Is There a Doctor in the House? 2013. 17, 18

WHO. Counterpart Technical Support between

Urban Tertiary Hospitals and Rural Hospitals in China. 2011.

World Bank. Hospital Reforms in Rural China Increased Patient Satisfaction. 2013.

22, 23

Transparency International. Corruption Perceptions Index 2014: Results. 2014. Beech H. “How Corruption Blights China’s Healthcare System.” Time. 2013.

CHINA

/ SAFETY

SAFETY AN ISSUE FOR PATIENTS AND PROFESSIONALS Safety is perhaps the most basic component of any healthcare system, but it is one in which China still struggles.

According to the limited information on the

EDUCATION AND TRAINING LEVEL OF

subject, the rate of hospital-acquired infections

DOCTORS VARIES

appears to be relatively low in China. The educa-

Having adequately educated and skilled care

tion and training of doctors, however, is a public

providers is one of the most vital components of

health concern, particularly for lower-income pa-

ensuring patient safety. China had about 2.3 mil-

tients in rural communities. 24,25 Additionally, a re-

lion doctors in 2010, 90% of whom are trained in

cent phenomenon of patient attacks on doctors

Western medicine. However, the level and quality

illuminates another side of the safety challenge

of training varies a great deal. Many doctors have

in China, as frustrations with poor and danger-

only a 3 year post-secondary certificate and the

ously inefficient treatment has been blamed for a

typical 8 year MD training of Western institutions

drastic increase in the number of incidents where

was, as of 2010, available only at two universi-

patients attack doctors. 26

ties. 27

Qualification of doctors and hospital acquired

Additionally, lacking a history of primary care,

infections are highlighted below as indicators

China has very few GPs. As such, most doctors

of the state of patient safety in Chinese health-

working at Community Health Centers (CHCs)

care. In addition, the aspect of physician safety

are not trained as GPs and are not necessarily

is presented as a unique propensity in Chinese

equipped to diagnose and treat common diseas-

healthcare.

es and chronic ailments experienced by patients at those facilities. 28,29

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

Beam C. “Under the Knife.” The New Yorker. 2013. 26

McKinsey & Company. China’s Healthcare Reforms. 2010. 27

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

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

Burkitt L. “Violence Against Doctors on the Rise in China.” Wall Street Journal. 2013. 34

Hesketh T et al. “Violence against doctors in China.” BMJ 2012; 345. 35, 36

Beam C. “Under the Knife.” The New Yorker. 2013. 37

THE CASE OF LEE MEGNAN 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 frustrations. As the New Yorker reported in 2014, “Li Mengnan wasn’t a lunatic, nor did he have a history of violence. He was a man whom society had failed so completely that he was impelled to lash out.”

MORE DATA NEEDED ON HOSPITAL ACQUIRED

WHEN THE SYSTEM ATTACKS

INFECTIONS

When most of us think of safety in the healthcare

Generally speaking, little data exist on the issue

sector, we think primarily of patient safety. Yet,

of healthcare associated infections in China. 30

in China, safety and treatment of patients has

Therefore, knowledge on this burden comes from

become increasingly tied to the safety of doctors

small scale studies in various regions and cannot

and other healthcare providers. A survey by

be regarded as representative of the country as

the China Hospital Management Association

a whole. Still, the different studies can give the

found that violence against medical personnel

reader an idea of the state of HAI’s in China.

increased an average of 23% each year between 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

from September 2004 to December 2009 and determined that the rate of device-associated

The survey identifies four primary contributing

healthcare-associated infections was 5.3%. 31

factors to this phenomenon in China, name-

Another report from 2014 – a one-day point

ly a deteriorating doctor-patient relationship,

prevalence study of HAIs in the Yijishan Hospital

caused by the shortcomings of the health system;

of Wannan Medical College – found that the

seeking high level specialist care even for minor

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-

in a significant knowledge gap. More extensive

ance coverage and lower out-of-pocket costs, a

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

prevalence and impact can be made.

CHINA

/ PERSON-CENTERED CARE

THE PATIENT IS A RESOURCE 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. Person-centered care has been discussed in

to create patient organizations. According to

China’s healthcare system since at least 1997, and

the Stockholm Network’s report “Patient Power

has, since the 2009 blueprint for future health-

– what it takes for patient associations to help

care, been an official consideration of the govern-

shape public policy,” China is among the nations

ment. 38 The approach to person-centered care

least conducive to the inclusion of the patient

has been top down, with policy makers imposing

voice in health policy, when compared with seven

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

treat patients with dignity, and smile more. 39 Still, these reforms have yet to truly take hold. As

Although China’s constitution officially includes

Jingqing Yang of the Institute for International

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 way to go. 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-

tion exists in the Chinese hospital system. Appointment booking, for example, often includes bureaucratic hurdles, 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, 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

E-HEALTH LANDSCAPE STILL FRAGMENTED eHealth and the use of electronic medical records 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 without interoperability; a lack of legislation and

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 municipal hospitals, to break down barriers between hospital departments so that beds could be utilized in an integrated and coordinated manner, with greater efficiency and exploitation.44 Currently, some hospital departments are at full capacity while others, in the same building, have vacant beds, but due to restrictions they cannot share beds between divisions. This restructuring plan could potentially allow more patients to be admitted.

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.

FIGURE 1.

INTERNET IS SPREADING RAPIDLY

Percentage of internet users in China over time

In the last decade the number of Internet users has exploded – paving the way for a more widespread implementation of eHealth.

10 Source: Internet Live Stats. China Internet Users. 2014.

0 2004

Yang J. The side-effects of China’s patient-centered healthcare reform. 2010.

Sustainia & DNV GL. Guide to Person-Centred Care. 2014.

39, 40

Stockholm Network. Patient Power – What it takes for patient associations to help shape public poilcy. 2013. 41

2006

2008

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.

2010

2012

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

Internet Live Stats. China Internet Users. 2014.

China-Japan Friendship Hospital. Municipal Hospitals to Pilot Internal Beds Coordination. 2013. 44

CHINA

/ COST-EFFICIENCY

THE ECONOMIC BURDEN OF NO GATE KEEPING 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.

Keeping costs low while maintaining a high

A LACK OF GATE KEEPING LEADS TO

quality of treatment is a fundamental challenge

CROWDED CITY HOSPITALS

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 contributes to overcrowded and inefficient care at hospitals in large cities.48 Patients travel long distances to these hospitals, unsatisfied with 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

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.

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,

income patients can gain affordable access

the plan meant for rural residents is operated by

to these basic medicines. 52

the Ministry of Health. Information on insured

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 improve both safety and cost-efficiency, by balancing expanded coverage with restricted supplementations.

The Free Dictionary by Farlex. Medical Dictionary. 2015. 47

WHO. Health insurance systems in China: A briefing note. 2010. 48

Swedish Agency for Growth Policy and Analysis. China’s Healthcare System – Overview and Quality Improvements. 2013. 50

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

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

CHINA

/ EFFECTIVENESS

EFFECTIVENESS IS IMPROVING, BUT IS NOT INCENTIVIZED In many respects, Chinaâ&#x20AC;&#x2122;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.

In 2006, only 45% of the population had health 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 citizens does not necessarily translate into better or less expensive care for patients. 59 Hospital bills are enormously high in China, and insurance rarely covers the full amount, meaning patients must pay a great deal out-of-pocket or forego care. Costs of care also vary a great deal depending on both the type of insurance someone has and where they live. Ultimately, China has one of the highest ratios of out-ofpocket payments to total health expenditure of any Asian country, and in 2012, 78% of all private expenditures on health came in the form of out-of-pocket payments.60 Additionally, over one-third of households have reduced their 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.

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

49%

42%

Government subsidy

Medical treatment income

Other

Source: KPMG. “The changing face of healthcare in China”. 2010. Page 8.

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 liberalization of China’s economy in the 1970s and 80s, the central government has cut vast amounts of public money for hospitals. As such, these facilities have had to fund themselves, ultimately redirecting costs to patients. Another method of obtaining revenue is by increasing the cost of pharmaceuticals, and as such, hospitals can charge a 15% mark-up on the price non-EDL drugs, and sometimes higher, which often encourages physicians to prescribe more expensive medicines and more of them. For example, 75% of patients suffering from a common cold are prescribed antibiotics, as are 79% of hospital patients – over twice the international average of 30%.62 Given the extremely low salaries of Chinese doctors – officially about $7,500 a year – this incentive to over-prescribe is particularly great.63

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

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.

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.

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

Woodhead M. “How much does the average Chinese doctor earn?” Chinese Medical News. 2014. 63

CHINA

/ TIMELINESS

WORTH THE WAIT? 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.

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.

86.7%, respectively. See figure 3.

Huang E. “It Isn’t Getting Any Easier to Get a Doctor’s Appointment in China.” The Atlantic. 2013.

China Smack. “Waiting All Night Outside A Hospital Hoping to See A Doctor.” China Smack. 2009.

China Economic Review. “China’s healthcare reform needs to address hospital waiting times.” China Economic Review. 2009.

Lim L. “China’s Professional Queuers Paid to Stand Around.” NPR. 2011.

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

FIGURE 3.

WAITING TIMES AND PATIENT DISSATISFACTION

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. Source: PricewaterhouseCoopers. Emerging Trends in Chinese Healthcare. 2010.

BEIJING 7.3%

75.6%

SHANGHAI

43.9%

7.3% 32.6%

64%

46.3%

35.5%

9.8%

CHENGDU

54.1%

22.7% 86.7%

40%

11.6%

20%

53.3%

CHINA

/ ENVIRONMENTAL SUSTAINABILITY

IN NEED OF A BREATH OF FRESH AIR 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.

An increasingly important aspect of the health-

without compliance with national or international

care system in China is its environmental impact.

standards of pollution control.72 According to a

Medical waste is a serious concern in China,

recent study in the Shandong Province, a great

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.

healthcare and the environment in China is the

In second- and third-level hospitals, for example,

impact that pollution – of both air and water – has

the average waste generation rate was 0.74kg

on the health of Chinese citizens. This leads to a

and 0.56kg per bed per day, whereas in first-level

less healthy population with greater healthcare

rural community hospitals this rate rose to 1.53 kg

needs and higher healthcare costs.

per bed per day.73

In the following, medical waste, air and water pollution are presented as primary indicators of the

AIR POLLUTION IS OFF THE CHARTS

current status of sustainability and the environ-

Pollution is undoubtedly an enormous concern

mental challenges the Chinese healthcare sector

of China’s, and one that severely impacts both

is faced with today.

its health and environmental sustainability. Air pollution is particularly apparent, with stories of China’s dense, grey air making headlines around

MEDICAL WASTE IS PILING UP

the world. Typically, air pollution is measured by

While most of the discussion around sustainabil-

the concentration of particulates in the atmo-

ity in China’s healthcare sector revolves around

sphere, and WHO guidelines state that anything

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

ADDRESSING THE WASTE CHALLENGE Some regions are attempting to address the

...NOT A DROP TO DRINK 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

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

adapted its own air quality scale, relative to that

cancers and diarrhea associated with water pol-

of Europe and the United States. This reflects

lution reached approximately $8 billion in 2003 in

their inability to reach what is elsewhere consid-

rural areas of China. 82

ered safe and healthy pollution levels. One positive element of these reports is the Pollution has drastic consequences for China’s

source from which they are coming. The fact

healthcare system. The OECD reported that in

that Chinese state media are voluntarily produc-

2010 the health impact of air pollution in China

ing such alarming information about their own

was approximately $1.4 trillion.76 With data from

pollution habits appears to be a sign of increasing

a Global Burden of Disease study, the New York

transparency and accountability. Additionally, in

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

means China lost 25 million healthy years of life

levels. 83 Such transparency and financial invest-

from the population.77 Beijing’s Center for Disease

ment are positive signs that the Chinese govern-

Control and Prevention recently reported that an

ment is serious about addressing its pollution

average 18 year old living in the city can expect

problems.

to spend as much as 40% of their remaining life in less than full health, suffering from cancer, cardiovascular disease, arthritis, and other ailments related to the city’s extremely poor environmental conditions.78

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.

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.

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.

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. To spur discussions, Dr. Duan Tao, President of Shanghai First Maternity & Infant Hospital and Mr. Alex Lam, Vice Chairman of Hong Kong Alliance of Patientsâ&#x20AC;&#x2122; Organizations (profiled in an interview on page 64) gave inspirational presentations and summarized the conclusions of the day.

THREE GLOBAL ROUNDTABLES In late 2014 and early 2015, DNV GL and Monday Morning Sustainia traveled to Shanghai, Brussels, and Washington DC to gain insights for this publication and start a conversation on challenges and opportunities for improving the quality of care in the healthcare systems of China, the EU and the USA. The guiding question for the roundtables was: HOW DO WE IMPROVE THE QUALITY OF CARE?

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 patientâ&#x20AC;&#x2122;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 of care

The roundtables were in the format of one-day interactive workshops that gathered key stakeholders from across the healthcare system, including patients, professionals, providers, policy makers and researchers, with the aim of identifying possible trajectories for change by spurring dialogue and discussions based on the various perspectives from the different stakeholders.

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 anger or dissatisfaction within the

views and have a say in choice of

system as the formal channels for

treatment through dialogue before

complaints are not working.

and after treatment. Currently the approach of the Chinese healthcare

Mr. Alex Lam Vice Chairman of the Hong Kong Alliance of Patients Organizations Participant at the Shanghai roundtable

WHAT IS TO COME IN THE FUTURE FOR PATIENT ORGANIZATIONS IN CHINA?

portunities for patient organziations as they are seen by medical service

HOW DO YOU SEE THE

ROLE OF PATIENT ORGANIZATIONS IN CHINA? Currently patient organizations

with doctors telling patients what treatment they will be given without listening to patients’ needs.

providers like hospitals and doctors as working against the interest of the system. What could change the situation

WHAT ARE SOME TANGIBLE WAYS THAT CHINESE PATIENTS CAN BECOME MORE ACTIVELY INVOLVED IN THEIR HEALTHCARE? In Hong Kong we have a public complaint committee within the

is that Chinese people are becoming

Hospital Authority. The commit-

are small scale and not yet seen as

more aware of their rights. When

tee includes a representative from

important institutions in the Chinese

they pay their taxes, they also want

patient organizations, making the

healthcare system. It is very difficult

to receive high quality services in

committee more representative and

to form patient organizations be-

the healthcare system. This push

impartial in terms of considering

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.

“Without patients, healthcare professionals don’t have a job to do.” that the patient voice is not as respected or recognized as it could be. The lack of focus on their inter-

I hope that more platforms will be

In Hong Kong, for instance, HOW CAN THE MINDSETS OF CHINESE HEALTH PROFESSIONALS BE CHANGED TO FOCUS MORE ON THE PATIENT AS AN ACTIVE PARTICIPANT OF THEIR OWN CARE?

professionals is more paternalistic,

Currently there are limited opto champion the voice of patients

The healthcare system needs to allow for patients to express their

Without patients, healthcare

the number of people expressing gratitude is four times higher than complaints. That is also why it is important to find a balance between the negative and positive feedback. We need to not only focus on complaints but also start to integrate approaches where patient appreciation

professionals don’t have a job to

is used actively to improve quality in

do. A mindset has to be devel-

the Chinese healthcare system.

ests has resulted in a lot of anger

oped where the patient’s interest is

and frustration from patients. Take

seen as pivotal for all professionals

WHAT IS THE BIGGEST

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

tunity, as fixing the problems that

and there is a need for a new mind-

care is provided in other parts of the

afflict the healthcare system has the

set from patients and their families.

world, I believe that we will see the

potential to improve the lives of a lot

In China, it is part of the culture that

needed mindset shift.

of people.

families take care of their elderly

Another challenge we are seeing

members. This is, in many instances,

is that the Chinese population is age-

not a good solution because the care

ing, which will change the healthcare

puts great strains on families and

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.

age, such as Alzheimer’s disease and dementia.

have become aware of how health-

HOW CAN PATIENT ORGANIZATIONS INFLUENCE THE POLITICAL DECISION-MAKING PROCESS IN CHINA? My organization has good access

My organization is working to

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

tions that benefit all parties involved.

center of care. We have suggested

The government will have to show

that the government sets up more

leadership and establish health-

healthcare facilities that can provide

care facilities that can provide care

the care that is needed for the

to elderly patients and treat their

elderly.

diseases.

This could also be done by establishing departments within hospitals

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 patients with Alzheimer’s, which is a risk factor because their treatment and medicine are not managed by health professionals.

“Patients should be willing to receive care outside of their home because it is in their own best interest, both socially and physically.”

Alzheimer’s is on the rise in China. We must think of new ways of treating the disease, but it is very important that the patients and their families are involved in this process and that we respect their culture.

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 â&#x20AC;&#x201C; 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 â&#x20AC;&#x153;Communication on Effective, Accessible and Resilient Health Systems,â&#x20AC;?

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.

EUROPE / EQUITY

PROTECTING UNIVERSAL CARE 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.

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 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?

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 example, more than 10% of the respondents had unmet needs for a medical examination, and this burden fell unevenly on low income groups. 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. The main reason for people in low income groups to report unmet healthcare needs was that care was too expensive. The proportion of people in low income groups reporting unmet needs 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

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.

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.

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 to the World Bank’s report, many low income

HEALTHCARE

individuals with chronic conditions are not aware

Most European countries have universal or near-uni-

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 improving access to, and quality and efficiency of public health services in Romania.10 The reforms include the streamlining of hospital services; enhancing primary care services,

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. These reforms are expected to improve the performance of the health system as a whole and reduce existing inequities in terms of access to quality care amongst the population. The World Bank program will run until 2020.11

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

The World Bank Europe and Central Asia Region. Romania Functional Overview – Health Sector. 2011. Page ix. 9

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.

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. 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

900,000 non-registered residents and introduced copayments for drugs on the grounds of austerity.14 These simultaneous phenomena are placing a double burden on vulnerable Europeans seeking healthcare. Figure 4 shows three examples.

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.

15 OECD & European Commission. Health at a Glance: Europe 2012. 2012.

EUROPE / SAFETY

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.

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 infections (HAIs), but adverse events also include medication-related errors, surgical errors, medical device failures, errors in diagnosis, or

The overall recommendations include: • 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

HAIs, and invited the Commission to report

recommendations, the state of HAIs, and a

on progress and further action.

lack of healthcare professionals are discussed below as indicators of the development of patient safety in the Europe.

16 European Commission. Special Eurobarometer 411: Patient Safety and Quality of Care. 2014.

FIGURE 5.

WHAT IS STANDING IN THE WAY OF PATIENT SAFETY RECOMMENDATIONS? 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.

ECONOMIC CRISIS AND RESULTING CONFLICTING PRIORITIES

FRAGMENTATION OF PROVISIONS AND ORGANIZATION

LACK OF POLITICAL WILL

BARRIERS DOMINATING “BLAME CULTURE”

LACK OF PATIENT SAFETY CULTURE

PUSHING SHARED PATIENT SAFETY GUIDELINES FORWARD The report from the European Commission from

Over the last couple of years, some progress has

2012, which analyzes Member countries’ imple-

been made in regards to the 13 recommenda-

mentation of the 13 recommendations, indicates

tions.

that while some countries focus intently on patient rights, patient safety strategies, and patient

An evaluation from 2014 shows that most

inclusion policies, others take a more passive

countries have implemented at least half of the

stance and place the burden on individual hospi-

Council’s 13 measures. Ireland, with 12 out of 13

tals to introduce patient safety measures.

actions in place, is near completion, followed closely by the UK and Germany, each with 10

Similarly, some EU member states have instituted

actions implemented. On the other end of the

official legislation on these strategies, while oth-

scale, Romania and Slovenia only have 3 out of 13

ers rely on less formal networks and platforms.17

actions implemented.19

From 2013-2014 the European Commission conducted an online survey on patient safety in the EU, particularly in order to highlight the barriers 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.

HARMED BY HEALTHCARE 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

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-

governance arrangements and qualified infection

planation for the error.

control staff; surveillance of targeted HAIs; surveillance of particular events for timely detection of

During the past few years, the EU has funded further

alert microorganisms or HAIs; and high quality mi-

projects aimed at improving the state of HAIs, such

crobiological documentation and patient records.

as the Third Health Programme 2014-20, which aims to improve patient safety and reduce HAIs in Euro-

• 14 out of 17 countries with an action plan at the na-

pean countries.24 This program focuses specifically

tional level had set up mechanisms to encourage

on the control of healthcare-associated infections

its implementation.

through exchanging good practices on quality assurance systems, developing guidelines and tools

• 15 countries had considered nursing homes and

to promote quality and patient safety, increasing

healthcare institutions other than acute care hos-

the availability of information to patients on safety

pitals when designing their action plans.22

and quality, and improving feedback and interaction between health providers and patients.25

Despite this development, the latest evaluation from EU “Patient safety and Health-Associated Infections” from 2014 concludes that HAIs continue to be a problem in Europe.

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.

19 European Commission. Patient Safety and Healthcare-Associated Infections. 2014. 20 Cilag GmbH International. Healthcare Associated Infections – Fact & figures. 2015.

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. 21

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.

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

is the fact that salaries in the healthcare sector are fairly low, the work physically and mentally demanding and the working conditions often

The 2014 European Commission report, “Map-

unfavorable.31 Reconciling this challenge will

ping and Analysing Bottleneck Vacancies in

be critical if Finland is to fulfill its demand for

EU Labour Markets,” examines the occupations

healthcare workers in the coming years.

where there is evidence of recruitment difficulties. In total, 21 of 29 European countries reported vacancies in their healthcare workforce. The findings show different reasons for the shortage of healthcare professionals. For instance, in most EU1528 countries not enough people are

Projects and organizations are being developed

training as health professionals, whereas the

in an effort to alleviate the problems caused by

challenge in newer EU states is that healthcare

cross border migration of professionals. The

professionals seek employment in other coun-

European Joint Action on Health Workforce

tries, where the salary and the working condi-

Planning and Forecasting, for instance, gathers

tions are better.

experiences and best practices in planning and assessing health workforce needs. Their work

Furthermore, mitigation strategies used by

seeks to uncover sustainable solutions to the

some countries to actively fill the gaps in their

challenge of the growing demand for healthcare

recruitment of healthcare professionals can have

workers throughout Europe.30

a detrimental impact on other countries in the region. For example, Norway is attracting labor from neighboring countries, which consequently further depletes the supply of labor in those nations.29 26Joint Action Health Workforce Planning and Forecasting. Leaflet. Undated.

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.

EUROPE / PERSON-CENTERED CARE

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. According to the Euro Health Consumer Index

study also identified different levels of

patient rights legislation and involvement in

person-centered care in what they define as

policy-making became standard in Europe

Eastern and Western Europe.

by 2013, and only 2 countries have not yet introduced healthcare legislation based on

In Russia, patient rights, as outlined in the

patient rights.32

WHO’s “Declaration of Patients’ Rights in Europe,” have not been actively implemented

Despite the positive development, Europe

and patients typically lack the information

still faces challenges in terms of delivering

needed to fully understand their illness or

person-centered care. The “Eurobarometer

potential treatment options. Without such

qualitative study” conducted for the Europe-

information, it is hard for patients to make

an Commission in 2012, which was based on

informed choices about their medical care.

interviews in 15 EU member states33, revealed that the meaning of the term “patient involve-

In the following dimension, we examine the

ment” was not clearly understood by either

state of integrated care, eHealth and health

practitioners or patients.34

literacy as three indicators of person-centered care in Europe, as they help to gauge

In fact, it was often perceived by both groups

how well patients understand their involve-

“as medical compliance and following doc-

ment in their own health and healthcare

tors’ orders,” which is quite the opposite of

system.

the co-creation approach that person-centered care is meant to evoke.35 The same

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.

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

AIM

OUTCOMES

ESTONIA

GERMANY

UKRAINE

To fully integrate communication through National Electronic Health Records, hosting over 3,000 e-services and health insurance systems for claims, reimbursement and prescriptions.

To implement integrated care pathways for selected treatments through an integrated contracting model designed to improve coordination between managers, doctors, psychiatrists and psychotherapists.

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.

Efficiency gains via the direct communication between institutions and providers.

Patients treated through integrated networks able to return to work 72 days earlier than those treated via conventional care pathways.

Improved HIV treatment outcomes, as well as reduced drug use through improved adherence to treatment and retention in care.

More patient empowerment via personal health records, virtual medical centers and mobile patient applications.

Improved user satisfaction.

Source: WHO Regional Office for Europe. Roadmap: Strengthening people-centred health systems in the WHO European Region. 2013.

A EUROPEAN VISION FOR INTEGRATED CARE

To help address some of these barriers, WHO

In the common policy framework – Health 2020 –

launched “Framework for Action towards Coor-

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

systems are defined as a shared goal. Figure 6

and recommendations that target key areas for

shows a selection of different nations’ integration

strengthening the coordination/integration of

initiatives. While they are very different cases, they

health services.

do illustrate that steps towards more integrated health systems are being taken.

The framework focuses on ensuring the participation of partners, including a network of focal points

One of the barriers standing in the way of further

in member states, external experts and leading

expanding people-centered initiatives is that ad-

organizations in the field, such as the International

vocating coordination and integration of services

Foundation for Integrated Care.

takes a backseat to other political priorities in times of economic crisis.36

FIGURE 7.

HEALTH LITERACY IS STILL A GREAT CHALLENGE Percentage distributions of general health literacy for each country and the 7,795 respondents

Inadequate health literacy

Problematic health literacy

Sufficient 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.

90 100

TREMENDOUS POTENTIAL FOR EHEALTH 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

and depends on public policy actions to create

empowerment is mentioned as part of the vision in

favorable framework conditions.

the eHealth Action Plan 2012-2020, put forward by the European Commission.

The European Commission was proven right in their prediction, since the market potential of eHealth has

However, eHealth is still not a common standard

remained strong, despite the economic crisis.

in the region. The study, “Overview of the national laws on electronic health records in the EU member

The global telemedicine market, for example, has

states and their interaction with the provision of

grown from $9.8 billion in 2010 to $11.6 billion in

cross-border eHealth services,” from 2013 concludes

2011, and is expected to continue to expand to $27.3

that, “there are major disparities between countries

billion in 2016.38 This increase indicates a growing

on the deployment of EHRs40 [as] part of an interop-

potential for the use of eHealth measures through-

erable infrastructure that allows different healthcare

out the world, including Europe.

providers to access and update health data in order to ensure the continuity of care of the patient”.41

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 challenge in the region. According to WHO, low health literacy is strongly associated with more hospitalization and less self-management. An individual’s level of literacy directly affects his or her ability to access health information, learn about disease prevention and health promotion, follow healthcare regimens and communicate about health messages with other people.42

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.

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.

43 European Health Literacy Project. Final Report – Executive summary (D17) – The European Health Literacy Project (HLS-EU). 2012.

EUROPE / COST-EFFICIENCY

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.

The healthcare sector accounts for 8% of the total EU workforce and 10% of the GDP. According to the 2013 report, “Investing in Health,” from the European Commission, the high healthcare costs in the EU pose the question of “cost efficiency and the financial sustainability of the region’s healthcare 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,

PRESCRIBING PREVENTION 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 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.

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

Long-term care

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,

49 Deloitte Center for Health Solutions. Impact of austerity on European pharmaceutical policy and pricing: Staying competitive in a challenging environment. 2013. 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

EUROPE / EFFECTIVENESS

EU GUIDES THE WAY TO MORE EFFECTIVE 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

STATE OF AMENABLE MORTALITY 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.

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.

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 Netherlands are at the top, while Latvia and Lithuania are at the bottom. Data for Greece not available.

600

Female

Source: Eurostat (2010)

Males

500 400 300 200 100 0

FR NL

ES LU BE DK SE PT

CY DE MT AT

UK PL CZ HR BG EE SK HU RO LT

CHALLENGE: ENSURING APPROPRIATE CARE 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

Union are hard to come by, and instead breast

at a community level and prevalence of resistant

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 certain treatments and thus not living up to

The volume of antibiotic use varies substantially

EU guidelines.58, 59 The European Commission

across EU member countries with the Nether-

has established the “European guidelines for

lands and Estonia reporting the lowest volumes

quality assurance in breast cancer screening and

and Greece, Cyprus and Belgium reporting

diagnosis”, which promotes a desirable breast

volumes around 1.5 times the European Union

cancer screening target of at least 75% of eligible

average.64 According to “Health at a Glance”,

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

according to the guidelines, only six countries

of this issue should involve multiple coordinated

had reached the target of 75% in 2010.

initiatives that include surveillance, regulation and education of professionals and patients.65

Participation in the programs also varied considerably 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 GUIDELINES FOR THE FUTURE ACTION ON HEALTH SYSTEMS ACCORDING TO MARIA IGLESIA GOMEZ FROM DG SANTE 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. The challenge is to measure improvements in the health status that are due to the health system, and not for instance to better nutritional habits, or safer roads and cars. The Commission is currently supporting member states with using health system performance assessment, through an expert 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 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 and fiscally sustainable. Clearly, innovation in health must be cost-effective; we give a great importance to increasing co-operation on Health Technology Assessment.”

AVOIDING HOSPITALIZATION THROUGH EFFECTIVE PRIMARY CARE Healthcare systems can avoid unnecessary hospitaliza-

However, variations across countries are prevalent.

tion through an effective primary care system. Looking

Asthma-related admissions in the Slovak Republic and

at chronic diseases such as asthma, chronic obstruc-

Latvia were more than double the EU average, where-

tive pulmonary disease (COPD), and diabetes, a high

as Italy, Portugal, Germany, Sweden and Luxembourg

performing primary care system could, to a significant

report rates that were less than half the EU average.

extent, avoid acute deterioration for people living with

Hospital admission rates for uncontrolled diabetes

these diseases and prevent admission to hospital.66

vary 8-fold across the EU member countries with Italy, United Kingdom and Spain showing the lowest rates,

These are all conditions that affect EU healthcare

and Austria and Hungary reporting rates that are near-

systems substantially with e.g. COPD accounting for

ly double the OECD average.69

approximately 3% of total deaths in the European Union and diabetes resulting in an estimated 10% of total adult deaths in Europe.67, 68 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.

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.

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.

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”.

75 The Guardian. Eight more hospitals declare critical incidents as demand surges. 2015. 76 The Independent. NHS in critical condition as A & E waiting times are worst in a decade. 2015. 77 Jayaprakash N, et al. “Crowding and Delivery of Healthcare in Emergency Departments: The

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 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

European Perspective.” Western Journal of Emergency Medicine 2009; 10(4): 233-239.

health care waiting times in EOCD countries.” Health Policy 2014; 118(3): 292-303.

78 OECD & European Commission. Health at a Glance: Europe 2014. 2014. 79 Siciliani L, Moran V & Borowitz M. “Measuring and comparing

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.

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 18 million tons of CO2 each year — 25% of total public spending.82

Despite initiatives like this, there is still a long way for a common green goal within healthcare 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

83 European Commission. Commission Staff Working Document – Accompanying document to the White Paper: “Adapting to climate change: Towards a European framework for action.” 2009.

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

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 increases by 1–4% for each one-degree rise in temperature, meaning that heat related mortality could rise by 30,000 deaths per year by the 2030s and by 50,000 to 110,000 deaths per year by the 2080s.85

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.

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, 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 Commissionâ&#x20AC;&#x2122;s priorities and policy initiatives for healthcare.

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

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 communities can play a crucial part in keeping

edge sharing within the EU holds

citizens healthy and these kinds of

great promise in terms of addressing

efforts need to be scaled up. But

some of the similar challenges we

just as with patient engagement,

are all facing.

it is essential that we don’t frame community involvement as a way to

HOW CAN PATIENTS TAKE PART IN ENHANCING THE QUALITY OF CARE IN THE EU?

simply cut budgets or as a last resort to save ailing healthcare systems. Companies also have an important role to play. By encouraging and fa-

of GDP in healthcare. This is certain-

I think patients are going to have

ly a challenge but it could also be an

to contribute more and be more ac-

lives, companies can also benefit

opportunity.

tive in the healthcare system of the

financially with greater employee

future. This could include measuring

satisfaction and fewer sick days.

HOW IS THE ECONOMIC CRISIS AN OPPORTUNITY FOR HEALTHCARE IN THE EU? The efforts to lower healthcare

greater personal responsibility by living healthier lifestyles with better 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.

on how to enhance the quality of life

cilitating employees to live healthier

their own blood pressure or taking

because the result is a clear focus

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

EU healthcare systems will have

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

The economic crisis could therefore

national budgets. Unfortunately, the

be seen as an advantage for patients

fact that these changes are framed

and healthcare systems alike, even

as service cuts rather than oppor-

“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”

“it is unacceptable not to grant access to the best care available to all European citizens”

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

reduce the incidence of cancer and therefore help our health systems saving billions of euros.

WHAT IS THE GREATEST OPPORTUNITY FOR IMPROVING HEALTH-

partners not only in the implemen-

of patient’s advocacy. ECPC’s

tation and evaluation of healthcare

advocacy efforts are based on real

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

specialised and professional advo-

Parliament demonstrated to be a

that a sustainable solution would be

cates to push on the crucial common

formidable partner in advocating pa-

to better integrate the promising

problems faced by all patients and

tients’ rights. The European Cancer

eHealth and mHealth technologies

raise awareness on the unbearable

Patient’s Bill of Rights, ECPC Call to

into European citizens’ lives, hence

national and local situations existing.

Action and several other advocacy

lowering the costs of several tradi-

efforts are finally bearing practical

tional care services. We are actively

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.

WHAT IS THE BIGGEST CHALLENGE FACING PATIENTS IN THE EU TODAY? There are still unbearable inequal-

CARE IN THE EU? Many of the problems European

Cancer Control and including pa-

ities in the way EU’s 500 million

tients’ representatives in the CanCon

citizens access healthcare. Inequal-

Joint Action.

ities in access to healthcare have different and varied faces: drugs are not evenly priced in all member states, and in several countries essential drugs are not available at all.

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

able to all European citizens. The

has to successfully beat his/her

Cross Border Healthcare Directive

disease. For a cancer patient, either

can provide a partial solution to the

in remission or facing the treatment,

Dr. Francesco De Lorenzo President of The Italian Federation of Cancer Patients Organizations (FAVO) Participant at the Brussels roundtable

THE UNITED STATES OF AMERICA BALANCING THE SCALES The United Statesâ&#x20AC;&#x2122; 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. In 2013, the USA spent $2.9 trillion on healthcare,

capita spent on healthcare.2 The costs are caused

amounting to $9,255 per person and 17.4% of the

by multiple factors: insurance, specialist visits,

GDP.1 The country outspends all others when

numerous expensive treatments, and overpriced

it comes to healthcare and by a considerable

pharmaceutical drugs.

margin â&#x20AC;&#x201C; the second highest-spending country is the Netherlands with 12% of GDP and $4,710 per

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

healthcare delivery in the country can improve.

and create a more sustainable, person-centered

As it stands now, the country is unable to provide

system for the entire country.

low cost, high quality care for all its citizens, even those unable or unwilling to purchase private 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.

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.

USA

EQUITY

WATCH THE ACCESS GAP 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 of care they receive, as state by state disparities are quite large. In fact, low income populations 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 narrowly on how entrenched inequality manifests

…AND BY PAYCHECK

in the healthcare system, particularly in terms of

37% of Americans went without care in 2013

location, income, and insurance coverage.

because of cost, meaning that they did not visit a physician when sick, did not get a prescription filled, or did not get a recommended test or treatment. See figure 10. Adults with lower socioeconomic status are more likely to experience high blood pressure, obesity, heart disease,

5 Commonwealth Fund. Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally. 2014.

9 Kaiser Family Foundation. Medicaid and the Uninsured. 2009.

infectious diseases and mental illness.8 Due to the incredibly high cost of care, access is often determined by whether or not someone is insured,

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.

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.

and it has been well-established that low income adults are more likely to be uninsured than highinequalities.9 In addition, when low-income people do have insurance, they are more likely to be “underinsured” with coverage that fails to provide

FIGURE 10.

RANKING SCORES (FROM 1-11 )

COSTS ARE KEEPING PEOPLE AWAY FROM HEALTHCARE

AUS

CAN

FRA

GER

NETH

NOR

SWE

SWIZ

COST-RELATED ACCESS PROBLEMS

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

cost-related access problems. 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

financial protection from out-of-pocket healthcare

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 changes to Medicaid coverage, in particular, have an enormous impact on equitable care distribution in the United States.

LEARNING FROM THE BEST While the American healthcare system’s inequitable access is truly astounding on an international

On June 28, 2012, the USA Supreme Court issued a ruling that states can decide whether or not to expand Medicaid to cover individuals with incomes

scale a great deal can be done to alleviate some of these disparities, and many solutions can be found without leaving the country. As the Commonwealth Fund reports, if all states could

up to 138% of the poverty line.11 This ruling has had

meet the benchmarks of the highest performing

a mixed effect on the alleviation of inequality of

American states, massive strides could be made

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 coverage, an average of 77% of uninsured adults are now eligible for Medicaid insurance. In states that did

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

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.

USA

â&#x20AC;&#x2030;â&#x20AC;&#x2030;SAFETY

THE FIGHT TO IMPROVE PATIENT SAFETY 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. A study released in 2013 by the Journal of Patient

the American healthcare system: diagnostic er-

Safety estimates that up to 400,000 people die

rors, healthcare acquired infections, and prevent-

each year due to preventable medical errors.16

able drug events.

The study places preventable medical errors as 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

died in the hospital and approximately $12 billion in healthcare costs were saved.18 See figure 11.

Misdiagnosis also strains budgets with diagnostic errors accounting for the largest fraction of

In the following section, we will look at some of

malpractice claim payouts, totaling $38.8 billion

the challenges that compromise patient safety in

between 1986 and 2010.20

FIGURE 11.

HACS ARE DECREASING SIGNIFICANTLY

Annual and cumulative decrease in HACs, 2010-2013

16 17%

The national HAC rate declined by 9% from 2012 to 2013 and was 17% lower in 2013 than in 2010 Source: AHRQ. Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted from 2010 to 2013.

9% 7%

4 0

2% Change in HACs, 2010 to 2011

Change in HACs, 2011 to 2012

Change in HACs, 2012 to 2013

Change in HACs, 2010 to 2013

HOSPITAL ACQUIRED INFECTIONS ARE DECREASING There is currently no system in place that can estimate 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

In August 2014, the first national action plan for ADE prevention – “The ADE Action Plan“ – was released by the Department of Health and Human Services Office of Disease Prevention and Health Promotion. The four pillars in the ADE Action Plan are surveillance, prevention, incentives and oversight, and research: 1) Surveillance—Coordinate existing Federal surveillance resources and data to assess the health burden

and approximately 75,000 hospital patients with HAIs

and rates of ADEs.

died during their hospitalizations.22, 23 In addition to costing human lives, HAIs also put a strain on healthcare budgets. HAIs alone are responsible for $28 billion to

2) Prevention—Share existing evidence-based prevention tools across Federal Agencies and with

$33 billion in potentially preventable healthcare expen-

non-Federal healthcare providers and patients.

ditures annually.24 In 2009 the USA Department of Health and Human

3) I ncentives and Oversight—Explore opportunities, including financial incentives and oversight authori-

Services set out the “National Action Plan to Prevent

ties, 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

significant reductions were reported in 2012 for nearly

prevention.

all infections. A main driver in this progress is, in part, 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

The ambition for the ADE Action Plan is that it will 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.

more than 80% of the respondents believe the Centers for Medicare and Medicaid Services policy has led to greater focus on the healthcare-associated infections targeted under the Medicare rule.27

PREVENTABLE MEDICATION ERRORS COST LIVES 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 billion annually.28 Medication errors typically occur because of prescription error, fragmentation of care, and lack of information technology infrastructure, such as Electronic Medical Records and electronic prescribing. Studies show that improved communication among physicians, pharmacists and nurses prevented 85% of serious medication errors and that including a pharmacist 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.

USA

PERSON-CENTERED CARE

TOWARDS HEALTHCARE OF, BY AND FOR THE PEOPLE 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.

In its Declaration on Patient-Centred Healthcare

these issues are the Accountable Care Organi-

from 2006, The International Alliance of Patients'

zations (ACO) for Medicare recipients, health

Organizations states that the essence of per-

homes for Medicaid recipients and a reward sys-

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 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

son-centered healthcare: respect; choice and em-

the challenges standing in the way of the scaling

powerment; patient involvement in health policy;

of person-centered care in the USA. These ele-

access and support; and information.31

ments are continuity of care, health information technology, and health literacy,

American frontrunners such as Planetree, The Institute of Medicine and Kaiser Permanente have focused on promoting and implementing person-centered care, but still there is a long way to 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

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.

IMPROVING PERSONCENTERED CARE THROUGH POLITICAL INITIATIVES •A n Accountable Care Organization is an entity

CONTINUITY OF CARE IS A PROBLEM 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 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

than one million Medicaid beneficiaries have

Health information technology has become a key

been enrolled. Nearly a dozen other states are

element of person-centered care as it encom-

planning health home models.35

passes a wide range of products and services

•T he 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, patients are surveyed randomly and asked

records. The USA federal government has put

about various aspects of their experience. In

forth legislation to make electronic health records

October 2012, Medicare began rewarding the

a national goal.40 This could explain why the

best performing hospitals with bonuses based

proportion of hospitals having electronic records

on the evaluations.

has tripled since 2010 and why 38% of physicians report having adopted basic digitization in 2012. Although the numbers point towards an increase in the adoption of electronic records overall, there is still room for improvement. A study from

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

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-

• GOAL 5: Build partnerships, develop guidance, and change policies

sponsiveness to public health emergencies. • GOAL 6: Increase basic research and the deThe economic repercussions of low health liter-

velopment, implementation, and evaluation of

acy have been estimated to cost the American

practices and interventions to improve health

economy between $106 billion and $236 billion

literacy

annually.43 • GOAL 7: Increase the dissemination and use of Several provisions in the Affordable Care Act

evidence-based health literacy practices and

directly acknowledge the need for greater atten-

interventions

tion to health literacy, and many others imply it. Moreover, the Plain Writing Act of 2010, requires Furthermore, the Department of Health and Hu-

all new publications, forms, and publicly distrib-

man Services developed the National Action Plan

uted documents from the federal government

to Improve Health Literacy in 2010. The National

to be written in a “clear, concise, well-organized”

Action Plan provides a framework for consistent

manner.44

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

cation and education.

Writing Act all point towards a positive focus on empowering the patients to become a more ac-

The seven goals in the plan are listed below:

tive part of their care. Whether they have helped produce positive results is too soon to tell.

• GOAL 1: Develop and disseminate health and safety information that is accurate, accessible, and actionable

43 Center for Health Care Strategies. Health Literacy Implications of the Affordable Care Act. 2010. 44 Plain Writing Act. 5 U.S.C. 301. 2010.

100

USA

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.

Since 1980, the USA has increased its healthcare spending from around 9% of its GDP to 17.7% in 2012.45 From 2007-2012, a period that encompassed the Great Recession, healthcare spending rose $491 billion, reaching $2.8 trillion nationally according to government estimates.46 Spending increased in all states on both a per capita basis and as a share of total state income. And still, the Commonwealth Fund’s 2014 “Scorecard on State Health Performance” points to deteriorating access to care for adults, stagnant or worsening performance on other key measures such as preventive care for adults, and widespread disparities in peoples’ healthcare experience across and within states.47, 48, 49

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

The American healthcare system therefore provides the lowest quality of care at the highest price tag – the definition of cost-inefficiency. Hence, gearing the system towards providing better quality care for less money is one of the great challenges that this region is up against. While the others sectors explored the quality of the American healthcare system, this section will look at some of the features that makes this system so expensive.

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.

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

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

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

accountable care organizations. See text box. DOCTORS ON THE DEFENSIVE SKY HIGH ADMINISTRATIVE COSTS

In a 2009 national survey of physicians, 75% of

The money spent on healthcare administration

doctors said that they order more tests, proce-

is more than twice the total spending on heart

dures and medicines than are medically nec-

disease and three times the spending on cancer.56

essary in an attempt to avoid lawsuits.59 About $650 billion are spent annually on defensive medicine, which, aside from the high cost also results in other consequences:

NEW PAYMENT MODELS TO PROMOTE QUALITY CARE

1) Limiting access to care for high-risk patients 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

3) F ostering distrust among patients and their physicians, which has resulted in lowered

•P atient-centered medical homes, which are redesigned primary care practices that focus 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

physician morale and manpower 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

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.

USA

EFFECTIVENESS

TOO MUCH AND NOT ENOUGH 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.

Applying the appropriate measures based

This section will provide a status on the devel-

on science, and thus ensuring the effective-

opment of underuse and overuse of treat-

ness of the healthcare system, has proven a

ment in the American healthcare system and

difficult task.60 Appropriate measures refer

highlight key developments within promoting

to the avoidance of both underuse – like not

the use of evidence based medicine.

receiving a vaccine despite its proven effectiveness – and overuse, e.g. treating a child’s simple ear infection with antibiotics.61 Overuse and underuse of treatment are both far too common in the USA. Overuse has been named one of the main contributors to the skyrocketing healthcare expenses, and underuse remains a challenge feeding into the ‘healthcare for all’ discussion. A trend away from employing evidence based medicine also contributes to improper and ineffective treatment.

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

is perhaps the most well-known issue, and it is

right evidence-based care for chronic conditions

particularly apparent in the USA. For instance,

like high blood pressure, diabetes and heart

60-90% of patients with acute bronchitis who

disease.69

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

positive news on this front has emerged recently,

of underuse is the degree to which a healthcare

though; the NCQA's 2014 “State of Healthcare

system manages the care of patients with chronic

Quality Report” found that avoidance of antibi-

illnesses and prevents future illnesses through

otic treatment in adults with acute bronchitis had

targeted interventions.70 The 2014 “Mirror Mirror

its first gain in the measure's seven-year history.

on the Wall” report from the Commonwealth Fund

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

health, antibiotic-resistant bacteria costs ap-

but average in comparison to other Western coun-

proximately $55 billion in health services and lost

tries on quality of chronic care management.71

productivity.66 Underuse in the American healthcare system The overuse of tests and procedures is also a

has traditionally been linked to equity with many

problem. The NCQA's 2014 State of Healthcare

patients not getting the care they need due to

Quality Report concludes that the USA is either

lack of insurance or ability to pay out of pocket.

stagnant in or overusing a range of medical

By expanding access to insurance, the Affordable

procedures. More than a quarter of all wasteful

Care Act has the potential to address underuse

spending in healthcare— $210 billion out of the

due to lack of insurance and ensure that more

estimated $765 billion in wasteful spending in

Americans get the appropriate treatment.72

2009—is attributed to overuse of services.67 This is due, in large part, to the fact healthcare providers are paid in a way that rewards doing more, rather than being efficient. Alternative payment models exist, such as prior authorization 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

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.

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.

EVIDENCE VS. EXPERIENCE In the USA, the lack of integration of evidence

This is in part due to evidence-based med-

based medicine (EMB) into the healthcare

icine being derived from averaged global

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

care not being based on the best available

circumstances. As Trish Greenhalgh explains,

evidence.73 Thus the USA will, in the coming

there are some additional crises in the EMB

years, be forced to reflect on how to better

movement, namely:

integrate EBM as a way to develop more scientifically valid and smart ways to care for patients.

• The evidence based “quality mark” has been misappropriated by vested interests

Not surprisingly, a lack of EBM – and health-

• The volume of evidence, especially clinical

care professionals’ reliance on tradition and

guidelines, has become unmanageable

anecdotal personal experience when making decisions – contributes to the aforementioned problems of inappropriately- and over-used

• Statistically significant benefits may be marginal in clinical practice

medical services.74 It has been estimated that about half of all physicians rely on clinical ex-

• Inflexible rules and technology driv-

perience rather than evidence to make deci-

en prompts may produce care that is

sions. This happens despite physicians rarely

management driven rather than patient

seeing enough cases of the same conditions

centered

to draw scientifically valid conclusions about treatment.75

• Evidence based guidelines often map poorly to complex multimobidity77

On the flip side, though, the evidence based medicine movement is struggling to narrow the gap between EBM and physician clinical

Greenhalgh continues that these problems

practice.76

don’t signify the end of EBM, but rather point toward a need to return to “real” evidence based medicine, that values individual patient care and sound, supported judgment rather than strict rules.78

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.

It has been shown that a lack of timely

GREAT VARIATION IN TIMELINESS

treatment may result in emotional dis-

FOR PRIMARY CARE AND SPECIALISTS

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 country ranks 3rd and 6th, respectively, on questions regarding waiting. The results correspond with the fact that the healthcare system in the USA puts less

In the following, waiting times for primary care, specialists and emergency wards are discussed as primary indicators for the state

emphasis than most countries on primary care and has a greater proportion of specialists than general physicians.85

of timeliness in the American healthcare sector.

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.

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,

utilization. For instance, the WHO’s European Ob-

where the open access strategy originated,

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

19% of ED visits, had one been available.88

than a year. Other examples of successful 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.

FIGURE 12.

IS THIS AN EMERGENCY?

27%

Urgency of emergency room visits Recent ED users’ responses to whether their problem could have been handled by a primary care physician Yes

N/A (Visit Was Prearranged)

Not Sure

46% 25%

Source: California Health Care Foundation. Overuse of Emergency Departments Among Insured Californians. 2006.

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 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.

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 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 implemented 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

...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 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,

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

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

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. 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.

110

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 â&#x20AC;&#x153;10 minute ruleâ&#x20AC;? to give physicians time for more meaningful conversations with patients

Include patient centeredness in the training of healthcare professionals

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 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? In short: teaching health profes-

Doctors need to realize that treatments are not prescribed, they

sionals a generic, patient-centered

are negotiated. When faced with the

approach that includes a greater fo-

difficult decisions regarding their

cus on mental healthcare. Students

healthcare, patients need assistance

and residents need to be trained

in understanding what is happening

intensively in the psychological and

to them. This is a negotiated process

social dimensions of medicine as

that is, in essence, bilateral between

well as basic principles of doctor-pa-

the healthcare professional and the

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

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

only 15% of the mentally ill, which

in mental healthcare will cost some-

they went in to their consultation.

means that the remaining 85% are

thing in the range of $300 million

This was a randomized, controlled

seen entirely by medical doctors.

over 10 years. That sounds like a lot

trial and it was quite effective in

Care is very poor because medical

of money but we are losing more

improving the dialogue between

doctors are not sufficiently trained in

than that every year due to poor

patients and doctors.

mental health. It is such an obvious

mental healthcare.

problem but nothing is being done about it.

The impact of teaching with a greater focus on patient-centeredness would be dramatic. It would

WHY DO YOU THINK THAT IS?

take twenty years to train everyone but the impact would be comparable

Medical education focuses almost 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.

112

“Doctors need to realize that treatments are not prescribed, they are negotiated.”

“We really have the opportunity to change the way the US healthcare system is run.”

WHAT MAIN CHALLENG-

ES DO YOU SEE FOR HEALTHCARE SYSTEM IN THE USA? As a whole for the US healthcare

by the year 2025 – due to graduate medical education funding. The US 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

instead of preventing people from

to provide training for the students

getting sick. We do not focus on

graduating from medical schools as

primary care, but on the myriad of

early as 2016.

Britani Kessler National President of the American Medical Student Association Participant at Washington DC roundtable

sub-specialties. We usually try to shuffle patients off to those instead of allowing ourselves to really focus on the patient and their needs.

HOW IS THE MINDSET OF THE FUTURE GENERATION OF DOCTORS DIFFERENT FROM THE CURRENT GENERATION?

WHAT’S THE BIGGEST OPPORTUNITY FOR IMPROVING THE QUALITY OF CARE IN THE USA? We are currently in a tremendous

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 physicians that really want to be active and to make things better in the healthcare system. They won’t settle

WHAT ARE SOME OF THE OBSTACLES PREVENTING CARE FROM BEING MORE PATIENT CENTERED?

time of change in the US healthcare

for the status quo, but want to be a

system. Politically the healthcare

strong voice in improving the state

We are fighting the status quo

system is up for debate and political

of the healthcare system. They are

at the moment. We have a history

initiatives such as the Affordable

focused on patients, patient safety

where care has been very paternal-

Care Act are changing the health-

and on improving the quality of the

istic. A majority of the older gen-

care system. For the new generation

healthcare system – both at hospitals

eration are used to a culture where

of professionals, but also for the

but also at a political level.

the doctor has the final say. This

patients, there is currently a realization that this time of change gives them the opportunity to make things better. We really have the opportunity to change the way the US healthcare system is run.

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

WHAT IS THE BIGGEST CONCERN FOR MEDICAL STUDENTS AND RESIDENTS IN THE USA? We are facing a physician shortage of more than 130,000 physicians

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

114

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.

115

A JOURNEY TOWARDS OPPORTUNITIES

LEARN ABOUT... ...PATIENT ENGAGEMENT PROGRAMS IN THE USA 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.

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.

Page 122

Seven opportunities – each paired with a case that highlights how to move from idea to action – serve as examples of how to improve the quality of healthcare in practice. They are framed around each of the 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

opportunities – with the right mind-set. They are leading the way and can inspire us to see that changing and improving the healthcare

model clusters and specific guides on how to achieve change can spearhead new agendas and promote behavioral shifts throughout the healthcare sector.

116

Page 137

QU AN

IT Y

...MEASURING HEALTHCARE’S TRUE VALUE IN GERMANY

...KNOWLEDGE SHARING IN THE UK

Knowing what we do, why we do it, at what price and with

Measuring the impact of healthcare and learning

TIT

AL QU

what specific outcome is vital Page 131

from the best are vital in

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.

...DIGITAL APPOINTMENT SCHEDULING IN CHINA 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.

Page 134

Page 125

...MOBIL HEALTH APP IN KENYA

...HEALTHCARE ALLIANCES IN NEW ZEELAND

Convenient, accessible and 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.

117

FROM OPPORTUNITY...

Mobile health apps open the door to universal healthcare Healthcare is online and provided increasingly

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 experience.

This changing tide is not a small wave, but a tsunami of new communication platforms transforming healthcare systems today and in the coming years. In terms of revenue, the mobile health market is expected to grow to $21.5 billion by 2018 with a compound annual growth rate of 54.9%, according to a report from the market research company, BCC Research.1 The growth and innovation of new mobile healthcare technologies is a positive addition to the world of healthcare – as these innovations 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 thus helping to break down barriers of income, race, ethnicity, geographic location and education.

BCC Research. Wireless Electronic Health Records: Technologies and Global Markets. 2014. 1

118

A doctor to the masses ... TO ACTION IN KENYA

The challenge: 40 million people, but only 7,000 doctors. The solution: 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 mobile phone subscriptions and makes it possible for all Kenyans with a mobile phone get access to healthcare and health information. 3 This allows for a whole new type of healthcare â&#x20AC;&#x201C; one that is much more accessible for everyone. It helps dissolve the barriers between the rich and poor, well educated and uneducated, and rural and urban â&#x20AC;&#x201C; and thus helps achieve a more equitable Kenya. The Kenyan healthcare system consists of a large number of fragmented and also fraudulent healthcare services, making it very difficult for consumers to access and identify quality care.

EQUITY

MEDAFRICA MHEALTH APP IN KENYA INITIATOR

PRIMARY DRIVER

Private company with support from leading

Mobile technology

healthcare institutions SCALE INVOLVED ACTORS

Kenya

Primarily potential and current healthcare users,

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

healthcare professionals, but also with providing safe and quality-

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 involving the individual patient as an active consumer of healthcare. Besides allowing the user to locate qualified healthcare providers, MedAfrica also provides a diagnostic tool to identify the potential cause of illness and then link patients to specialists who can treat them.4 Furthermore, it offers information on recommended drugs and diets for specific medical conditions. By providing this kind of information, the app is taking a great step towards closing the gap between the supply of professionals and demand of the Kenyan people. It helps 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 guide healthcare consumers in the right direction. The app was developed in partnership between Samsung, Nokia, the Kenya Open Data Initiative, and others. The app is not publicly funded, but is rather a product based on a clear underlying business model. Thus, Shimba Technologies receive revenues for the free app through targeted ads and extended subscription services. 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. These numbers clearly indicate that the app is an accessible and necessary tool for the average Kenyan; it’s a spot-on solution for meeting the country’s healthcare demands. 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

120

FROM OPPORTUNITY...

The patient as the expert Since the 2000 Institute of Medicine report, “To

The patient role in improving patient safety is

err is human – building a safer health system,” pa-

widely recognized by the WHO.

tient safety has gained an increasingly prominent place on the international health policy agenda.7

A main part of their “Patient Safety Program” and

Fifteen years on, the quest continues to find new

work for promoting patient safety throughout the

models and new systems that can help improve

world is initiatives that include and incorporate

patient safety in healthcare. 8

patients as active players in this process. 9 One example from the WHO is the “Patients for Safety” initiative that was launched in 2004. The initiative aims to build a global network that champions patients as key change makers when it comes to improving safety in the healthcare sector. Through the initiative, the WHO works actively for “a world in which patients are treated as partners in efforts to prevent all avoidable harm in healthcare.” 10 Looking to the future, patient involvement and engagement as a means of improving the culture of safety are recognized as key components of creating much safer healthcare systems. 11,12

WHO. Exploring patient participation in reducing health-care-related safety risks. 2013. 7, 8, 9

WHO. Patients for Patient Safety. 2015. 10

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 Patient safety improvements do not happen to patients – but with them. Partnerships with patients and families are thus an essential

SAFTEY

... TO ACTION IN THE USA

aspect of improving patient safety and healthcare quality. But patients and their families are not always engaged, and they do not automatically take on an active role in ensuring their own safety. They need to learn and become equipped to take on this role. At the Dana-Farber Cancer Institute in Boston, USA, this is a primary 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 institute has incorporated patient-centered care as a key element of

INITIATOR

their healthcare services – and has used this approach to create a

Healthcare provider

stronger culture of patient safety. They focus on collaboration, comINVOLVED ACTORS

munication, and engagement with the patients and their families in

Management, patients,

a range of aspects in order to improve the quality and safety of their

professionals

care.13

PRIMARY DRIVER

Patient Involvement

Their work began in 1994 due to a heartbreaking incident. Betsy Lehman, a 39 year-old Boston Globe health reporter suffering from

SCALE

breast cancer died at the Dana-Farber Cancer Institute because of

Dana-Farber Cancer Institute

four overdoses of chemotherapy. Doctors apparently refused to hear her warnings that something was drastically wrong and ignored the

TYPE OF CHANGE

results of tests indicating heart damage.14,15 This incident prompted the

Improving patient safety by

hospital to engage in self-examination of the state of patient safety at

involving patients

the Institute. Setting out on this journey, the patients were given a pivotal role. In the Institute’s mission statement they state that patients and their families have “experience; expertise; insights; and perspectives that can 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.

122

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

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 board level committees to committees on quality improvement and risk management. One example is the Patient and Family Advisory Council that serves as an important part of the organizational structure for quality improvement. Another is the Adult Oncology Clinical Services Quality Improvement Committee, where patients review patient falls and accidents, medication errors, and patient survey results. Another initiative aimed at involving the patients at the Dana-Farber Cancer Institute is Patient Safety Rounds, which was implemented in 2004. Patient Safety Rounds help the institute identify and eliminate patient safety risks through two methods: internal staff communication about actual and potential safety problems,17 and interviews between former and current patients and families about their perception of safe care, with the ultimate goal of improving patient safety at the institute.18,19 Now, more than 20 years after the death of Betsy Lehman, the Dana-Farber Cancer Institute offers a free toolkit for other healthcare providers to become inspired and learn how to implement Patient Safety Rounds. The Institute has received a line of recognitions for its work of improving patient safety through patient involvement. The Leapfrog Group, for instance, recently named Dana-Farber Cancer Institute to its annual list of Top Hospitals. The Leapfrog Top Hospital Award is given to less than seven percent of all eligible hospitals nationwide – based on their demonstration of excellence in hospital safety and quality. Additional recognition comes from News & World Report’s Best Hospitals 2010 Guide, which ranked Dana-Farber Cancer Institute the top Cancer Center in New England and 5th overall in the USA. 20

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

123

FROM OPPORTUNITY...

Healthcare: more than the sum of its parts Integrated care, patient involvement, and shared

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

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 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.

DNV GL and Monday Morning Sustainia. Person-Centred Care. 2014. 21

The bmj Spotlight. Patient Centred Care. 2014. 22

124

Strong alliances create integrated healthcare What can the healthcare sector learn from the world of construction?

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

PERSONCENTERED CARE

... TO ACTION IN NEW ZEALAND

Looking at healthcare systems that are defined by fragmentation and 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

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

125

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 20 healthcare districts to work collaboratively within a whole system approach to ensure that services are designed with what is best for patients and the public in mind. Each alliance is a way to bring together a range of providers from across a healthcare district and encourage them to work collaboratively on what the system should look like from a patient perspective. 29 Alliance members are healthcare leaders from different service areas, such as GPs, nurses, and professionals in aged care, ambulance services, public health and different hospital specialties. Each alliance member signs a charter which binds them to work together and build trust in one another. The charter stipulates that they focus on the whole system, and not the specific interests of the sector they may work for, and that they agree to help one another to achieve the alliance’s goals. These goals include a wide range of elements focused on improving and redesigning healthcare services, such as integrated services for older people with chronic care needs, or access 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 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

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

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.

FROM OPPORTUNITY...

Knowing the value of healthcare is key Rising costs, distorted incentive structures and errors

The need for forward thinking and innovative mind-

in diagnosing and providing care are all great challeng-

sets has never been greater, as new ideas are vital for

es for healthcare systems across the globe. These chal-

meeting the demands of more cost-efficient health-

lenges threaten not only patient safety and well-be-

care sectors of the future. This is precisely what the

ing, but also the cost-efficiency and sustainability of

concept of value based healthcare entails. Value based

healthcare models. Overcoming these challenges and

healthcare has emerged as a strategy for delivering

making healthcare systems more cost-efficient is vital,

healthcare at lower costs. It has been championed by

as the demand of providing more healthcare for less

Professor Micheal Porter 32, who believes value should

money is projected to become a major challenge for

define the framework for performance improvement in

healthcare systems throughout the world.

healthcare. As Porter notes, “rigorous, disciplined measurement and improvement of value is the best way to

Cost-efficiency often is associated with layoffs, fund-

drive system progress.”

ing cuts and increasing the speed of operations. But making a healthcare system more cost-efficient need

Yet value in healthcare remains largely unmeasured

not come at the expense of quality. On the contrary,

and misunderstood. Value should always be de-

it can lead to improved healthcare services, a much

fined around the customer, and in a well-functioning

needed freeing up of resources and new means of

healthcare system, the creation of value for patients

delivering care.

should determine the rewards for all other actors in the system. 33 A value based approach to healthcare has

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

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

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

... TO ACTION IN GERMANY

– a hospital group consisting of 17 hospitals across Germany, special-

COST-EFFICIENCY

ized in orthopedics, neurology, and psychosomatic medicine. Over the past years, the clinic has become one of the leading international pioneers in value based healthcare as a new approach to healthcare. 35 The Schön Klinik has made the approach standard in their healthcare delivery and services.

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

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 continuous improvement of the clinic’s efficiency and performance

INVOLVED ACTORS

in delivering healthcare. The basic idea is to know the value of their

Management, professionals

healthcare – what they deliver, and at what costs. Therefore, the Schön PRIMARY DRIVER

Klinik focuses intensely on measuring health outcomes of specific

Measuring the price and quality

patient groups and understanding resource requirements and costs in

of healthcare

the context of these outcomes.

SCALE

Schön Klinik’s 17 hospital units

The Schön Klinik’s goal is that the combination of accurate outcome and cost measurements will empower the local personnel – physicians,

TYPE OF CHANGE

nurses, and administrators – at the Schön Klinik’s different sites to

Knowledge of specific value

improve the value of care they deliver, but also to open the door to

improve the cost-efficiency of

benchmarking across the 17 different hospitals in order to identify and

healthcare

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 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

At that time the Schön Klinik, like other hospitals in Germany, had reduced the capacity of its knee replacement rehabilitation units in part because the existing cost system portrayed them as less profitable than acute-care units. But during the Schön Klinik’s value based cost measurement of the knee replacement process, they discovered that the existing cost system allocated support-department costs largely 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 hospital units spent 75% of their stay in the rehab facility, rehab had been allocated about 75% of support department costs. The analysis showed, however, that the demand for many support-unit services, such as medical billing, is far higher during the days a patient spends in the acute-care facility than during rehab days. With support costs properly assigned, the rehab facility showed improved profitability. Based on the value analysis, the Schön Klinik thus began to contemplate the expansion of its rehabilitation capacity—a complete reversal of common standard in Germany— and shifted its focus more intensively on reducing support costs incurred during the acute-care stay. 37 The Schön Klinik has received international recognition for the value based approach to patient care – from, among others, Harvard Business School.

TAKE AWAY

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...

Knowledge sharing helps healthcare do its job 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.

world must ask themselves when it comes to 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.

the years to come.

130

Commissioning for Value increases effectiveness

EFFECTIVENESS

Since 2010, the UK government has pushed a line of

COMMISSIONING FOR VALUE IN THE UK’S NHS

reforms through the National Healthcare System – the NHS. This has led to heated debate and negative cri-

INITIATOR

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 healthcare – benchmarking the performance with the best SCALE

England TYPE OF CHANGE

Using performance measurement as a vehicle for improving healthcare

... TO ACTION IN ENGLAND

Policy makers and publicly

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

131

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. There are a number of examples of CCGs that have used the numbers and recommendations from Commissioning for Value initiative to improve their performance and quality of healthcare. One example is the CCG in Warrington where the Commissioning for Value approach was used to identify where savings could be made to help overcome 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 improvement opportunities, but at the time, Warrington was spending $2.3 million more on these conditions than equivalent CCGs. As a response, the respiratory service in Warrington was redesigned. The primary changes included: • Extending the pul-

• Targeting patients

monary rehabili-

with acute epi-

• Commissioning 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 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

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.

FROM OPPORTUNITY...

Bridging time lags with better communication 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

are currently transforming how healthcare is provided

and patients, including, for instance, booking appoint-

in regions all over the world – opening healthcare sys-

ments online, communication on estimated waiting

tems up to new possibilities in healthcare services, new

time in doctors’ offices and information on the interval

types of treatments, new healthcare monitoring, and

between referrals and treatment. It also allows for

ensuring new and improved communication channels.

much more widespread, proactive and timely communication between healthcare providers, including

The development and adaptation of technology can

communication between departments or booking new

not only improve the standard of healthcare, but can

appointments with specialists. 41

also serve as an important driver for augmenting patient-provider relationships and supporting human needs throughout the healthcare journey. Electronic medical records and mHealth apps are two well-known examples of how technology is improving the speed 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

133

It’s time for a change in healthcare provision Imagine a Chinese woman, 55 years old and suffering from a severe case of osteoporosis. Her pains are worsening, so her family urges her to go to the nearest hospital to see a specialist. Sick, tired and in pain, she has to get up at one o’clock in the morning, drive three

... TO ACTION IN CHINA

hours by car to reach the nearest hospital, and then stand in a line in front of the hospital entrance. Eight hours later, she reaches the reception desk and gets her appointment to see a specialist – in two weeks. This kind of story is far from rare in China. On the contrary, long waiting times just to book an appointment are commonplace.42 Fortunately, this kind of healthcare experience could soon be in China’s past, thanks to blossoming technological healthcare platforms, like Guahao. Guahao means scheduling a patient appointment in Chinese, and this is exactly what the platform enables the Chinese healthcare consumer to do. Through Guahao, healthcare consumers are able to schedule appointments with doctors online based on location, medical specialties and other criteria. The Guahao platform lets patients assess their personal calendars, local hospitals, and physicians to make an appointment one day to two weeks in advance. In addition, the healthcare consumers can read medical advice and suggestions for different kinds of medical treatments.

TIMELINESS

THE GAUHAO HEALTH TECHNOLOGY PLATFORM IN CHINA INITIATOR

SCALE

Providers, policy makers and private

China

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

In recent years online healthcare platforms have become very popular with Chinese consumers, allowing services like Gauhao to revolutionize the interaction between users and providers and improve the quality and timeliness of healthcare immensely. This type of online reservation service also opens the door to a much more person-centered approach to healthcare delivery. Furthermore, online scheduling provides healthcare providers with the ability to better predict patient flow and more efficiently allocate resources. 43 Guahao was founded in Shanghai in 2010 as a collaboration between the Chinese Health Education Network, Fudan Hospital and Healthcare Management Co., and the Chinese Hospital Association, and later expanded nationally. Today the online platform has spread to all of the country’s 23 provinces and boasts over 37 million verified users, around 120,000 registered doctors and covers more than 900 major hospitals in China.44 The site has a team of 3,000 personnel that helps patients who are new to internet usage make appointments with doctors. Guanhao also launched a mobile phone app in 2013, making its services even more convenient and user-friendly. In late 2014, China’s internet giant, Tencent, invested $120 million in the platform. The Tencent investment is expected to expand Guahao’s user base as the health platform seeks to upgrade its WeChat payment service. WeChat is a mobile text and voice messaging communication 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

Guahao. 2014. www.Guahao.com

Asia First. Health platform Guahao gets USD120m Tencent investment. 2014. 45

TAKE AWAY 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

FROM OPPORTUNITY...

Green thinking is becoming the new normal Environmental sustainability is becoming reality

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.

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 space.46 Brazil’s hospitals are reported to account for 10.6% of the country’s commercial energy use.47 There is also a growing recognition of the effects of climate change on health and the fact that these effects will continue to drive up the cost and the demand for health services around the world. Among others, the National Institute of Environmental Health Sciences in the USA has concluded that climate change “stresses our healthcare infrastructure and delivery systems.” 48 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 are incorporating sustainability into their decision-making processes and operations. 49

KPMG. Trends, risks and opportunities in healthcare. 2012. 46, 47

National Institute of Environmental Health Sciences. Climate Change & Human Health. 2014. 48

Greenbiz. Kaiser, Metro Health bet big on sustainability. 2013. 49

136

Hospitals are leading the green battle A sustainable healthcare system – within reach or a distant utopia? A 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

... TO ACTION IN THE USA

where green is the new black for the healthcare industry. 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. The goal of the initiative is to prove that implementing strategies to reduce costs, improve environmental performance and meet broad environmental health goals is, in fact, possible for hospitals and healthcare providers. The 12 healthcare providers are working to actively pool their collective sustainability experience, purchasing power and industry representation in order to accelerate the process of greening the entire healthcare system. Consequently, the initiative is not limited to Healthier Hospitals Initiative. What we do. 2012. 50

ENVIRONMENTAL SUSTAINABILITY

the 12 founding members, but invites healthcare organizations across the country to join and to become an active part of the initiative. 50

HEALTHIER HOSPITALS INITIATIVE IN THE USA 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

the patient

Advocacy and campaigning

137

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. 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

community through the HHI

studies, success stories,

network

leadership insights 51

• Hospital-to-hospital mentorship programs

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 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

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.

THE CHANGE MAKERS 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.

We have established that healthcare systems are complex organisms. They consist of various fields of expertise, a multitude of stakeholders with different objectives and numerous terms for the same concept. However, the complexity of healthcare systems shouldnâ&#x20AC;&#x2122;t hold us back from trying to change them for the better. To move from great ambitions to real change takes leadership, examples of success and people who dare to defy the norm. Therefore, we present to you three change makers in healthcare, from China, Europe and the USA, who dared to challenge the status quo and succeeded in creating a better tomorrow.

139

CHANGE MAKER IN EUROPE JEFFREY V. LAZARUS

CLOSING THE “KNOWING-DOING” GAP IS KEY TO IMPROVING THE STATE OF HEALTHCARE 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

For years Jeffrey Lazarus has been on a quest

lion people infected with HIV in the European

to bridge the knowing-doing gap in HIV test-

Region, one in three remains undiagnosed.

ing and care through a series of research proj-

This situation is resulting in significant levels

ects, initiatives and collaborations. This quest

of late diagnosis, ill health, and HIV trans-

is what motivated him to co-found the HIV in

mission across the region. Furthermore, the

Europe Initiative – a platform for increasing

region is characterized by large variations in

early diagnosis and timely care for people

HIV testing recommendations and in access

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

has promoted the sharing of knowledge and

around the importance of providing earlier

best practices across different European re-

HIV testing and care. Considering the course

gions and institutions – ultimately broadening

of the HIV epidemic in Europe over the last

HIV awareness. A prominent example of this

decade, this work is very much needed.

is the European HIV testing week, initiated in

Despite the fact that there is now widespread

2013. The second European HIV testing week

knowledge of preventive tools such as con-

was held in November 2014 with more than

doms and access to life-saving antiretroviral

700 organizations across Europe hosting ac-

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

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 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

translates scientific evidence into a practical approach to iden-

around the world. But what kept

tifying HIV-positive people who might not otherwise be tested.

us from seizing this great opportu-

The guide is targeted at healthcare providers in all relevant

nity was the fact that not enough

specialties and settings, as well as at administrators and pol-

people were testing for HIV. And

icy-makers responsible for overseeing HIV testing programs

not enough of those who did learn

at the national and local levels. Today it is increasingly used in

they were HIV-positive went on to

healthcare systems across the region.

initiate treatment.

BIOGRAPHY

JEFFREY V. LAZARUS DIRECTOR OF HEALTH SYSTEMS GLOBAL

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

for Health and Infectious Disease

Fund to Fight AIDS, Tuberculosis

Research and WHO Collaborating

and Malaria, where he led knowledge

Centre on HIV and Viral Hepatitis at

translation and oversaw publication

the University of Copenhagen. He

of the Fund’s global and regional

is also a Professor at the Lithuanian

impact reports. Upon his return to

University of Health Sciences, Medical

Copenhagen in 2012, he became the

Academy, and an Affiliated Professor

co-founding Secretariat Director of

at the Institute of Public Health,

Health Systems Global, an international

University of Porto.

health systems membership society.

His ten-year career as a health systems and communicable diseases expert

141

It was estimated that almost half of all people living with HIV in Europe were unaware of their status – a totally unacceptable figure, from my perspective, especially in a region with so many well-functioning and well-resourced healthcare systems. This was the impetus for founding the HIV in Europe Initiative.

WHAT WAS YOUR FIRST STEP? We started as five people who came together from different fields. In addition to myself there were two clinician-researchers and two representatives of HIV community 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?

– whether it is our conferences,

To introduce the initiative and

We started with funding from

advocacy activities, research or the

increase awareness of our work, we

industry. We also applied for and

European HIV testing week. We do

arranged a major conference on

received grants from the Europe-

not just focus on reaching one type

earlier diagnosis of HIV. It was held in

an Commission. For example, we

of stakeholder – we are trying to

Brussels in 2007 and had more than

recently initiated “Optimizing Testing

engage everyone who is or should

300 participants from 27 countries

and Linkage to Care for HIV across

be invested in this issue. From the

– including the European Commis-

Europe,” where I sit on the advisory

beginning, we have worked as a

sioner for Health and Consumer

board. And there is a lot of volunteer

multidisciplinary team because we

Protection.

time from the Steering Committee,

are convinced that broad action

not least from our co-chairs.

is needed to meet this challenge.

With the conference we wanted to create a common understanding of the role of HIV testing and counseling in optimizing diagnosis and of the need for earlier care. We chose Brussels as our kick-off location in

142

“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.”

Participants at our conferences, for HOW DID YOU INVOLVE OTHER PEOPLE, AND WHOM DID YOU INVITE?

example, have diverse backgrounds. They include clinicians, researchers, policy-makers, community representatives, and NGO advocates

order to be close to the political

We always have put a great deal

– all in the same room to talk about

epicenter of Europe, and we were

of effort into involving a wide range

how they can play an important part

successful in engaging stakeholders

of people through our activities

in overcoming this challenge.

subsequent evaluation leads me to

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

The first barrier we faced was

Europe Initiative’s long-term vision.

that the guide was a major European

getting people involved. That was

Several hepatitis experts have joined

action to co-create healthcare. It

actually a barrier that we were able

our Steering Committee since the

encompassed the key stakeholders,

to overcome quickly because the

conference.

including physicians, researchers,

WHAT WERE THE MAIN BARRIERS AND HOW DID YOU OVERCOME THEM?

people whom we were approaching were, in one way or another, already involved in the fight against HIV and could clearly see the relevance of our initiative. Our second barrier was funding. This also proved to be surmountable

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 awareness of their HIV status. The

thanks to support from the man-

We have been measuring the

situation has improved considerably

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.

Now, almost ten years later, we are confronted by other types of

An early result of the initiative

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

huge gap between knowledge and

society. We received a lot of support

action across Europe. We are clearly

and made more people aware of

failing in terms of seeing that knowl-

the Initiative. From the first to the

edge about testing and treating

second year, the number of partners

hepatitis is actually reflected in the

and the number of people who got

care Europeans receive. This is par-

tested increased greatly. Here it is

ticularly concerning now that there

important to stress that the Initiative

is an effective cure for hepatitis C.

often functions as an umbrella

Incorporating a focus on hepatitis

organization that adds value to

brings about some challenges for

work already happening. For Testing

the HIV in Europe Initiative in terms

Week there were thousands of

of our identity, which is very much

people, including many people who

linked to our experience of working

volunteered their time to provide

on HIV for all of this time.

on-the-ground testing and raise

We made the first effort to put hepatitis squarely on our agenda at

“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

the Initiative’s 2014 conference in

guide, “HIV Indicator Conditions:

Barcelona. Interest from conference

Guidance for Implementing HIV Test-

participants and feedback from the

ing in Adults in Healthcare Settings,”

143

CHANGE MAKER IN USA SUSAN SHERIDAN

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.

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.”

days after his birth in 1995 because his neonatal jaundice was untreated. A one dollar

The story of PICK is a story of success built

bilirubin test could have prevented it. This

upon Susan Sheridan’s and the six other

led Susan Sheridan to leave behind a career

moms’ personal tragedies. Since its founding,

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

– a battle to put the awareness and improve-

awareness about kernicterus and strategies

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

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

ers in October 2000. An organization dedi-

and non-governmental organizations related

defined as the “kind of mistake that should never occur” in the field of medical treatment. 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

BIOGRAPHY Susan Sheridan became involved

organization that seeks a safe,

in patient safety after her family

compassionate and just healthcare

experienced two serious medical

system through proactive partnerships

system failures. Her son, Cal, suffered

between consumers and providers of

severe brain damage called kernicterus

care. Sheridan served at President of

five days after his birth in 1995 when

CAPS from 2003-2010.

his neonatal jaundice was untreated. Her husband, Pat, died in 2002 after his diagnosis of spinal cancer failed to

SUSAN SHERIDAN DIRECTOR OF PATIENT ENGAGEMENT FOR THE PATIENT-

be communicated.

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.

CENTERED OUTCOMES

co-founder and past President of

RESEARCH INSTITUTE

Parents of Infants and Children with

(PCORI)

Kernicterus (PICK), and in 2003, she co-founded Consumers Advancing Patient Safety (CAPS), a non-profit

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.”

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

that my story could become part of

tiative. One of our first decisions was

mothers formulated a to-do-list for

a greater system-wide change.

to go big and to focus on the entire

the healthcare system, researching

healthcare system. We did not want

and identifying the responsibilities

risks and consequences of the

to stay local, because the mistreating

and roles for each stakeholder in

current protocol and improve the

of newborn jaundice was happen-

the healthcare system. We created a

guidelines for practicing pedia-

ing across the country. This also

security blanket showing what could

tricians. I wanted to contribute to

meant that our mission and what we

and should be done to prevent this

getting kernicterus on the radar for

worked for was a nationwide system

from happening again.

the US healthcare authorities, which

change. We wanted to implement a

it was not at that time. There was

universal bilirubin test for the entire

a perception that this disease was

healthcare system for all newborns,

simply not happening in the USA.

to create awareness of the problem

Thus, we parents needed to get

and to push forward education of

involved and to tell the story – that

parents and professionals.

I wanted to tell the story of the

this was a preventable patient injury

Our basic idea was then, and still

HOW DID YOU GET RESOURCES TO CREATE THE CHANGE YOU WANTED? At the beginning all we had was our own time, so we used a lot of our

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

the knowledge of what happened,

So in the forming of PICK we

more actively on getting funds for

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

of making the patient voice count.

a part of the initiative. Based on this,

researchers that we partnered with

We wanted to advocate for the

our first big step was to work with

also received money from govern-

importance of bringing patients,

our lead researchers to organize

ment agencies to conduct research.

patient advocates and family mem-

the roundtable, “Strategies for a

One grant came from The Centers

bers to the table to help redesign the

System-wide Change in the Manage-

for Disease Control and Prevention

healthcare system and to improve

ment of Neonatal Hyperbilirubinemia

to conduct more research on a

patient safety.

to Prevent Kernicterus,” in February

database of children with kernicter-

2001. At this roundtable we brought

us, and to create a public education

basically the entire healthcare sys-

campaign. We also got some funding

tem to the table. Accreditors, regula-

from parents through our fundrais-

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-

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

kind of radical change throughout the entire healthcare system. We saw our own role as being catalytic for bringing the partners together. In terms of getting the right

that once the test was made a HOW DID YOU OVERCOME THESE BARRIERS? There was no silver bullet, but

national standard, newborn readmissions decreased by 30%. We have also managed to change the way people talk about jaundice –

people to attend our first round-

there was will. We were complete-

both in the healthcare system, where

table, we had opened some doors

ly mission driven – focused on our

the previous misinformation about

when I testified in Washington. At

north star. We just had to look at our

the seriousness of jaundice has been

that summit there were a number of

children, as they were a constant re-

replaced by more fact-based discus-

leading figures within the healthcare

minder of the importance of pushing

sions on the risks of not getting your

system, including the Joint Commis-

through and making kernicterus a

baby tested, as well as in families,

sion, who I reached out to when we

phenomenon of the past.

where parents now demand that

decided to have the first roundtable.

We were very true to our mission.

their babies be tested.

I picked up the phone and talked to

We focused on consistency and a

their CEO, and he agreed to come to

clear message that was not attack-

based on the anecdotes we hear.

our event – the first one to step up.

ing, but trying to engage and involve

We get many personal stories from

This opened the door to get other

the system. This helped us get

moms and dads that have just had a

stakeholders involved, because we

through and make a difference. We

baby that had jaundice and was test-

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

ing our partners as means of being

we really made a difference.

WHAT WERE THE MAIN BARRIERS First of all, we moms were not

considered a serious and important voice. We overcame a lot of the barriers

healthcare professionals. So at first,

by making the concept of partner-

in terms of eradicating Kenicterus,

ships a very important aspect of our

we did not see the barriers, but

work. We did not know it was a great

only the possibilities. But one of the

strategy at first, but it was key for

challenges when we started was

our success as a vehicle for bridging

that they asked us: where is the

patients and professionals. In regard

evidence? We lacked evidence of the

to this, we also had immense help

extent of kernicterus and the treat-

from some remarkable partners

ment failures. We had to take on the

within the system. They were bold

task of uncovering and making this

and progressive enough to support

research available.

us even though this meant support-

Another great barrier was to

Success, for us, is also very much

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

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”.

On the 2nd of June, 2011, the Salt Reduction

and doctors, LifeSeeds is introducing effec-

and Health Education Campaign launched in

tive, low-cost and sustainable interventions

Lianghu– a small village in the Shanxi prov-

for cardiovascular disease that will enable

ince of Northern China. The launch was or-

widespread prevention and management

chestrated as a village celebration equipped

programs to be implemented in rural China.

with drummers and dancing. Healthcare

LifeSeeds is thus addressing a greater health

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.

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, 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

LIFESEEDS’ TWO PRIMARY ACTIVITIES: • Training of “village doctors” through the Healthcare 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.

a lack of knowledge of healthy living among the Chinese people, and to a healthcare system that is currently

So far the success has been great. An evaluation of the

not properly managing these health challenges. The

first part of the project showed that the people in rural

campaign launched in Lianghu marks a new beginning –

northern China reduced their salt intake after participat-

confronting the lack of knowledge and action from both

ing in a community-based sodium reduction program.

the healthcare consumers and providers.

120 villages from five of the Northern provinces of China - Hebei, Liaoning, Ningxia, Shanxi, and Shaanxi – are par-

Chen 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.

BIOGRAPHY

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.

STARTING LIFESEEDS? We didn’t have many models to follow, because at the time we start-

we not focus on the most or least developed provinces, but rather find provinces in the middle, where there was the greatest potential for change and scale-up.

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

with the Ministry of Health to look at

and heart disease. Most of the global

runs from the middle of China above

a few clinical centers in some rural

interest in healthcare in China had

Beijing to the east coast. Here stroke

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

tion, as stroke is the leading cause

West. So ailments that weren’t a

care provided, the health systems

of death and disability in China.

threat to the West, like heart disease

are strong enough to support the

And the results were pretty grim in

or stroke, weren’t on the Western

implementation of new programs.

terms of the treatments people were

agenda. Part of the rationale for es-

And as it has turned out, the Minis-

receiving if they’d had a stroke, and

tablishing The George Institute was

ter’s advice was extremely helpful

the absence of anything being done

that the West has so much experi-

and the provinces we chose to be

for those at risk.

ence in the management of these

great places to run this project.

On that basis, we put together

So we focused on what is basical-

chronic conditions, that we have

a partnership with Peking Universi-

something to offer China and other

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 WANTED?

to train “village doctors,” who are

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

or who had had a stroke, and provide

a visit to Sydney and he emphasized

heart disease and stroke in low and

low-cost evidence based treatment.

that the most important challenge

middle income countries. We suc-

The program ran for 2 years and

was to improve care in Chinese rural

ceeded in gaining their support, and

then we assessed the outcomes.

communities. We discussed with

they funded the project for the best

him the selection of provinces for

part of 5 years.

I was involved in raising financial support for this project, but

150

WHAT WERE YOUR FIRST STEPS IN

LifeSeeds and he suggested that

Until very recently, the Chinese

Ministry of Health (now the National

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 therefore the days of the United States, Australia, the UK and other Western countries providing research funds to China are over. We’d like to get

by building technology systems to 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-

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

future. To do so, we’re focusing on

tending their reach, even to cover

to regular doctors. As long as we

closer engagement with the Ministry

something as important as stroke

can ensure safe, effective care, this is

of Science and Technology.

prevention and treatment, was not

potentially a very scalable solution.

The George Institute is a global

a straightforward task. Also, the

We’ve begun some work on this,

organization, and not a techni-

very modest level of training of

and have shown that a very basic

cally Chinese organization, so we

doctors was an issue. So while the

prototype technology has the ca-

cannot seek resources directly from

stroke prevention program clearly

pacity to improve outcomes. What

the government, as only Chinese

improved the quality of the care that

we now need is a bespoke Chinese

organizations can apply for funding

was delivered, the impact was still

version and a completely new phase

from the Chinese government. That

well short of what we had hoped for.

of LifeSeeds, targeting the same

said, we need to find other ways to work with the government through partnerships or joint venture with Chinese organizations with interests in improving healthcare for the poor.

HOW DID YOU INVOLVE OTHER PEOPLE AND ORGANIZATIONS AND HOW DID YOU CHOOSE WHO TO INVITE? When we first established our

or similar populations, to assess HOW WILL YOU OVERCOME THESE BARRIERS? AND WHAT ARE THE CHALLENGES TO OVERCOME IN THE FUTURE? The next phase of this project will

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-

Institute in China, we developed it as

gram, we will provide mobile internet

a partnership with Peking University.

based programs, which provide

We chose Peking University because

instructions directly to the doctor

it’s the leading university in China,

about how to manage the patient

so in that sense it was a carefully

in front of him or her. This includes

planned strategic partnership. Sim-

instructions about risk assessment,

“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

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

industries, and our everyday lives.

reality for all. To learn more about our work to establish a collaboration, please visit us at: www.dnvgl.com/pa-

The concept of Sustainia was developed by Scandina-

tientsafety

vian think tank, Monday Morning, in a collaborative effort 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

Erik Rasmussen Founder of Sustainia and CEO of Monday Morning

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

sectors, institutions, and leaders are torn down in an ef-

DNV GL - Healthcare | Strategic Research and Innovation

fort to locate common challenges and shared solutions. To find out more, visit: www.sustainia.me

Eva Turk 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

Stephen McAdam Global Technical Director for Healthcare DNV GL - Healthcare | Business Assurance

assurance along with software and independent expert

Fabijana Popovic

advisory services to the maritime, oil and gas, and

Project Manager, Monday Morning Sustainia

energy industries. It also provides certification services to customers across a wide range of industries. Combining leading technical and operational expertise, risk

Esben Alslund-Lanthén Research Analyst, Monday Morning Sustainia

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-

Anna Fenger Schefte Journalist, Monday Morning

laborative innovation to provide customers and society

Lisa Haglund

at large with operational and technological foresight.

Head of Design, Monday Morning Sustainia

DNV GL, whose origins date back to 1864, operates globally in more than 100 countries, with its 16,000 professionals dedicated to helping their customers make the world safer, smarter, and greener. Always looking

SUSTAINIA

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

INSPIRATION FOR FURTHER READING 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:

BMJ SPOTLIGHT: PATIENT CENTRED CARE, 2015 Healthcare faces serious threats to its sustainability. Ageing populations, the rise of co-morbid chronic conditions, an unenviable safety record and the impact of austerity collectively mean that health systems around the world have to change if they are to achieve improved well-being for individuals and populations. Such change is possible if we join the power of systems thinking with the engagement of service users as equal and active partners alongside practitioners, provider organizations and policy makers. This is the message of the new publication on person-centred care from the BMJ and DNV GL.

MIXED METHODS: IMPROVING THE ASSESSMENT OF SAFETY CULTURE IN HEALTHCARE, 2014 Safety culture is the way in which organizations live and breathe safety. If there is to be improvement in the quality of healthcare, the assessment of safety culture is paramount. This position paper makes the case for using a mixed methods approach, in which quantitative and qualitative methods are combined to improve the accuracy of results in the assessment of a healthcare organizationâ&#x20AC;&#x2122;s safety culture.

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 looks at schools, workplaces, the food sector, healthcare and communities and 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 could live in ten years from now based on solutions available today.

THE GUIDE TO PERSON-CENTRED CARE, 2014 While the current healthcare systems of the world are unsustainable, their challenges 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 personcentered care is made a reality for all. The guide features interviews with world leaders in person-centered care, 10 illuminating case studies from around the world, a review of the challenges and obstacles to person-centered care and an accessible and engaging review of the evidence.

155

REFERENCE LIST A

Alkenizan A & Shaw C. Impact of ac-

of university-affiliated hospitals in Shiraz,

creditation on the quality of healthcare

Iran. Journal of Infection and Public

Adam T. Advancing the application of

services: a systematic review of the

Health 2012; 5: 169-176.

systems thinking in health. Health Re-

literature. Ann Saudi Med 2011; 31(4): 407-

search Policy and Systems 2014; 12(50):

416. http://www.ncbi.nlm.nih.gov/pmc/

Aspden P, Wolcott J, Bootman JL,

1-5.

articles/PMC3156520/

Cronenwett LR (eds.). The Betsy Lehman

Agency for Healthcare Research and

Altman LK. Big Doses of Chemother-

Quality Chasm Series. 2007. http://

Quality. Calculated from Healthcare Cost

apy Drug Killed Patient, Hurt 2d. New

www.nap.edu/openbook.php?record_

and Utilization Project. Kids’ Inpatient

York Times. 1995. http://www.nytimes.

id=11623&page=27

Database. Undated. http://hcupnet.ahrq.

com/1995/03/24/us/big-doses-of-che-

gov/

motherapy-drug-killed-patient-hurt-2d.

Australian Institute of Health and

html

Welfare. Survey in Australia’s hospitals.

Case. Preventing Medication Errors:

Agency for Healthcare Research and

2014. www.aihw.gov.au/haag12-13/sur-

Quality. Care Coordination. 2014. http://

American Medical Association. Quality of

www.ahrq.gov/professionals/preven-

Patient Care Drives Physician Satisfaction;

tion-chronic-care/improve/coordination/

Doctors Have Concerns About Electronic

gery/#hp-elective B

Health Records, Study Finds. 2013. http:// Agency for Healthcare Research and

www.ama-assn.org/ama/pub/news/

Barnes J. Moving Away from Fee-for

Quality. Interim Update on 2013 Annual

news/2013/2013-10-09-rand-study-phy-

Service. The Atlantic. 2012. http://www.

Hospital-Acquired Condition Rate and

sician-satisfaction.page

theatlantic.com/health/archive/2012/05/

Estimates of Cost Savings and Deaths

moving-away-from-fee-for-ser-

Averted from 2010 to 2013. 2013. http://

American Meteorological Society Policy

www.ahrq.gov/professionals/quality-pa-

Program. Under The Weather: Envi-

tient-safety/pfp/interimhacrate2013.pdf

ronmental Extremes and Health Care

BCC Research. U.S. Market For Med-

Delivery. 2010. http://www2.ametsoc.

ical Waste Treatment, Containment,

Agency for Healthcare Research and

org/ams/assets/File/Under_The_Weath-

Management, and Disposal To Reach

Quality. Open Access Scheduling for

er_2010.pdf

Nearly $3.2 Billion In 2017. 2012. http://

Routine and Urgent Appointments.

vice/256755/

www.bccresearch.com/pressroom/env/

Undated. https://cahps.ahrq.gov/qual-

American Society of Health-System Phar-

arket-medical-waste-treatment-contain-

ity-improvement/improvement-guide/

macists. Federal Plan Aims to Reduce

ment-management-disposal-reach-near-

browse-interventions/Access/Open-Ac-

Adverse Drug Events. 2014. http://www.

ly-$3.2-billion-2017

cess.html#_ftn15

ashp.org/menu/News/PharmacyNews/ NewsArticle.aspx?id=4132

Agency for Healthcare Research and

BCC Research. Wireless Electronic Health Records: Technologies and Global

Quality. Organizational Change in the

Amnesty International. The Crumbling

Markets. 2014 http://www.bccresearch.

Face of Highly Public Errors. The Da-

State of Health Care in North Korea.

com/market-research/healthcare/wire-

na-Farber Cancer Institute Experience.

2010. www.amnesty.org/en/news-and-

less-electronic-health-records-hlc147a.

2005. http://webmm.ahrq.gov/perspec-

updates/report/north-koreas-crumbling-

html

tive.aspx?perspectiveID=3

health-system-dire-need-aid-2010-07-14

Agency for Healthcare Research and

Andel C, Davidow SL, Hollander M &

2013. http://www.newyorker.com/maga-

Quality. The Role of Patients in Safety.

Moreno DA. The economics of health

zine/2014/08/25/under-the-knife

2015. http://psnet.ahrq.gov/primer.aspx-

care quality and medical errors. Journal

?primerID=17

of Health Care Finance 2012; 39(1):

Beech H. How Corruption Blights China’s

39-50. http://www.ncbi.nlm.nih.gov/

Healthcare System. Time. 2013. http://

pubmed/23155743

world.time.com/2013/08/02/corrup-

Beam C. Under the Knife. The New Yorker.

Al-Khatib I. Medical waste management in healthcare centres in the

tion-blights-chinas-healthcare-system/

occupied Palestinian territory. Eastern

Asia First. Health platform Guahao gets

Mediterranean Health Journal 2007;

USD120m Tencent investment. 2014.

Bloomberg. Most Efficient Health Care

113(3): 694-705. www.ncbi.nlm.nih.gov/

https://www.asia-first.com/newsletter/

2014: Countries. 2014. media.bloomberg.

pubmed/17687844

health-platform-guahao-gets-usd120m-

com/bb/avfile/rhpTqieX4Fuc

tencent-investment.html Askarian M, Yadollahi M & Assadian O. Point prevalence and risk factors of hospital acquired infections in a cluster

156

Bossone A. Sharing the pain: Improving

Center for American Progress. Alter-

Centers for Medicaid and Medicare

healthcare in warzones. Nature – Middle

natives to Fee-for-Service Payments

Services. Medicare ACOs continue to

East. 2014. www.natureasia.com/en/

in Health Care. 2012. http://cdn.

succeed in improving care, lowering

nmiddleeast/article/10.1038/nmiddlee-

americanprogress.org/wp-content/up-

cost growth. 2014. http://www.cms.

ast.2014.21

loads/2012/09/FeeforService-1.pdf

gov/Newsroom/MediaReleaseData-

Boudreau RM et al. Improving the

Center for Health Care Strategies Inc.

timeliness of written patient notification

Health Literacy Implications of the

of mammography results by mam-

Affordable Care Act. 2010. www.iom.

Centers for Medicaid and Medicare

mography centers. The Breast Journal

edu/~/media/Files/Activity%20Files/

Services. National Health Expenditures

2004;10(1):10-9. http://www.ncbi.nlm.nih.

PublicHealth/HealthLiteracy/Commis-

2013 Highlights. 2014. http://www.cms.

gov/pubmed/14717754

sioned-Papers/Health%20Literacy%20

gov/Research-Statistics-Data-and-Sys-

Implications%20of%20Health%20

tems/Statistics-Trends-and-Reports/

Care%20Reform.pdf

NationalHealthExpendData/Downloads/

base/Fact-sheets/2014-Fact-sheets-

Boyle D & Harris M. The challenge of co-production: How equal partnerships

items/2014-09-16.html

highlights.pdf

between professionals and the public

Center for Strategy and Evaluation Ser-

are crucial to improving public services.

vices & Oxford Research. Final Evaluation

Centers for Medicaid and Medicare

2009. http://b.3cdn.net/nefoundation/

of the Lead Market Initiative. 2011. http://

Services. National Health Expenditures –

312ac8ce93a00d5973_3im6i6t0e.pdf

ec.europa.eu/enterprise/dg/files/evalua-

Table 1. Undated. http://www.cms.gov/

tion/final-eval-lmi_en.pdf

Research-Statistics-Data-and-Systems/

Budryk Z. Value-based model could

Statistics-Trends-and-Reports/National-

improve hospital performance 30%.

Centers for Disease Control and Preven-

HealthExpendData/Downloads/tables.

Fierce Pharma. 2014. http://www.fierce-

tion. Health-associated Infections (HAIs) –

pdf

healthcare.com/story/value-based-mod-

Data and Statistics. 2015. http://www.cdc.

el-could-improve-hospital-perfor-

gov/HAI/surveillance/

mance-30/2014-09-12

Center for Medicaid and Medicare Services. Total All Payers State Es-

Centers for Disease Control and Preven-

timates by State of Residence. 2011.

Burkitt L. Violence Against Doctors on

tion. Meaningful Use. 2012. http://www.

http://www.cms.gov/Research-Sta-

the Rise in China. Wall Street Journal.

cdc.gov/ehrmeaningfuluse/introduction.

tistics-Data-and-Systems/Statis-

2013. http://blogs.wsj.com/chinareal-

html

tics-Trends-and-Reports/NationalHealth-

time/2013/08/16/violence-against-doctors-on-the-rise-in-china/ C California Health Care Foundation.

ExpendData/Downloads/res-tables.pdf Centers for Disease Control and Prevention. Wait Time for Treatment in Hospital

Chen C & Bennett S. China Smog at

Emergency Departments: 2009. 2012.

Center of Air Pollution Deaths Cited by

http://www.cdc.gov/nchs/data/data-

WHO. Bloomberg Business. 2014. www.

briefs/db102.htm

bloomberg.com/news/2014-03-25/

Overuse of Emergency Departments

tainted-air-kills-more-than-aids-diabetes-

Among Insured Californians. 2006.

Centers for Medicare and Medicaid

http://www.chcf.org/~/media/MEDIA%20

Services. Hospital-Acquired Conditions.

LIBRARY%20Files/PDF/E/PDF%20

2014. http://www.cms.gov/Medicare/

Chen X, Li L, Zhou T, Li Z. Prevalence of

EDOveruse.pdf

Medicare-Fee-for-Service-Payment/Hos-

Hypertension in Rural Areas of China: A

pitalAcqCond/Hospital-Acquired_Condi-

Meta-Analysis of Published Studies. PLOS

tions.html

One 2014; 9(12): e115462.

Guardian. 2014. http://www.theguardian.

Centers for Medicaid and Medicare

Chen Y, Zhou Y & Xie Q. Suggestions to

com/society/2014/oct/17/nhs-staff-short-

Services. Medicaid Health Homes: An

ameliorate the inequity in urban/rural al-

ages-risk-patients-cqc-report

Overview. 2014. http://www.med-

location of healthcare resources in China.

icaid.gov/State-Resource-Center/

International Journal for Equity in Health

Canadian Health Coalition. Wait Times:

Medicaid-State-Technical-Assis-

2014; 13:34. http://www.equityhealthj.

Causes and Cures. 2009. medicare.ca/

tance/Health-Homes-Technical-As-

com/content/13/1/34

main/the-facts/wait-times-causes-and-

sistance/Downloads/Medic-

cures

aid-Health-Homes-Overview.pdf

Campbell D. NHS staff shortages pose

who-report-shows.html

risk to patients, warns watchdog. The

157

Cheng SL, Zhao JZ, Bai J & Zang XY.

Commonwealth Fund. Aiming Higher:

Continuity of Care for Older Adults with

Results from a Scorecard on State Health

Chronic Illness in China: An Explorato-

System Performance. 2014. http://www.

Deloitte. Global healthcare outlook:

ry Study. Public Health Nursing 2014.

commonwealthfund.org/~/media/files/

Shared challenges, shared opportunities.

http://onlinelibrary.wiley.com/doi/10.1111/

publications/fund-report/2014/apr/

2014. https://www2.deloitte.com/con-

phn.12163/abstract

state_scorecard_2014_supplemental_

tent/dam/Deloitte/global/Documents/

data_tables.pdf

Life-Sciences-Health-Care/dttl-lshc-

China Daily. China’s medical waste

2014-global-health-care-sector-report.

piles up. China Daily. 2013. http://www.

Commonwealth Fund. America’s Under-

chinadaily.com.cn/china/2013-11/17/con-

insured: A State-by-State Look at Health

tent_17111037.htm

Insurance Affordability Prior to the New

Deloitte Center for Health Solutions.

Coverage Expansions. 2014. http://www.

Impact of austerity on European phar-

China Economic Review. China’s health-

commonwealthfund.org/~/media/Files/

maceutical policy and pricing: Staying

care reform needs to address hospital

Publications/Fund%20Report/2014/

competitive in a challenging environ-

waiting times. China Economic Review.

Mar/1736_Schoen_americas_underin-

ment. 2013. https://www2.deloitte.com/

2009. http://www.chinaeconomicreview.

sured.pdf

content/dam/Deloitte/dk/Documents/

com/node/27471

pdf

life-sciences-health-care/European_ausCommonwealth Fund. Healthcare in

terity.pdf

China-Japan Friendship Hospital. Mu-

the Two Americas. 2013. http://www.

nicipal Hospitals to Pilot Internal Beds

commonwealthfund.org/~/media/

Department of Health, Social Services

Coordination. 2013. http://english.zryhyy.

files/publications/fund-report/2013/

and Public Safety, UK. Dignified Person

com.cn/news/News.aspx?NewsId=255

sep/1700_schoen_low_income_score-

Centred Care - Learning from the USA.

card_full_report_final_v4.pdf

2013. www.dhsspsni.gov.uk/digni-

China Smack. Waiting All Night Outside

fied-family-presentation2013.ppt

A Hospital Hoping to See A Doctor. China

Commonwealth Fund. Mirror, Mirror

Smack. 2009. http://www.chinasmack.

on the Wall: How the Performance of

DiMatteo MR et al. Patient adherence and

com/2009/pictures/chinese-waiting-hos-

the U.S. Health Care System Compares

medical treatment: A meta-analysis. Med

pital-crowds.html

Internationally. 2014. http://www.com-

Care 2002; 40: 794-811. http://www.ncbi.

monwealthfund.org/~/media/files/publi-

nlm.nih.gov/pubmed/12218770

China Water Risk. North China Plain

cations/fund-report/2014/jun/1755_da-

Groundwater: >70% Unfit for Human

vis_mirror_mirror_2014.pdf

Touch. 2013. http://chinawaterrisk.org/

Dinesh TA, et al. Reducing Waiting Time in Outpatient Services of Large University

notices/north-china-plain-groundwater-

Commonwealth Health Online. Health in

Teaching Hospital – a Six Sigma Ap-

70-unfit-for-human-touch/

Sri Lanka. Undated. www.commonwealth-

proach. Management in Health 2013; 1(17).

health.org/asia/sri_lanka/

journal.managementinhealth.com/index.

Cilag GmbH International. Healthcare As-

php/rms/article/view/259/823

sociated Infections – Fact & figures. 2015.

Connecticut Energey Efficiency Fund.

http://www.aspjj.com/emea/latestnews/

Energy Efficiency At Work – Case Study:

Dixon-Woods M et al. Explaining Match-

HAI_Facts_and_Figures

Greenwich Hospital. http://www.cl-p.

ing Michigan: An Ethnographic Study of a

com/downloads/Greenwich%20Hospital.

Patient Safety Initiative. Implementation

pdf?id=4294986860&dl=t

Science 2013; 8(70): 1-13.

Cochrane Collaboration. The Cochrane Acute Respiratory Infections Group. 2013. www.ari.cochrane.org

Cumming J. Integrated care in New Zealand. International Journal of Integrated

Commonwealth Fund. A Call for Change:

Care Special 10th Anniversary Edition

The 2011 Commonwealth Fund Survey of

2011 e138. http://www.ncbi.nlm.nih.gov/

Public Views of the U.S. Health System.

pmc/articles/PMC3226018/

2011. http://www.commonwealthfund. org/~/media/files/publications/is-

Cutler D, Wikler E & Basch P. Reducing

sue-brief/2011/apr/1492_stremikis_pub-

Administrative Costs and Improving

lic_views_2011_survey_ib.pdf

the Health Care System. New England Journal of Medicine 2012; 367: 1875-1878. http://www.nejm.org/doi/full/10.1056/ NEJMp1209711

E The Economist. Feeling your pain. The Economist. 2013. http://www.economist. com/news/china/21576670-despite-extraordinary-progress-reforming-health-care-creating-almost-many-problems-it eHealth Africa. Micro-Solar Systems for Maternal Health. Undated. ehealthafrica.org/projects/micro-solar-systems-for-maternal-health/

158

Einhorn B & Loo D. China Raises Doctor

European Commission. Investing in

European Health Literacy Project. Final

Fees, Lowers Drug Bills to Ease Anger.

Health. 2013. http://ec.europa.eu/health/

Report – Executive summary (D17) – The

Bloomberg Business. 2012. http://www.

strategy/docs/swd_investing_in_health.

European Health Literacy Project (HLS-

bloomberg.com/news/2012-09-26/china-

pdf

EU). 2012.

European Commission. Mapping and Ana-

European Parliament. Charter of Funda-

lysing Bottleneck Vacancies in EU Labour

mental Rights of the European Union.

Markets. 2014.

2000. http://www.europarl.europa.eu/

raises-doctor-fees-lowers-drug-bills-toease-anger.html Ericsson. Health care and painting apps win top prizes in 2012 Ericsson

charter/pdf/text_en.pdf

Application Awards. 2012. http://www.

European Commission. On effective,

ericsson.com/news/120522_health_

accessible and resilient health systems.

European University Institute. EU Sta-

care_and_painting_apps_win_top_priz-

2014. http://ec.europa.eu/health/health-

tistics on Income and Living Conditions.

es_in_2012_ericsson_application_

care/docs/com2014_215_final_en.pdf

2015. http://www.eui.eu/Research/

awards_244159019_c

Library/ResearchGuides/Economics/StaEuropean Commission. Patient Safety and

tistics/DataPortal/EU-SILC.aspx

European Center for Disease Preven-

Healthcare-Associated Infections. 2014.

tion and Control. Healthcare-associated

http://ec.europa.eu/health/patient_safe-

EU Health & Consumer Protection Di-

infections. 2015. http://www.ecdc.europa.

ty/docs/ec_2ndreport_ps_implementa-

rectorate-General. European guidelines

eu/en/healthtopics/Healthcare-associat-

tion_en.pdf

for quality assurance in breast cancer

ed_infections/Pages/index.aspx

screening and diagnosis. 2006. http:// European Commission. Report on the

ec.europa.eu/health/archive/ph_proj-

European Commission. Commission Staff

Public Consultation on Patient Safety and

ects/2002/cancer/fp_cancer_2002_ext_

Working Document – Accompanying

Quality of Care. Undated. http://ec.eu-

guid_01.pdf

document to the White Paper: “Adapting

ropa.eu/health/patient_safety/docs/

to climate change: Towards a European

pasq_public_consultation_report.pdf

framework for action.” 2009. http://

Evertsen J, Baumgardner DJ, Regnery A, Banerjee I. Diagnosis and management of

ec.europa.eu/health/archive/ph_threats/

European Commission. Special Euroba-

pneumonia and bronchitis in outpatient

climate/docs/com_2009-147_en.pdf

rometer 411: Patient Safety and Quality of

primary care practices. Primary Care

Care. 2014. ec.europa.eu/health/patient_

Respiratory Journal 2010; 19:237.

European Commission. Detailed analysis

safety/docs/ebs_411_en.pdf

of countries’ reports on the implemen-

tation of the Council Recommendation

European Commission & OECD. Health

(2009/C 151/01) on patient safety, includ-

at a Glance: Europe 2012. 2012. http://

Families USA. The Promise of Care

ing the prevention and control of health-

www.oecd.org/health/health-systems/

Coordination: Transforming Health Care

care associated infections. 2012. http://

HealthAtAGlanceEurope2012.pdf

Delivery. 2013. http://familiesusa.org/

ec.europa.eu/health/patient_safety/ docs/council_2009_report_swd_en.pdf

sites/default/files/product_documents/ European Commission & OECD. Health

Care-Coordination.pdf

at a Glance: Europe 2014. 2014. ec.euEuropean Commission. Eurobarometer

ropa.eu/health/reports/docs/health_

Fan R. Corrupt Practices in Chinese Med-

Qualitative Study – Patient Involvement.

glance_2014_en.pdf

ical Care: The Root in Public Policies and

2012. http://ec.europa.eu/health/health-

a Call for Confucian-Market Approach.

care/docs/eurobaro_patient_involve-

European Federation of Pharmaceuti-

Kennedy Institute of Ethics Journal.

ment_2012_en.pdf

cal Industries and Associations. Annual

2007; 111-131. http://muse.jhu.edu/login?-

Review of 2011 and Outlook for 2012.

auth=0&type=summary&url=/journals/

European Commission. European guide-

Undated. http://www.efpia-annualreview.

kennedy_institute_of_ethics_journal/

lines for quality assurance in breast can-

eu/uploads/efpia.pdf

v017/17.2fan.pdf

ec.europa.eu/health/ph_projects/2002/

European Foundation for the Improve-

Friends of Europe. Healthcare in Times

cancer/fp_cancer_2002_ext_guid_01.

ment of Living and Working Conditions.

of Austerity: Boosting Cost-Effective

pdf

Access to healthcare in times of crisis.

Prevention. 2013. http://www.friendso-

2014. http://eurofound.europa.eu/sites/

feurope.org/media/uploads/2014/10/

European Commission. Health at a

default/files/ef_publication/field_ef_doc-

FoE-Report-Vaccination-20130522.pdf

Glance: Europe 2014 Executive Summary.

ument/ef1442en.pdf

cer screening and diagnosis. 2006. http://

2014. http://ec.europa.eu/health/reports/ docs/health_glance_2014_exs_en.pdf

159

Gillies S & Gretch S. Coping with Medicare

Healthcare Without Harm. Climate

Advantage fee-for-service plans. Ameri-

change and Health. Undated. https://no-

Gai R et al. Hospital medical waste man-

can Academy of Orthopaedic Surgeons.

harm-europe.org/issues/europe/climate-

agement in Shandong Province, China.

2008. http://www.aaos.org/news/aaos-

change-and-health-0

Waste Management & Research 2009;

now/sep08/managing5.asp

27(4): 336-42. http://www.researchgate.

Health Care Without Harm. Healthier Hos-

net/publication/26258093_Hospital_

Global Health Workforce Alliance. The

pitals Initiative’s 2013 Milestone Report

medical_waste_management_in_Shan-

Morocco Country Case Study: Positive

Shows Sustainability Trends Catching

dong_Province_China

Practice Environments. 2010. www.who.

on Among U.S. Hospitals. 2014. https://

int/workforcealliance/knowledge/PPE_

noharm-uscanada.org/articles/news/

Morocco_CaseStudy.pdf

us-canada/healthier-hospitals-initia-

Ganju N & Walsh M. Sustainable Computing: How Digital Healthcare can Help the

tives-2013-milestone-report-shows-sus-

Environment, Reduce Costs, and Improve

Greenbiz. Kaiser, Metro Health bet big on

Patient Service. TechNet Magazine. 2009.

sustainability. 2013. http://www.greenbiz.

tainability

http://technet.microsoft.com/en-us/mag-

com/blog/2013/05/10/kaiser-met-

Health Care Without Harm. Medical

azine/2009.04.digitalhealthcare.aspx

ro-health-sustainability

Waste and Human Rights. 2011. noharm.

Gao X, Xu J, Sorwar G & Croll P. Imple-

Greenhalgh T. Evidence based medicine:

mentation of E-Health Record Systems

a movement in crisis? BMJ 2014; 348.

and E-Medical Record Systems in China.

http://www.bmj.com/content/348/bmj.

Health Care Without Harm. Unused

The International Technology Manage-

g3725

Pharmaceuticals Where Do They End

org/lib/downloads/waste/MedWaste_

ment Review 2013; 3(2): 127-139. p131

Human_Rights_Report.pdf

Up? A Snapshop of European ColGuahao. 2014. www.Guahao.com

Gauld R. NHS can learn a lot from New

lection Schemes. Undated. https:// noharm-europe.org/sites/default/files/

Zealand’s healthcare system. The Guard-

Guanche-Garcell H, et al. Device-associ-

documents-files/2616/Pharm%20Re-

ian. 2014 http://www.theguardian.com/

ated infection rates in adult intensive care

port_WEB.pdf

healthcare-network/2014/oct/21/nhs-

units of Cuban university hospitals: In-

learn-new-zealand-healthcare-system

ternational Nosocomial Infection Control

Health Consumer Powerhouse. Euro

Consortium (INICC) findings. Interna-

Health Consumer Index. 2014. http://

Gauld R. New Zealand’s ‘integrated

tional Journal of Infectious Diseases 2011;

www.healthpowerhouse.com/files/

performance and incentive framework’:

15(5): 357-362. www.sciencedirect.com/

EHCI_2014/EHCI_2014_report.pdf

Will it drive a ‘whole of system’ approach

science/article/pii/S1201971211000373

to health service design? Universi-

Health Programme of the European

ty of Birmingham. 2014. http://www.

Guardian. Eight more hospitals declare

Union. Overview of the national laws

birmingham.ac.uk/schools/social-policy/

critical incidents as demand surges.

on electronic health records in the EU

departments/health-services-manage-

2015 http://www.theguardian.com/soci-

Member States and their interaction with

ment-centre/news/viewpoint/2014/

ety/2015/jan/06/hospitals-struggling-de-

the provision of cross-border eHealth

new-zealands-integrated-perfor-

mand-cancel-operations-major-incidents

services – Final report and recommenda-

mance-and-incentive-framework.aspx

tions. 2014. http://ec.europa.eu/health/ Guzman-Blance M, et al. Epidemiology

ehealth/docs/laws_report_recommenda-

Gauld R. What should governance for

of meticillin-resistant Staphylococcus

tions_en.pdf

integrated care look like? New Zealand’s

aureus (MRSA) in Latin America. Inter-

alliances provide some pointers. The

national Journal of Antimicrobial Agents

Healthcare Information and Management

Medical Journal of Australia. 2014.

2009; 304-308. www.slipe.org/pdf/

Systems Society. Integrated Health Inno-

https://www.mja.com.au/jour-

guzman%20blanco%20mrsa%20epi%20

vations Conference: Press Release. 2013.

nal/2014/201/3/what-should-gover-

in%20la.pdf

www.himssmiddleeast.com/innova-

nance-integrated-care-look-like-new-zea-

tions13/media/pressRelease_131118.aspx

lands-alliances-provide

George Washington University. Low

Hay MC et al. Harnessing experience: ex-

do. 2012. http://healthierhospitals.org/

Health Literacy: Implications for National

ploring the gap between evidence-based

about-hhi/what-we-do

Health Policy. 2007. http://publichealth.

medicine and clinical practice. Journal of

gwu.edu/departments/healthpolicy/

Evaluation in Clinical Practice 2008; 14(5):

Hesketh T et al. Violence against doctors

CHPR/downloads/LowHealthLiteracyRe-

707-713. http://www.ncbi.nlm.nih.gov/

in China. BMJ 2012; 345. http://www.bmj.

port10_4_07.pdf

pubmed/19018899

com/content/345/bmj.e5730.abstract

Healthier Hospitals Initiative. What we

160

HIMA Research. Untitled.2013.http://

Huang E. It Isn’t Getting Any Easier to Get

Institute for Health Systems Research.

www.hima-research.com/useful-info/hos-

a Doctor’s Appointment in China. The At-

Adverse Events in MOH Non-Specialist

pital-grading-system-in-china/

lantic. 2013. http://www.theatlantic.com/

Hospital. 2010.

china/archive/2013/05/it-isnt-gettingHibbard JH et al. Patients with lower ac-

any-easier-to-get-a-doctors-appoint-

Institute for Healthcare Improvement.

tivation associated with higher costs; de-

ment-in-china/276400/

Across the Chasm Aim #2: Health Care

livery systems should know their patients’

Must Be Effective. 2015. http://www.ihi.

“scores”. Health Affairs 2013; 32: 216-22.

org/resources/Pages/ImprovementSto-

HIMSS Analytics. Saudi hospital first in

IHS Inc. Ecuadorian government introduc-

the Middle East to achieve global recog-

es price controls for essential medicines.

Institute for Healthcare Improvement.

nition for its healthcare IT. 2012. www.

2014. www.ihs.com/country-indus-

Across the Chasm: Six Aims for Changing

himssmiddleeast.com/analytics/about/

try-forecasting.html?ID=1065991469

the Health Care System. 2015. http://

ries/HealthcareMustBeEffective.aspx

pressRoom-pressrelease120125.asp

www.ihi.org/resources/Pages/ImproveIMS Consulting Group. New Game.

mentStories/AcrosstheChasmSixAims-

Himmelstein D, et al. A Comparison of

New Opportunities. New Direction.

forChangingtheHealthcareSystem.aspx

Hospital Administrative Costs in Eight

2013. https://www.imshealth.com/de-

Nations: US Costs Exceed All Others By

ployedfiles/imshealth/Global/Content/

Institute for Patient- and Family-Centered

Far. Health Affairs 2014; 33(9): 1586-

Home%20Page%20Content/High-

Care. Partnering with Patients and Fam-

1594. content.healthaffairs.org/con-

Growth%20Markets/New_Game_New_

ilies to Design a Patient and Family-Cen-

tent/33/9/1586.full.pdf

Opportunites_ChinaWP.pdf

tered Health Care System. 2008. http://

Hoath B. Guahao: VC Fantasy. Online

The Independent. NHS in critical condi-

Appointment Registration System for

tion as A&E waiting times are worst in a

China’s 700 Million Internet Users. The

decade. 2015 http://www.independent.

Health Care Blog. 2013. http://the-

co.uk/life-style/health-and-families/

healthcareblog.com/blog/2013/06/13/

health-news/nhs-in-critical-condition-

Jackson Healthcare. Quantifying the Cost

guahao-vc-fantasy-online-appoint-

as-ae-waiting-times-are-worst-in-a-de-

of Defensive Medicine. 2010. http://www.

ment-registration-system-for-chi-

cade-9961509.html

jacksonhealthcare.com/media-room/sur-

www.ipfcc.org/pdf/PartneringwithPa-

nas-700-million-internet-users/

tientsandFamilies.pdf J

veys/defensive-medicine-study-2010/ International Alliance of Patients’ Organi-

Hu B et al. Device-associated infection

zations. Declaration on Patient-Centred

James J. A New, Evidence-Based

rates, device use, length of stay, and

Healthcare. 2006. http://iapo.org.uk/

Estimate of Patient Harms Associated

mortality in intensive care units of 4 Chi-

sites/default/filesfiles/IAPO_declara-

with Hospital Care. Journal of Patient

nese hospitals: International Nosocomial

tion_English.pdf

Safety. 2013; 9(3): 122-128. http://journals.

control Consortium findings. American

lww.com/journalpatientsafety/Fulltex-

Journal of Infection Control 2013; 41(4):

International Diabetes Federation. IDF

t/2013/09000/A_New,_Evidence_

301-306. http://www.researchgate.net/

Diabetes Atlas, Sixth Edition. 2013. www.

based_Estimate_of_Patient_Harms.2.as-

publication/232065132_Device-associat-

idf.org/sites/default/files/EN_6E_At-

px#

ed_infection_rates_device_use_length_

las_Full_0.pdf

of_stay_and_mortality_in_intensive_

Jayaprakash N, et al. Crowding and

care_units_of_4_Chinese_hospitals_In-

International Finance Corporation –

Delivery of Healthcare in Emergency

ternational_Nosocomial_Control_Con-

World Bank Group. IFC Investment in

Departments: The European Perspective.

sortium_findings

Medical Waste Treatment Plants in China

Western Journal of Emergency Medicine

is Expected to Benefit 120 million people.

2009; 10(4): 233-239. http://www.ncbi.

Huang C. Healthcare Is So Corrupt In Chi-

2007. http://www.ifc.org/wps/wcm/t/

nlm.nih.gov/pmc/articles/PMC2791723/

na That Patients Have To Bribe Doctors

6c360a004970c0289aa2da336b93d75f/

For Proper Care. Business Insider. 2014.

Medical%2BWaste.pdf?MOD=AJPERES

http://www.businessinsider.com/health-

Johns Hopkins Medicine. Diagnostic Errors More Common, Costly And Harmful

care-is-so-corrupt-in-china-that-patients-

Internet Live Stats. China Internet Users.

Than Treatment Mistakes. 2013. http://

have-to-bribe-doctors-2014-5?IR=T

2014. http://www.internetlivestats.com/

www.hopkinsmedicine.org/news/media/

internet-users/china/

releases/diagnostic_errors_more_common_costly_and_harmful_than_treatment_mistakes

161

Joint Action Health Workforce Plan-

Kaplan RS & Porter ME. The Big Idea: How

Lim L. China’s Professional Queuers Paid

ning and Forecasting. Leaflet. Undated.

to Solve the Cost Crisis in Health Care.

to Stand Around. NPR. 2011. http://www.

http://euhwforce.weebly.com/up-

Harvard Business Review. 2011. https://

npr.org/2011/07/25/138549322/chinas-

loads/2/3/0/5/23054358/leaflet_jah-

hbr.org/2011/09/how-to-solve-the-cost-

professional-queuers-paid-to-stand-

wf_print_website.pdf

crisis-in-health-care

around

Joint Action Health Workforce Planning

Kaplan RS, Witkowski ML, & Hohman JA.

Lua W. Universal Rural healthcare in

and Forecasting. Welcome page. Undat-

Schön Klinik: Measuring Cost and Value.

China? Not So Fast. The Atlantic. 2013.

ed. http://euhwforce.weebly.com/

Harvard Business School Case 112-085,

http://www.theatlantic.com/china/

2012. (Revised December 2014.) http://

archive/2013/09/universal-rural-health-

Joszt L. Uninsured Rate Fell to 12.9% by

www.hbs.edu/faculty/Pages/item.aspx?-

care-in-china-not-so-fast/279429/

the End of 2014. American Journal of

num=41579

Managed Care. 2015. http://www.ajmc.

com/newsroom/Uninsured-Rate-Fell-to-

KPMG International. Improving energy

129-by-the-End-of-2014

and resource efficiency. 2012. http://

Madsen F, Ladelund S & Linneberg A.

www.kpmg.com/Global/en/IssuesAn-

High Levels of Bed Occupancy Asso-

dInsights/ArticlesPublications/care-in-a-

ciated With Increased Inpatient And

changing-world/Pages/improving-ener-

Thirty-Day Hospital Mortality In Denmark.

gy-resource-efficiency.aspx

Health Affairs 2014; 33(7): 1236-1244.

K Kaiman J. China says more than half of its groundwater is polluted. The Guardian.

http://content.healthaffairs.org/con-

2014. http://www.theguardian.com/envi-

KPMG. Trends, risks and opportunities in

ronment/2014/apr/23/china-half-ground-

healthcare. 2012. http://www.kpmg.com/

water-polluted

global/en/issuesandinsights/articlespub-

Magill S et al. Multistate Point-Prevalence

Kaiser Family Foundation. A Guide to

lications/care-in-a-changing-world/pag-

Survey of Health Care-Associated Infec-

the Supreme Court’s Decision on the

es/trends-risks-opportunities.aspx

tions. New England Journal of Medicine.

ACA’s Medicaid Expansion. 2012. https://

tent/33/7/1236.abstract

2014; 370: 1198-1208. http://www.nejm.

kaiserfamilyfoundation.files.wordpress.

Kroening-Roche JC, Soroudi A, Castillo

com/2013/01/8347.pdf

EM, Vilke GM. “Antibiotic and bronchodi-

org/doi/pdf/10.1056/NEJMoa1306801

lator prescribing for acute bronchitis in

McKinsey & Company. An essential strate-

Kaiser Family Foundation. Medicaid

the emergency department.” The Journal

gy for the essential drug list. 2013. http://

and the Uninsured. 2009. https://kai-

of Emergency Medicine 2012; 43:221.

www.mckinseychina.com/wp-content/

serfamilyfoundation.files.wordpress.

uploads/2014/09/McKinsey-An-essen-

com/2013/01/7914.pdf

tial-strategy-for-the-essential-drug-list.

Kaiser Family Foundation. Number of

Lee G et al. Perceived impact of the Medi-

Uninsured Eligible for Medicaid Under the

care policy to adjust payment for health

McKinsey & Company. China’s Healthcare

ACA. 2015. http://kff.org/health-reform/

care-associated infections. American

Reforms. 2010.

state-indicator/number-of-uninsured-el-

Journal of Infection Control 2012; 40(4):

igible-for-medicaid-under-the-aca/#table

314-319. http://www.ajicjournal.org/

McKinsey & Company. Healthcare in

article/S0196-6553%2811%2901253-3/

China: Entering ‘uncharted waters’. 2012.

abstract

http://www.mckinsey.com/insights/

pdf?afc765

Kaiser Family Foundation. The Coverage Gap: Uninsured Poor Adults in States that

health_systems_and_services/health_

Do Not Expand Medicaid – An Update.

Legido-Quigley H. Erosion of universal

care_in_china_entering_uncharted_wa-

2014. http://kff.org/health-reform/

health coverage in Spain. The Lancet

ters

issue-brief/the-coverage-gap-uninsured-

2013; 382(9909): 1977.

poor-adults-in-states-that-do-not-expand-medicaid-an-update/

McTiernan R. China’s EDL release a Leyshon S & McAdam S. The importance

positive for patients, pharma firms to

of taking a systems approach to per-

face pricing pressure. IHS Life Sciences

Kan H. Environment and Health in China:

son-centred care. BMJ Spotlight Supple-

Blog. 2013. http://healthcare.blogs.ihs.

Challenges and Opportunities. Environ-

ment on Patient Centred Care. 2015.

com/2013/03/28/chinas-edl-release-a-

mental Health Perspectives 2009; 117(2):

positive-for-patients-pharma-firms-to-

530-531. http://www.ncbi.nlm.nih.gov/

Li Z, Guo X, Zheng L, Yang H, Sun Y. Grim

pmc/articles/PMC2799473/

status of hypertension in rural China: Re-

face-pricing-pressure/

sults from Northeast China Rural Cardio-

Mead N & Bower P. Patient-centred con-

vascular Health Study 2013. Journal of the

sultations and outcomes in primary care:

American Society of Hypertension 2015.

a review of the literature. Patient Education and Counselling 2002; 48: 51-56.

162

Medafrica. 2012. http://www.medafrica.

Mobile Monday. Mobile Southeast Asia

Nhavoto JA & Grönlund Å. Mobile Tech-

org/

Report 2012: Crossroads of Innovation.

nologies and Geographic Information

2012. www.mobilemonday.net/reports/

Systems to Improve Health Care Systems:

SEA_Report_2012.pdf

A Literature Review. JMIR mHealth and

Medecins Sans Frontieres. Yemen: Enrolment for antiretroviral treatment increas-

uHealth 2014; 2(2). http://www.ncbi.nlm.

ing in health facilities. 2014. www.msf.

Monday Morning Sustainia & DNV GL.

org/article/yemen-enrolment-antiretrovi-

Person-Centred Care: Co-Creating a

ral-treatment-increasing-health-facilities

Healthcare Sector for the Future. 2014.

NHS Warrington CCG. Commissioning

http://issuu.com/sustainia/docs/person-

for Value Insight Pack. 2013. http://

centredcare?e=4517615/9843475

www.england.nhs.uk/wp-content/up-

Medscape. Overuse Accounts for Up to 30% of Healthcare Spending. Medscape.

nih.gov/pmc/articles/PMC4114429/

loads/2013/11/CfV-warring2.pdf

2012. http://www.medscape.com/viewar-

Moore M. China’s ‘airpocalypse’ kills

ticle/757527

250,000 to 500,000 each year. The Tele-

graph. 2014. www.telegraph.co.uk/news/ Ministry of Health, China. Counterpart

worldnews/asia/china/10555816/Chinas-

OECD. The Cost of Air Pollution. 2014.

Technical Support between Urban Tertia-

airpocalypse-kills-350000-to-500000-

http://www.oecd.org/environment/the-

ry Hospitals and Rural Hospitals in China.

each-year.html

cost-of-air-pollution-9789264210448-en.

WHO – Global Health Workforce Alliance.

htm

2011. http://www.who.int/workforcealli-

Murray M and Tantau C. Must patients

ance/forum/2011/hrhawardscs9/en/

wait? Joint Commission Journal on Quali-

OECD. StatExtracts – Health expenditure

ty Improvement 1998; 24(8): 423-5.

and financing, main indicators. 2013.

Ministry of Health. Better, Sooner, More Convenient Health Care in the Commu-

http://stats.oecd.org/index.aspx?DataN

SetCode=HEALTH_STAT

system/files/documents/publications/

National Committee of Quality Assurance.

OECD. Structural Policy Country Notes:

better-sooner-more-convenient-health-

The State of Healthcare Quality: 2003.

Thailand. 2013. www.oecd.org/dev/

care_0.pdf

2003. http://www.ncqa.org/Portals/0/

asia-pacific/Thailand.pdf

nity. 2011. https://www.health.govt.nz/

Publications/Resource%20Library/ Ministry of Health, New Zealand. NZ

SOHC/SOHC_2003.pdf

Health Systems, Key Organizations,

Office of Disease Prevention and Health Promotion. National Action Plan to Pre-

Health alliances. 2011. http://www.

National Committee for Quality Assur-

vent Health Care-Associated Infections:

health.govt.nz/new-zealand-health-

ance. The Essential Guide to Healthcare

Road Map to Elimination. 2013. http://

system/key-health-sector-organisa-

Quality. 2007. http://www.ncqa.org/

www.health.gov/hai/pdfs/hai-ac-

tions-and-people/health-alliances

Portals/0/Publications/Resource%20

tion-plan-executive-summary.pdf

Library/NCQA_Primer_web.pdf Ministry of Health, Singapore. Patient Sat-

Official Journal of the European Union.

isfaction Survey 2013. 2013. www.moh.

National Commission on Physician Pay-

Regulation (EU) No 282/2014 of the Euro-

gov.sg/content/dam/moh_web/Press-

ment Reform. Report on The National

pean Parliament and of the Council. 2014.

Room/Press%20releases/Annex%20A.

Commission on Physician Payment

http://eur-lex.europa.eu/legal-content/

pdf

Reform. 2013. http://physicianpay-

EN/TXT/PDF/?uri=CELEX:32014R0282&-

mentcommission.org/wp-content/

from=EN

Minter A. Why Living in Beijing Could

uploads/2013/03/physician_payment_re-

Ruin Your Life. Bloomberg View. 2014.

port.pdf

http://www.bloombergview.com/arti-

Orlanes JE. Health Check: The Cost of Medical Care in Japan. Tokyo Week-

cles/2014-06-19/why-living-in-beijing-

National Institute of Environmental Health

ender. 2014. www.tokyoweekender.

could-ruin-your-life

Sciences. Climate Change & Human

com/2014/12/health-check-the-cost-of-

Health. 2014. http://www.niehs.nih.gov/

medical-care-in-japan/

Mobaraki A & Soderfeldt B. Gender

research/programs/geh/climatechange/

inequity in Suadi Arabia and its role

index.cfm

ranean Health Journal 2010; 16(1):

New England Health Institute. Preventing

Pan American Health Organization. Costa

113-118. applications.emro.who.int/

Medication Errors: A $21 Billion Opportu-

Rica. 2012. www.paho.org/saludenlasa-

emhj/1601/16_1_2010_0113_0118.pdf p116.

nity. 2010. http://www.nehi.net/bendthe-

mericas/index.php?option=com_doc-

curve/sup/documents/Medication_Er-

man&task=doc_view&gid=124&Itemid=

in public health. Eastern Mediter-

rors_%20Brief.pdf

163

Patient Protection and Affordable Care

Robert Wood Johnson Foundation.

Skoll Foundation. Partners in Health. 2015.

Act, 42 U.S.C. § 18001. 2010. http://www.

Doing Better by Doing Less: Approach-

www.skollfoundation.org/entrepreneur/

gpo.gov/fdsys/pkg/BILLS-111hr3590enr/

es to Tackle Overuse of Services. 2013.

dr-paul-farmer/

pdf/BILLS-111hr3590enr.pdf

http://www.rwjf.org/content/dam/farm/

Peerapakorn S & Jayawickramarajah PT.

reports/issue_briefs/2013/rwjf403697/

Smith R & Coast J. The True Cost of

subassets/rwjf403697_1

Antimicrobial Resistance. BMJ 2013; 346.

Role of Medical Education in patient safe-

http://dx.doi.org/10.1136/bmj.f1493

ty. South East Asian Journal of Medical

Robert Wood Johnson Foundation &

Education 2008; 1(1). seajme.md.chula.

Johns Hopkins Bloomberg School of Pub-

Spongenberg H. Chronic diseases: forcing

ac.th/articleVol1No1/CM2_Somchai%20

lic Health. Chronic Care: Making the Case

change in EU healthcare management. EU

Peerapakorn.pdf

for Ongoing Care. 2010. http://www.

Observer. 2014. https://euobserver.com/

rwjf.org/content/dam/farm/reports/re-

chronic-diseases/125922

Pfizer. The Global Burden of Noncom-

ports/2010/rwjf54583

municable Diseases. 2011. https://www. pfizer.pt/Files/Billeder/Pfizer%20

Stewart M et al. Patient-Centered MedS

P%C3%BAblico/Not%C3%ADcias/Glob-

icine. Transforming the Clinical Method. 2003.

al%20Burden%20of%20Noncommunica-

Schatz M, Rachelefsky G, Krishnan JA.

ble%20Diseases.pdf

Follow-up after acute asthma epi-

Stockholm Network. Patient Power –

Plain Writing Act, 5 U.S.C. 301. 2010.

sodes: what improves future outcomes?

What it takes for patient associations to

http://www.gpo.gov/fdsys/pkg/PLAW-

Proceedings of the American Thoracic

help shape public poilcy. 2013. http://

111publ274/pdf/PLAW-111publ274.pdf

Society 2009;6: 386-93.

www.stockholm-network.org/down-

Porter ME. A Strategy for Health Care

Shaw C et al. Accreditation and ISO

Reform — Toward a Value-Based System.

certification: do they explain differences

The New England Journal of Medicine

in quality management in European hos-

Sustainability Roadmap for Hospitals.

2009; 361: 109-112. http://www.nejm.org/

pitals? International Journal for Quality in

Waste. 2015. http://www.sustainabili-

doi/full/10.1056/NEJMp0904131

Health Care 2010; 22(6): 445-451. http://

tyroadmap.org/topics/waste.shtml#.

intqhc.oxfordjournals.org/content/in-

VJQYFsAOA

loads/publications/Patient_Power_Fi-

Porter ME. What Is Value in Health

tqhc/22/6/445.full.pdf

Care? The New England Journal of

Swedish Agency for Growth Policy and

Medicine 2010; 363: 2477-2481. http://

Shimba Mobile. Medafrica. 2014 http://

Analysis. China’s Healthcare System –

www.nejm.org/doi/full/10.1056/NE-

shimbamobile.com/project/medafrica/

Overview and Quality Improvements.

JMp1011024?viewType=Print

2013. http://www.tillvaxtanalys.se/ Sidani S. Effects of patient-centered

download/18.5f097bc113eacc3d-

Porter ME & Guth C. Redefining German

care on patient outcomes: An evalua-

6d513e/1369033621751/direct_re-

Healthcare: Moving to a Value-Based

tion. Research And Theory For Nursing

sponse_2013_03.pdf

System. 2012.

Practice: An International Journal 2008; 22(1): 24-37.

PricewaterhouseCoopers. Emerging

Swedish Competition Authority. The EU GPP criteria for medical devices. 2014.

Trends in Chinese Healthcare. 2010.

Siciliani L, Moran V & Borowitz M.

http://ec.europa.eu/environment/gpp/

https://www.pwc.com/gx/en/healthcare/

Measuring and comparing health care

pdf/WebinarEUGPP_Swedish_Competi-

pdf/emerging-trends-in-chinese-health-

waiting times in EOCD countries. Health

tion_Authority.pdf

care.pdf

Policy 2014; 118(3): 292-303. http://www. sciencedirect.com/science/article/pii/

PricewaterhouseCoopers. Socio-eco-

S0168851014002267

nomic impact of mHealth. 2013. www.

Tao L et al. Device-associated infec-

gsma.com/latinamerica/wp-content/

Singh H, Meyer A & Thomas E. The fre-

tion rates in 398 intensive care units in

uploads/2013/05/mhealth-brazil-mexico.

quency of diagnostic errors in outpa-

Shanghai, China: International Noso-

pdf

tient care: estimations from three large

comial Infection Control Consortium

observational studies involving US adult

(INICC) findings. International Journal of

populations. BMJ Quality and Safety

Infectious Diseases 2011; 15(11): 774-780.

2014; 23(9). http://qualitysafety.bmj.

http://www.ijidonline.com/article/S1201-

Reuters. China to invest $227 billion to

com/content/early/2014/04/04/bm-

9712(11)00149-4/abstract

curb air pollution: state media. Reuters.

jqs-2013-002627.abstract

2013. http://www.reuters.com/article/2013/07/25/us-china-pollution-idUSBRE96O01Z20130725

164

nal_1.pdf

Tao X et al. Hospital-acquired infection

Transparency International. Corruption

Webster P. Health in Colombia: a system

rate in a tertiary care teaching hospital in

Perceptions Index 2014: Results. 2014.

in crisis. Canadian Medical Association

China: a cross-sectional survey involving

http://www.transparency.org/cpi2014/

Journal 2012; 184(6): 289-290. www.ncbi.

2434 inpatients. International Journal

results

nlm.nih.gov/pmc/articles/PMC3314050/

Weir K. Closing the health-wealth gap.

of Infectious Diseases. 2014; 27: 7-9. http://www.ijidonline.com/article/S12019712(14)01539-2/pdf

American Psychological Association. US Department of Health and Human

2013; 44(9): 36. http://www.apa.org/

The BMJ Spotlight. Patient Centred Care.

Services. The Affordable Care Act is

monitor/2013/10/health-wealth.aspx

2015. http://www.bmj.com/patient-spot-

Working. 2015. http://www.hhs.gov/

light

healthcare/facts/factsheets/2014/10/af-

Wellards. What is commissioning for

fordable-care-act-is-working.html

value? 2014. http://www.wellards.co.uk/

The Dana-Farber Cancer Institute. Paths

papers/courses/channels/commission-

of Progress Volume 2011; 20(2). http://

US Department of Health and Human

ing/what_is_commissioning_for_value/

www.dana-farber.org/uploadedfiles/

Services. Primary Protection: Enhancing

index.html

library/newsroom/publications/paths-of-

Health Care Resilience for a Changing

progress/2011/fall-winter/pop_fw2011_fi-

Climate. 2014. http://toolkit.climate.gov/

Wong E. Air Pollution Linked to 1.2

nal.pdf

sites/default/files/SCRHCFI%20Best%20

Million Premature Deaths in China. New

Practices%20Report%20final2%20

York Times. 2013. http://www.nytimes.

2014%20Web.pdf

com/2013/04/02/world/asia/air-pollu-

The Free Dictionary by Farlex. Medical Dictionary. 2015. http://medical-dictionary.thefreedictionary.com/gatekeeper

tion-linked-to-1-2-million-deaths-in-china. US Department of Health and Human

html

Services. Testimony on U.S. Efforts to The King’s Fund. Evaluation of the UK

Reduce Healthcare-Associated Infections.

Woodhead M. How much does the

Pilots. 2011. http://www.kingsfund.org.uk/

2013. http://www.hhs.gov/asl/testi-

average Chinese doctor earn? Chinese

sites/files/kf/field/field_publication_file/

fy/2013/09/t20130924.html

Medical News. 2014. http://www.chinese-

schwartz-center-rounds-pilot-evalua-

medicalnews.com/2014/03/how-much-

tion-jun11.pdf

does-average-chinese-doctor.html

The King’s Fund. Patient-Centred

Wang Q & Lu Y. Medical Education

The World Bank. Climate Change in the

Leadership: Rediscovering Our Purpose.

Reforms in China. Asia Pacific Biotech

Maldives. 2010. www.worldbank.org/

2013. http://www.kingsfund.org.uk/

News 2014; 10(15): 805-808. http://www.

en/news/feature/2010/04/06/climate-

sites/files/kf/field/field_publication_file/

asiabiotech.com/publication/apbn/10/en-

change-in-the-maldives

patient-centred-leadership-rediscover-

glish/preserved-docs/1015/0805_0808.

ing-our-purpose-may13.pdf

pdf

The King’s Fund. The NHS under the

Wannian L & Chan D. Community

tion. 2013. http://www.worldbank.org/

coalition government. 2015. http://www.

Healthcare Reform and General Practice

en/news/feature/2013/06/06/Hospi-

kingsfund.org.uk/publications/nhs-un-

Training in China – Lessons Learned. Med-

tal-reforms-in-rural-china-increased-pa-

der-coalition-government

ical Education Online 2004; 9(10). http://

tient-satisfaction

The World Bank. Hospital Reforms in Rural China Increased Patient Satisfac-

www.med-ed-online.net/index.php/meo/ The State Council of the People’s Repub-

article/viewFile/4366/4548

lic of China. Guideline targets improving

The World Bank. Out-of-pocket health expenditure (% of private expenditure on

healthcare. 2015. http://en.nhfpc.gov.

Washington Post. Worst air pollution

health). Data. 2015. http://data.world-

cn/2014-06/19/content_17573833.htm

in China and the U.S. Washington Post.

bank.org/indicator/SH.XPD.OOPC.ZS

2014. http://www.washingtonpost.com/ The White House. Greening America’s

world/worst-air-pollution-in-china-and-

Hospitals Part 1. 2012. https://www.

the-us/2014/02/02/6362127e-8c5b-11e3-

youtube.com/watch?v=u5LWxKf2BBA&-

833c-33098f9e5267_graphic.html

feature=plcp WebMD. Acute Bronchitis—Topic Overview. 2015. http://www.webmd.com/ lung/tc/acute-bronchitis-topic-overview

165

The World Bank. Project appraisal docu-

World Health Organization. Achieving the

World Health Organization. Systems

ment on a proposed Loan in the amount

health-related Millennium Development

Thinking for Health Systems Strength-

of Euro 250 million to Romania for a

Goals in the Western Pacific Region. 2012.

ening. 2009. http://whqlibdoc.who.int/

health sector reform – improving health

www.wpro.who.int/publications/mdg_

publications/2009/9789241563895_eng.

system quality and efficiency project.

booklet_2012_final.pdf

pdf

external/default/WDSContentServer/

World Health Organization. Background

World Health Organization. The

WDSP/IB/2014/03/13/000442464_2014

Paper 6.13: Chronic Obstructive Pulmo-

African Regional Health Report.

0313102315/Rendered/PDF/PAD6500P-

nary Disease (COPD). 2013. www.who.

2014. apps.who.int/iris/bitstre

145174010Box382166B00OUO090.pdf

int/medicines/areas/priority_medicines/

am/10665/137377/4/9789290232612.

BP6_13COPD.pdf

pdf?ua=1

at the World Bank: Burundi’s National

World Health Organization. Counterpart

World Health Organization. The Global

Performance Based Financing (PBF) Pro-

Technical Support between Urban Tertia-

Numbers and Costs of Additionally Need-

gram. 2011. www.rbfhealth.org/sites/rbf/

ry Hospitals and Rural Hospitals in China.

ed and Unnecessary Caesarean Sections

files/Burundi_country_example.pdf

2011. http://www.who.int/workforcealli-

Performed per Year: Overuse as a Barrier

ance/forum/2011/09_China.pdf?ua=1

to Universal Coverage. 2010. www.who.

2014. http://www-wds.worldbank.org/

The World Bank. Results Based Financing

The World Bank. Romania – Health

int/healthsystems/topics/financing/heal-

Sector Reform – Improving Health

World Health Organization. Country Co-

System Quality and Efficiency Proj-

operation Strategy at a glance: Cambo-

ect. 2015. http://www.worldbank.org/

dia. 2014. www.who.int/countryfocus/co-

World Health Organization. Working

en/news/loans-credits/2014/03/28/

operation_strategy/ccsbrief_khm_en.pdf

document for discussion at the 7th Global

romania-health-sector-reform-improv-

threport/30C-sectioncosts.pdf

Conference on Health Promotion, ‘Pro-

ing-health-system-quality-and-efficien-

World Health Organization. Explor-

moting Health and Development: Closing

cy-project

ing patient participation in reducing

the Implementation Gap’, Nairobi, Kenya,

health-care-related safety risks. 2013.

26-30 October 2009. http://www.who.

The World Bank. Who Pays?: Out-of-

http://www.euro.who.int/_ _data/assets/

int/healthpromotion/conferences/7gchp/

Pocket Health Spending and Equity

pdf_file/0010/185779/e96814.pdf

Track1_Inner.pdf

Africa. 2010. siteresources.worldbank.

World Health Organization. Health insur-

World Health Organization European Ob-

org/HEALTHNUTRITIONANDPOPULA-

ance systems in China: A briefing note.

servatory on Health Systems and Policies.

TION/Resources/281627-1095698140167/

2010. http://www.who.int/healthsystems/

Health Systems in Transition: Russian Fed-

WhoPays.pdf

topics/financing/healthreport/37ChinaB_

eration. 2011. www.euro.who.int/_ _data/

YFINAL.pdf

assets/pdf_file/0006/157092/HiT-Rus-

Implications in the Middle East and North

The World Bank Europe and Central Asia

sia_EN_web-with-links.pdf

Region. Romania Functional Overview

World Health Organization. Health sector

– Health Sector. 2011. http://www-wds.

reform in China. 2015. http://www.wpro.

World Health Organization European

worldbank.org/external/default/WD-

who.int/china/mediacentre/factsheets/

Observatory of Health Systems and Poli-

SContentServer/WDSP/IB/2012/12/10/0

health_sector_reform/en/

cies. Health Systems in Transition: United

00425962_20121210160554/Rendered/ PDF/NonAsciiFileName0.pdf

States. 2013. http://www.euro.who. World Health Organization. Health Sys-

int/_ _data/assets/pdf_file/0019/215155/

tem Financing Country Profile: Philip-

HiT-United-States-of-America.pdf

World Wide Web Foundation. Problem:

pines. 2012. apps.who.int/nha/database/

7,000 Doctors Serve a Nation of 40

Country_Profile/Index/en

Million People. Solution: MedAfrica. 2012

Observatory on Health Systems and Pol-

http://webfoundation.org/2012/03/

World Health Organization. Patients for

icies. The impact of the financial crisis on

medafrica-interview/

Patient Safety. 2015. http://www.who.int/

the health system and health in Ireland.

patientsafety/patients_for_patient/en/

2014. www.euro.who.int/_ _data/assets/

Wharton – University of Pennsylvania.

166

World Health Organization European

pdf_file/0011/266384/The-impact-of-

Healthcare in China: Is There a Doctor in

World Health Organization. Public health,

the-financial-crisis-on-the-health-system-

the House? 2013. http://knowledge.whar-

environmental and social determinants

and-health-in-Ireland.pdf?ua=1

ton.upenn.edu/article/health-care-in-chi-

of health (PHE). 2015. www.who.int/phe/

na-is-there-a-doctor-in-the-house/

health_topics/outdoorair/databases/en/

World Health Organization Regional Of-

World Health Organization Regional

fice of the Eastern Mediterranean. Demo-

Office of the Western Pacific. Antimicro-

graphic, Social and Health Indicators for

bial Resistance. 2014. www.wpro.who.

Countries of the Eastern Mediterranean.

int/about/regional_committee/65/docu-

2013. http://applications.emro.who.int/

ments/wpr_rc065_07_amr.pdf

dsaf/EMROPUB_2013_EN_1537.pdf World Health Organization Regional OfWorld Health Organization Regional

fice of the Western Pacific. Health Sector

Office of Europe. Better noncommu-

Reform in China. 2015. http://www.wpro.

nicable disease outcomes: challenges

who.int/china/mediacentre/factsheets/

and opportunities for health systems.

health_sector_reform/en/

Country assessment: Turkey. 2014. www.euro.who.int/_ _data/assets/

pdf_file/0004/260266/Better-non-communicable-disease-outcomes,-challeng-

Yang H et al. Determinants of Initial Utili-

es-and-opportunities-for-health-sys-

zation of Community Healthcare Services

tems,-No.-2,-Turkey-Country-Assessment.

among Patients with Major Non-Commu-

pdf?ua=1

nicable Chronic Diseases in South China. PLOS One 2014: 9(12). http://www.ncbi.

World Health Organization Regional Of-

nlm.nih.gov/pmc/articles/PMC4278805/

fice of Europe. Regional Pharmaceutical Situation Report. 2013. www.euro.who.

Yang J. The side-effects of China’s pa-

int/_ _data/assets/pdf_file/0014/237011/

tient-centered healthcare reform. 2010.

WHO-EURO-Regional-Pharmaceuti-

http://www.social-policy.org.uk/lincoln/

cal-situation-Report.pdf?ua=1

Yang.pdf

World Health Organization Regional

Yip W & Hsiao W. The Chinese Health Sys-

Office for Europe. Roadmap: Strength-

tem At A Crossroads. Health Affairs 2008;

ening people-centred health systems

460-468. http://www.hsph.harvard.edu/

in the WHO European Region. 2013.

wp-content/uploads/sites/100/2012/09/

http://www.euro.who.int/_ _data/assets/

hsiao_2008_-_the_chinese_health_sys-

pdf_file/0005/231692/e96929-replace-

tem_at_a_crossroads.pdf

ment-CIHSD-Roadmap-171014b.pdf?ua=1 World Health Organization Regional Office of South-East Asia. Health in South-East Asia. 2013. www.searo.who. int/entity/health_planning_financing/ documents/HISEA.pdf?ua=1 World Health Organization Regional Office of South-East Asia. eHealth in South East Asia Region of WHO. 2013. www.itu.int/en/ITU-D/ICT-Applications/ eHEALTH/Documents/JC_30_Sept_ WHO_ITU_COIA_eHealth_Workshop_ v1.pdf World Health Organization Regional Office of South-East Asia. A Decade of Public Health Achievements in WHO’s South-East Asia Region. 2013. apps.searo. who.int/PDS_DOCS/B5003.pdf

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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

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