DNV GL - The State of Healthcare by DNV AS

FROM CHALLENGES TO OPPORTUNITIES

SUSTAINIA

a part of

MONDAY MORNING

FROM CHALLENGES TO OPPORTUNITIES

ACKNOWLEDGEMENTS DNV GL and Monday Morning Sustainia would like to thank the following for their contribution to the publication: The participants at the roundtables in Shanghai, Brussels and Washington DC. For each roundtable we were happy to see a diverse group of patient representatives, professionals, policy makers, providers and researchers working together on mapping challenges in their region and pointing towards opportunities for the future. Their willingness to share experiences and thoughts has been an invaluable part of this publication. The regional experts. Thank you to Mr. Alex Lam, Ms. Weiwei Zhang, MEP Christel Schaldemose, Professor Francesco De Lorenzo, Professor Bob Smith and Ms. Britanni Kessler for sharing their perspectives on the present challenges and future possibilities for healthcare in China, Europe and the USA. The change-makers. Thank you to Ms. Susan Sheridan, Professor Jeffery Lazarus and Professor Stephen MacMahon for sharing their stories of creating change in the healthcare system and thereby inspiring others to dare dream of a safer, smarter and more sustainable future for healthcare. ÂŠ DNV GL and Monday Morning Sustainia 2015 Print: Rosendahls ISBN: 978-87-93038-30-1

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FOREWORD

The unfolding science of patient engagement

Over the last 5 years of evangelizing a new view of the role of the patient in medicine, it has become apparent to me that changing the cultural conversation about who is capable of what is challenging because it creates a shift in the balance of power. The people that had been viewed as the responsible leaders can experience a loss of power and authority. While the Scientific Revolution brought an understanding of how medicine works, one of the unintended side effects was the disenfranchisement of anyone without medical training. Today, we are in an era of awakening that recognizes the need to better incorporate patients in their own treatment programs. We cannot co-create healthcare systems if providers do not accept patient engagement as both helpful and necessary. In my case, my oncologist agreed to be quoted in the British Medical Journal saying that the information I got from a patient community about how to cope with side effects of a treatment that sometimes kills people increased my chances of survival. Clearly, change is possible when knowledge in the patient community is harnessed.

In order to create that, we must acknowledge the clear evidence that activated, engaged and informed patients today are quite capable of truly improving their outcomes. If we create a scientific model for patient engagement, one of the parameters will be usability. In any other industry, if what you want the customer to do is too difficult, you go out of business. In medicine, you blame the victim. The art of culture change – in healthcare as well as any other matter – is to see clearly what is newly possible without giving up what has always been valuable. This publication helps guide us to that goal by outlining our current state of affairs and offering exciting opportunities for change. One of the most wonderful things that could happen in my view is for the doctors and nurses and researchers whose work saved my life to find that they themselves now have a better life because their contributions can unfold in a richer more effective environment. That is co-creation.

E-PATIENT DAVE BIO Dave deBronkart, known on the internet as e-Patient Dave, is the author of the highly rated Let Patients Help: A Patient Engagement Handbook and one of the world’s leading advocates for patient engagement. After beating stage IV kidney cancer in 2007 he became a blogger, health policy advisor and international keynote speaker. An accomplished speaker in his professional life before cancer, he is today one of the best-known spokesman for the patient engagement movement, attending nearly 300 conferences and policy meetings internationally, including testifying in Washington for patient access to the medical record under Meaningful Use. e-Patient Dave was a participant at the Co-Creating Healthcare Roundtable in Washington DC

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

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

Table of Contents 8

INTRODUCTION

EUROPE– SHARING A HEALTHCARE GOAL

Protecting universal care

Creating a patient safety culture

10 EXECUTIVE SUMMARY

Towards co-creation at different speeds

Growing demand and shrinking budgets

EU guides the way to more effective care

13 WHAT WE DID AND WHY 14

16 17

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 FROM EAST TO WEST

CHINA – RECALIBRATING A SYSTEM FOR NEW DISEASE PATTERNS

32 EASTERN MEDITERRANEAN

48 Physical and social inequalities

34 EUROPE

CO-CREATING HEALTHCARE

SEEING THE WHOLE SYSTEM

STANDARDS FOR COCREATION

Safety is a challenge for patients and professionals

SOUTH-EAST ASIA

WESTERN PACIFIC

The patient is a resource

GLOBAL OVERVIEW

The economic burden of no

A healthy environment

Brussels roundtable

Effectiveness is improving but

Worth the wait? In need of a breath of fresh air

door to universal healthcare 119

Case in Kenya: A doctor to the masses

121 122

Case in USA: Bringing the patient safety

94 96

Watch the access gap

103

Healthcare: more than the

Case in Australia: Strong

106

108

128

Case in Germany: Improving quality by measuring the

130

131

133

134

– Steven MacMahon, China

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

Chronic disease management in rural China

better communication

Healthcare on time…

112

148

Knowledge sharing helps

increases effectiveness

Washington DC roundtable

– Susan Sheridan, USA

healthcare do its job

worth?

110

Improving patient safety through advocacy

true value of care

Commissioning for Value

sometimes

144

Knowing the value of

Getting your money’s

Too much and not enough

– Jeffrey V. Lazarus, Europe

healthcare is key

Towards healthcare of, by and for the people

101

127

The fight to improve patient safety

Bridging the “Knowing-Doing” Gap

sum of its parts

Expert insight

THE UNITED STATES OF AMERICA – BALANCING THE SCALES

140

The patient as the expert

patient voice to the world of

125

139 THE CHANGE MAKERS

Mobile health apps open the

healthcare

Shanghai roundtable Expert insight

118

A JOURNEY TOWARDS OPPORTUNITIES

alliances create integrated

not incentivized 58

116

125

gatekeeping

Timing is everything

19 SYSTEMS THINKING AND CO-CREATION

115 ROADMAP TO CHANGING HEALTHCARE

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

HEALTH SYSTEMS IN FOCUS This section of the publication

gram tackling the challenge of NCDs

can seem so enormous and sys-

in rural China. It is our hope that the

USA in order to map out the differ-

temic that it may feel impossible

stories of their efforts will inspire

ences and similarities and flesh out

to separate them from each other.

and galvanize each reader to take

how and why healthcare systems

But improvement is possible and is

charge of healthcare in his or her

struggle to deliver the best quality

happening.

own community.

selected because they face similar

This final chapter of the publication

challenges in terms of rising demand

puts the spotlight on seven case

CO-CREATION

and costs, concerns with quality

studies highlighting opportunities

and changing disease patterns.

for improvement within the seven

They represent different underlying

dimensions of healthcare. From

causes, different types of health

mobile health apps in Kenya to

systems and different responses. A

cost-efficiency measurements at

comparison of these three health-

clinics in Germany, the solutions that

Before making an improvement,

care systems offers valuable insight

will form the healthcare systems of

we need to know where we stand

into changing healthcare dynamics

tomorrow are popping up all around

today. In this section we synthe-

in the world today.

the world to address the specific

of care. These three regions were

GLOBAL HEALTHCARE

process that went before it is to

closer look at healthcare systems

OUTLOOK

enrich the conversation about the

around the world in order to exam-

future of healthcare by including

ine what is holding the quality of

solutions, innovations and people

care back and what solutions exist

that are co-creating greener and

today.

size data on health systems from

process of stakeholder engagement The overall challenge that this pub-

throughout 2014 and the first half

lication addresses is the fact that

of 2015. Over the last 18 months we

quality improvement1 and evidence

have met with people from around

based practice movements2 have

the world who are showing that

not been able to change health sys-

change in healthcare is possible.

tems so that they deliver consistent care that improves both individual

Our findings are presented in the

and population well-being.

following chapters: Global Healthcare Outlook, Health Systems in

A key reason for this is that such

Focus and Roadmap to Changing

attempts at change have tended

Healthcare.

to focus on preventing the reoccurrence of particular ailments and their immediate causes rather than

needs of specific locations.

around the world to give a snapshot

China, Europe and the USA are

of healthcare. We frame this by

examined through seven dimensions

Finally, revolutions need leaders, and

placing it in the context of the WHO

of healthcare quality: equity, safety,

healthcare is no exception. To guide

regions.

person-centered care, effective-

the reader from learning about the

ness, cost-efficiency, timeliness

inspirational performances of others

The data offer insight into the chal-

and environmental sustainability.

towards creating change in their

lenges faced in different regions.

Healthcare in China is challenged by

own system of healthcare, three

For instance, NCDs cause 87% of

its extreme urban and rural divide,

change makers tell the story of how

deaths in Europe, but only 28% in

while in the USA, historical social

they saw a need and created a solu-

Africa. However, developing coun-

inequalities continue to have an

tion to meet it.

tries struggle with a lack of health-

impact on the healthcare systems

care resources compared to more

of today. Europe, meanwhile, is

We learn how Susan Sheridan, after

industrialized regions.

performing a balancing act between

her family experienced two serious

leaving health issues to the nations

medical system failures, succeed-

Importantly, when compared, alarm-

and consolidating policymaking at

ed in changing the standards of

ing figures from one region can

an EU level.

care. We meet Jeffrey Lazarus,

be seen as warning signs for other

understanding and strengthening the underlying system and promoting co-creation between different stakeholders. 3

MacMahon and Lifeseeds, a pro-

systems in China, Europe and the

On the following pages, we take a

This publication is the result of a

And we hear the story of Stephen

Challenges in healthcare systems

The aim of this publication and the

healthcare systems of tomorrow.

CHANGING HEALTHCARE

sets out to examine the healthcare

“We cannot solve our problems with the same thinking we used when we created them.” This quote from Albert Einstein hits the nail on the head when it comes to the publication you hold in your hands.

smarter pathways towards the

ROADMAP TO

– FRONT AND CENTER Voices of patients, professionals, policy makers and researchers are all vital in collecting the puzzle pieces that constitute a healthcare system. Without this complete picture, long term, systemic change is unlikely. Through our roundtables in Shanghai, Brussels and Washington DC; interviews with experts at each location; and in-depth profiles of three leading change makers, healthcare experts – in every sense of the word – have helped outline the current challenges and illuminate the future opportunities. This publication is a truly co-created effort.

who co-founded the HIV in Europe

regions hoping to avoid the same

But despite the differences, all three

Initiative as a way of closing the gap

health problems in due time.

regions have been subject to polit-

between what we know and what

ical reforms and policy change on

we do.

the subject of health and healthcare, pointing to the fact that the unsustainability of current healthcare systems is on the top of the agenda for decision makers in all three regions.

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

Greenhalgh T et al. Evidence Based Medicine: A Movement in Crisis? BMJ 2014; 348: 1-7. 2

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

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

THE 7 QUALITY DIMENSIONS OF HEALTHCARE

By adding it to the existing quality dimensions, we

world are facing are known – they are documented and

Here, we present the reader with an examination of

We have adapted the six quality dimensions of

provide a framework for identifying priority areas

communicated in various indices, reports and fore-

healthcare systems in China, Europe and the USA

the Institute of Medicine by adding sustainabili-

that, if improved, would increase healthcare’s abili-

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

by using 7 quality dimensions of healthcare as an

ty. The impact of healthcare on the environment

ty to meet the needs of service users and commu-

the newest information on the challenges, select the

analytical framework, outlined on page 15. The health

and the environment on healthcare is increasingly

nities today and tomorrow.

relevant data and present them in an easy to under-

systems profiled in this section are chosen due to

recognized as an important factor in the ability of

stand and engaging way that enables comparison

their importance and impact on the global economy,

healthcare to deliver services that meet the needs

between regions.

the sheer size of their populations, and their different

of individuals and populations.1

healthcare schemes. They each represent different The result of the literature review is presented in the

funding models but each are going through periods of

Global Healthcare Outlook and in the Health Systems

significant change.

in Focus section. The data used to create the Global Healthcare Outlook THE GLOBAL HEALTHCARE OUTLOOK

and Health Systems in Focus are found by gathering

This chapter uses the WHO-defined 6 world regions

knowledge and research from leading global health-

and highlights key and comparable figures on health-

care organizations and institutions such as the Com-

care and society in every region, each time touching

monwealth Fund, the WHO and EU institutions. We’ve

down in 10 specific spots to shed some light on exam-

analyzed and synthesized data from leading regional

ples of healthcare in action.

and national healthcare authorities and institutions to compile a snapshot of current performance and

The data we have chosen for the Global Healthcare

challenges.

EQUITY

SAFETY

PERSON-CENTERED

EFFECTIVENESS

Providing care that does

Avoiding harm arising from

CARE

Providing services based

not vary in quality because

the way care is delivered.

Providing care that is

on scientific knowledge to

of personal characteristics

respectful of and respon-

all who could benefit, and

such as gender, ethnicity,

sive to individual patient

refraining from providing

geographic location, and

preferences, needs, and

services to those not likely

socioeconomic status.

values, and engaging them

to benefit.

Outlook gives the reader a quick overview of the

as equal partners in co-cre-

healthcare system and health in society for each

ating care.

region.

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

DATA USED FOR THE HEALTHCARE SYSTEM OVERVIEW

Physicians

Hospital beds

Total

General

per 10,000 people

Out-of-pocket

Per capita total

per 10,000

expenditure

people

on health as %

Government

expenditure

Expenditure

as % of private

on health

of GDP

of total

expenditure on

at average

expenditure on

health

exchange rate

health

COST-EFFICIENCY

TIMELINESS

ENVIRONMENTAL

Avoiding waste, including

Reducing waits and some-

SUSTAINABILITY

waste of equipment, sup-

times harmful delays for

Limiting the negative

plies, ideas, and energy.

both those who receive

impact of the healthcare

and those who give care.

sector on the environment and simultaneously better managing the impact of the environment (including,

DATA USED FOR THE HEALTH IN SOCIETY OVERVIEW

climate change) on the healthcare sector2 Life expectancy

Under-five

Deaths

HIV

Obesity

mortality rate

caused by

mortality rate

rate

NCDs

Alcohol consumption and tobacco use NHS Sustainable Development Unit. Sustainable, Resilient, Healthy People & Places: A Sustainable Development Strategy for the NHS, Public Health and Social Care system. 2014. 1

The definitions are adapted from the 2001 Institute of Medicine report, Crossing the Quality Chasm, except for the sustainability dimension, which we have defined. 2

WASHINGTON DC 9TH OF FEBRUARY 2015

BRUSSELS 18TH OF NOVEMBER 2014

SHANGHAI 28TH OF OCTOBER 2014

3) Highlighting Opportunities, Inspiring Change

2) Roundtables With Key Healthcare Stakeholders

An overview of the challenges for global health-

We identified numerous cases that fit the above

care systems lets us know where we stand. But a

criteria and then focused on the 7 selected based

focus on opportunities helps us share the solu-

on their quality, potential and diversity.

tions. Therefore, this publication includes seven inspirational performances from across the globe.

In order to inspire the reader to initiate change in

They illustrate the fact that innovative, sustainable

his or her own healthcare setting, we also present

developments already exist and are tackling some

three change maker interviews with people that

of the challenges within healthcare.

have a proven track record for tackling healthcare challenges and changing healthcare systems for

THE CRITERIA FOR SELECTING THE CASES

the better.

The aim of this chapter is to highlight a variety of Although gathering and analyzing existing knowl-

The roundtable participants were selected by com-

solutions which demonstrate that opportunities are

The change makers, and the initiatives for which

edge gives the publication a strong foundation,

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

created all around the world and come in different

they are responsible, correspond to the three loca-

we also wanted to listen to key stakeholders in our

networks, and reaching out to experts in each loca-

shapes and sizes.

tions of the Health Systems in Focus: China, Europe

three core regions and extract what they consid-

tion. This process ensured that each participant list

ered to be the biggest challenges and opportuni-

included patients, professionals, providers, policy

The seven inspirational performances reflect our

each change maker using core questions in order

ties for healthcare in their region. The roundtable

makers and researchers.

7 quality dimensions of healthcare. They span

to extract common threads and best practices for

different countries, costs, and scopes of change.

success in transforming healthcare sectors around the world.

locations were chosen to match the policy epicen-

and the USA. An interview was conducted with

ters of each of our three Health Systems in Focus:

After the roundtables, we conducted interviews

Some are multi-million dollar, large scale initiatives,

Shanghai, Brussels and Washington DC.

with two participants from each region in order to

while others are home grown and locally supported

harvest even more of their knowledge within the

campaigns. They also differ in terms of where they

The roundtables were in the format of one-day

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

are in the implementation process. This breadth

interactive workshops. Each roundtable included

standing of the different healthcare systems.

of coverage is important in order to stress that

an inspirational talk from an expert participant, fol-

solutions to healthcare issues exist at every level of

lowed by structured group-work and discussions.

operation.

What you should keep in mind when reading this publication In the pursuit of creating a publication that is accessible and inspiring for a broad group of readers, we have created a narrative that gives an overview and a taste of the different challenges and opportunities. It is not an extensive review of all the challenges and opportunities. We are aware that with a different focus, we could have found other inspirational performances or other experts with different viewpoints and included other challenges that would have painted a different picture of the healthcare landscapes. For the purposes of this publication, we have used the WHO global regions to frame our analysis. The exception is in relation to Europe where we have drawn on both the broader WHO region as well as the narrower European Union (EU) that sits within it. The WHO includes 53 countries within its definition of Europe; the EU consists of 28 Member States. Although we

This publication does not target one specific type of reader but rather is meant to inspire all the different stakeholders across healthcare systems worldwide and to encourage discussion and debate on how we can collectively change

SYSTEMS THINKING AND COCREATION

healthcare for the better.

have included examples from across the 53 countries defined by the WHO, we have also focused particualrly on the policies and regulations of the EU as these represent an attempt to create a common ambition to improve the well-being of populations across national borders. In order to allow easy comparisons between the different regions and health systems, we have converted all currency to American dollars through Google Financeâ&#x20AC;&#x2122;s currency exchange system. The figures express the exchange rates from 2 March 2015.

BEYOND MAPPING THE STATE OF GLOBAL HEALTHCARE AND THE CHALLENGES IT FACES, THIS PUBLICATION HIGHLIGHTS EXAMPLES FROM LOW, MIDDLE AND HIGH INCOME COUNTRIES IN WHICH PATIENTS, HEALTH PROFESSIONALS, MANAGERS AND POLICY MAKERS ARE PROVING, FROM MICRO TO MACRO LEVELS, THAT CHANGE IS BOTH DESIRED AND ACHIEVABLE.

What connects each of these stories is their focus of patient empowerment, systems-thinking approaches to problem-solving, and cultivation of healthcare environments that allow for and encourage the co-creation of person-centered care.

CO-CREATING SAFER, SMARTER

Co-Creating Healthcare

AND MORE SUSTAINABLE SYSTEMS Healthcare has changed greatly over the last century. New technology and advances in treatment mean that a girl born in 2012 can expect to live around 73 years and a boy to the age of 68 years. This is six years longer than average global life expectancy for a child born in 1990.1

Co-creation means delivering services “… in an equal and reciprocal relationship Yet, as the regional analyses in the following chapters show, all countries are cur-

between professionals, people using services, their families and their [communi-

rently struggling to deliver safe and sustainable healthcare. Ageing populations,

ties … so that both services and communities] become far more effective agents

the pandemic of non-communicable diseases, rising costs, disparities in access

of change”.4 Engaging patients as active partners in the design and delivery of

between rich and poor and unacceptably high rates of patient harm are clear and

services is a powerful tool for transformational change, resulting in:

significant threats to sustainable healthcare around the world. 1) IMPROVED COSTS

The growing complexity of healthcare, with care becoming ever more sub-specialized, poses an additional challenge. Increasing numbers of health and social

Patients who are actively engaged have better health outcomes at lower costs

care professionals are involved in each patient’s journey through the system, par-

compared with less activated patients. For example, patients with the lowest

ticularly those with multiple co-morbidities. Within this complexity the patient is

activation scores (i.e. people with the least skills and confidence to participate in

in danger of becoming lost as different parts of the health and social care system

their own healthcare) can cost 8 to 21% more than patients with the highest acti-

struggle to coordinate with one another. 2 Too often services are fractured and

vation levels, even after adjusting for health status and other factors. 5

fragmented: reflecting the evolution of abstract political ambitions rather than a purposeful and coherent system design based on what patients need or want.

2) IMPROVED OUTCOMES

Attempts to improve healthcare have relied on narrowly defined, technocrat-

Working with patients and their family members to co-create person-centered

ic approaches with inadequate attention to context and engagement of local

care is proven to have a positive impact on outcomes in low, middle, and high

providers, practitioners and patients as co-creators of health systems. 3 There is,

income countries, including: health status6, knowledge7, adherence 8 , and patient

therefore, a clear need to look for ways that build on the knowledge of quality

and practitioner satisfaction. 9, 10

improvement and evidence based practice by involving stakeholders in strengthening health systems as a whole.

But to achieve this requires an understanding of how systems and their different components work together to produce results.

Such change is possible. Beyond mapping the state of global healthcare and the challenges it faces, this publication highlights examples from low, middle and high income countries in which patients, health professionals, managers and policy makers are proving, from micro to macro level; that change is both desired and achievable. What connects each of these stories is their focus on patient empowerment, systems-thinking approaches to problem-solving, and cultivation of healthcare environments that allow for and encourage the co-creation of person-centered care. 1

WHO. World Health Statistics. 2014.

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

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

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

Hibbard JH et al. Patients with lower activation associated with higher costs; delivery systems should know their patients’ “scores”. Health Affairs 2013; 32: 216-22. 5

Sidani S. Effects of patient-centered care on patient outcomes: An evaluation. Research And Theory For Nursing Practice: An International Journal 2008; 22(1): 24-37.

DiMatteo MR et al. Patient adherence and medical treatment: A meta-analysis. Med Care 2002; 40: 794 – 811. 8

The King’s Fund. Patient-Centred Leadership: Rediscovering Our purpose. 2013. 9

Stewart M et al. Patient-Centered Medicine: Transforming the Clinical Method. 2003. 10

Mead N & Bower P. Patient-centred consultations and outcomes in primary care: a review of the literature. Patient Education and Counselling 2002; 48: 51–56.

Seeing the whole system Systems-thinking is an approach to improvement that sees challenges to quality as part of a wider, dynamic structure: looking for patterns of distributed risk rather than fragments or individual episodes.11 It involves more than a reaction to a particular outcome or event; it requires a deeper understanding of the distribution, linkages and relationships among the processes that characterize the entire system.12 As such, systems thinking is a:

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

“… mindset that views systems and their sub-components as intimately related and connected to each other, believing that mastering our understanding of how things work lies in interpreting interrelationships and interactions within and between systems.” 13

Creating pre-emptive and mitigation controls to deliver safe and consistently reliable results

Establishing policies that set clear and explicit goals and directions regarding quality (including defining what quality means for an organization)

Standards for co-creation

Identifying and assessing risks to human, technologiContinuously improving

cal and organizational safety

through the analysis of

and performance (including

One way to ensure that the co-creation of person-cen-

The Global Healthcare Outlook examines and com-

tered care and systems-thinking are put into practice is

pares systems on a macro and regional level giving the

through accreditation. Accreditation provides a prac-

reader an immediate overview of the state of health-

tical, structured framework for addressing the quality

care around the world. In the Health Systems in Focus

improvement needs of healthcare. Trained external

chapter, we zoom in to the Chinese, American and Eu-

peer reviewers evaluate an organization’s compliance

ropean healthcare systems and examine the different

Mapping processes and iden-

with pre-established performance standards that

quality components of a healthcare system, offering

tifying indicators to monitor

can be applied to specific threats (such as managing

the reader a basis for further discussing what the

infection risk) or across services. Evidence shows that

systems have in common, what needs to be changed

healthcare providers “… that have either ISO certifica-

and what three seemingly different health systems can

tion or accreditation are safer and better than those

learn from each other.

performance and the

how these are distributed

adoption of necessary

within and across organiza-

process changes to

tions and who owns them)

achieve results

those processes (including Measuring process performance and

how they connect within and between organizations)

monitoring the efficacy of controls

that have neither” 14 and that “… accreditation programs should be supported as a tool to improve the quality of

Lastly, in the Roadmap to Changing Healthcare

healthcare services”.15

chapter, we continue to dig deeper, highlighting the solutions, organizations and people that constitute

Combining systems-thinking with the co-creation of

the disruptive elements in healthcare systems in low,

person-centered care plus frameworks such as accred-

middle and high income countries. These solutions

itation offers a powerful way to redesign healthcare.

address system failures with truly co-created efforts.

In this publication, we examine systems on different levels of action.

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

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

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

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.

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.

Algeria Angola

AFRICA

Global Healthcare Outlook

Benin Botswana Burkina Faso Burundi Cabo Verde Cameroon

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

In this chapter, we map out the state of healthcare throughout the

Guinea

Lesotho

Niger

South Sudan

Eritrea

Liberia

Nigeria

Swaziland

Ethiopia

Madagascar

Rwanda

Togo

Gabon

Malawi

Uganda

Gambia

Mali

Sao Tome and Principe

Ghana

Mauritania

Guinea

Mauritius

Guinea Bissau

Mozambique

Kenya

Namibia

Senegal Seychelles

Tanzania Zambia Zimbabwe

Sierra Leone South Africa

world, using the six WHO regions as guides, in order to give a broad, chapter. The Outlook includes key health-related financial indicators, such as total expenditure on health and out of pocket expenditures, but also figures on social elements of health, like the prevalence of non-communicable diseases and life expectancy. These numbers provide a

THE AMERICAS

global overview before diving into our three health systems in the next

Antigua and Barbuda

Brazil

Dominican Republic

Haiti

Peru

Canada

Honduras

Argentina

Chile

Ecuador

Jamaica

Saint Kitts and Nevis

Bahamas

Colombia

El Salvador

Mexico

Saint Lucia

Barbados

Costa Rica

Grenada

Nicaragua

Cuba

Guatemala

Panama

Bolivia

Dominica

Guyana

Saint Vincent and the Grenadines

Paraguay

Suriname

Afghanistan

Iran

Lebanon

Pakistan

Sudan

Bahrain

Iraq

Libya

Qatar

Djibouti

Jordan

Morocco

Saudi Arabia

Syrian Arab Republic

Belize

Trinidad and Tobago United States of America Uruguay Venezuela

Therefore, each regional outlook also presents 10 illustrations of healthcare in particular countries, allowing the reader to zoom in and get a more complete look at the challenges, opportunities and com-

EUROPE

plexities of healthcare in every region.

EASTERN MEDITERRANEAN

general overview of healthcare in each region, but lack a local context.

Egypt

Kuwait

Oman

Somalia

Tunisia

Albania

Croatia

Hungary

Malta

Andorra

Cyprus

Iceland

Monaco

Russian Federation

Armenia

Czech Republic

Ireland

Montenegro

Austria

Denmark

Israel

Netherlands

Azerbaijan Belarus Belgium Bosnia and Herzegovina

SOUTH EAST ASIA WESTERN PACIFIC

Finland France Georgia

Italy Kazakhstan Kyrgyzstan Latvia

Germany

Lithuania

Greece

Luxembourg

Bhutan

Democratic People’s Republic of Korea

Australia Brunei Darussalam

Bulgaria

Norway Poland Portugal Republic of Moldova

Yemen

San Marino

The former Yugoslav Republic of Macedonia

Serbia

Turkey

Slovakia

Turkmenistan

Slovenia

Ukraine

Spain

United Kingdom

Sweden

Uzbekistan

Switzerland

Romania

Tajikistan

India

Maldives

Nepal

Thailand

Indonesia

Myanmar

Sri Lanka

Timor-Leste

Fiji

Marshall Islands

Niue

Micronesia

Palau

Republic of Korea

Tuvalu

Japan Kiribati

Mongolia

Samoa

Vietnam

Cambodia

Lao PDR

Nauru

Papua New Guinea

China

Malaysia

New Zealand

Philippines

Solomon Islands

Bangladesh

Cook Islands

Estonia

United Arab Emirates

Vanuatu

Singapore Tonga

AFRICA

PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)

2.6 0.1 – 12.1 Tanzania, Liberia – Algeria

Ethiopia’s community-based nutrition interventions have

HOSPITAL BEDS PER 10,000 PEOPLE (2000 – 2009)

increased primary healthcare coverage from 77% of communities in 2004 to 92% in 2010. This preventive care has also decreased

10 facts about healthcare in the region

2 1 – 63 Mali – Ethiopia, Gabon

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

The removal of user fees for

Rwanda has mandatory health in-

children’s healthcare in 12 districts

surance (even for visitors staying

in Burkina Faso led to an average

less than 15 days). Currently 92%

increase of 2,000 visits per year

of the population is covered. 2

per center – a 110% spike. 3

THE HEALTHCARE SYSTEM

under –five mortality from 139

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

sick children sought treatment

TOTAL EXPENDITURE ON HEALTH AS % OF GDP (2011)

GENERAL GOVERNMENT EXPENDITURE OF TOTAL EXPENDITURE ON HEALTH (2011)

90% of births in the richest quin-

In Ghana, 92% of caregivers of

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

$99

$12 – $1,051 Eritrea – Equatorial Guinea

6.2%

1.7% –16.3% South Sudan –Sierra Leone

48.3% 16.2% –94.8% Sierra Leone – Seychelles

from community-based agents OUT-OF-POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH

trained to manage pneumonia and malaria and most sought care for their children within 24 hours of the onset of fever. 5

A study in Zambia found that

56.6% 12.7% –100% Botswana – Comoros, Eritrea

68% of children with pneumonia received early and appropriate treatment from community health workers, and that overtreatment of malaria significantly declined. 9

The introduction of results-based

and the McArthur Foundation

financing (RBF) in Burundi – the

worked together on the devel-

allocation of bonuses based on

opment, installation, monitoring,

performance and quality – result-

and maintenance of micro-solar

ed in visits per child increasing

installations in 28 health facilities

from 1.16 in 2009 to 1.6 in 2010,

in Nigeria. 6

and institutional deliveries increasing from 51% in 2009 to 62% in 2010.11

Only five countries: Botswana, Studies on hospital-wide health-

Madagascar, Rwanda, Togo

care associated infections from

and Zambia, have been able to

African countries report high

achieve the target set in the Abuja

infection rates e.g. Mali 18.9%, the

Declaration – dedicating more

Tanzania 14.8% and Algeria 9.8%. 8

than 15% of general government expenditure to healthcare.10

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

World Health Organization. The African Regional Health Report. 2014. 2, 3, 4, 5, 7, 8, 9, 10

eHealth Africa. Micro-Solar Systems for Maternal Health. Undated. 6

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

LIFE EXPECTANCY AT BIRTH IN YEARS (2012)

HEALTH IN SOCIETY

eHealth Africa, WE CARE SOLAR

46 –74 Sierra Leone – Cape Verde, Seychelles, Mauritius

DEATHS CAUSED BY NCDS 1 (2008)

28%

20% – 85% Central African Republic – Mauritius

UNDER-FIVE MORTALITY RATE DEATHS PER 1,000 LIVE BIRTHS (2012)

13 – 182 Seychelles – Sierra Leone

low health literacy are estimated my between $106 billion and $236 billion annually. 4

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

10 facts about healthcare in the region

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

to cost the United States econo-

A 3-year study of two ICU hos-

Partners in Health’s mobile clinics in Haiti have helped more than 33,000 patients since 2013, and

By staggering start-times for sur-

who tested HIV+ to receive fur-

equipment, wait times dropped

ther care.7

75% and the number of surgeries

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

completed increased by 136% in

23 6 – 62 Guatemala – Barbados

$3,482

$62 – $8,467 Haiti – USA

TOTAL EXPENDITURE ON HEALTH AS % OF GDP (2011)

GENERAL GOVERNMENT EXPENDITURE OF TOTAL EXPENDITURE ON HEALTH (2011)

have referred over 450 people

gery and standardizing surgical

20.8

2.1 – 67.2 Guyana – Cuba

The economic repercussions of

THE HEALTHCARE SYSTEM

THE AMERICAS

PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)

14.1%

4.5% – 17.7% Venezuela – USA

49.5% 21.5% – 94.7% Haiti – Cuba

some Canadian hospitals. 9 OUT-OF-POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH

In Brazil, it is estimated that 76% of towns dispose of medical and municipal wastes together at the An estimated 1.6 million chronic

Costa Rica has one of the most

patients could benefit from

effectively universalized health-

mHealth in Mexico, which would

care systems in Latin America. Its

result in per capita healthcare

health insurance coverage rate

spending reductions of 25%. 3

rose from 87.6% in 2006 to 91.9%

Webster P. “Health in Colombia: a system in crisis.” Canadian Medical Association Journal 2012; 184(6): 289-290. 2

in adult intensive care units of Cuban university hospitals: International Nosocomial Infection Control Consortium (INICC) findings.” International Journal of Infectious Diseases 2011; 15(5): 357-362. Skoll Foundation. Partners in Health. 2015. 7

PricewaterhouseCoopers. Socio-economic impact of mHealth. 2013. 3

covered by health insurance, only

controls for essential medicines,

40% of the country receives high

which account for more than 54%

quality care, typically at private

in the Ecuadorian pharmaceutical

hospitals. 60% of people rely

market, making access to these

on inadequate care at crowded,

drugs less expensive and more

public facilities. 2

equitable.10

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

Meticillin-resistant Staphylococcus aureus is the most common hospital acquired infection in Latin America, and the disease had a 51% infection rate in Argentine hospitals in 2006. 5

Guzman-Blance M, et al. ”Epidemiology of meticillin-resistant Staphylococcus aureus (MRSA) in Latin America.” International Journal of Antimicrobial Agents 2009; 304-308. 5

Guanche-Garcell H, et al. “Device-associated infection rates 6

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

LIFE EXPECTANCY AT BIRTH IN YEARS (2012)

HEALTH IN SOCIETY

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

Ecuador has introduced price

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

municipal landfills.11

in 2010. 8

While 97% of Colombians are

30.1%

62 – 82 Haiti – Canada

79%

DEATHS CAUSED BY NCDS 1 (2008)

47% – 88% Guatemala – Canada, USA

UNDER-FIVE MORTALITY RATE DEATHS PER 1,000 LIVE BIRTHS (2012)

15 5 – 79 Canada – Haiti

10 facts about healthcare in the region

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

between 50,000 and 100,000 Iraqis travel each year to countries in the region like Lebanon,

Pakistan’s government spent only $36 per person on health in 2011, the lowest in the region, while Qatar spent the most, at $1,738.

HAI prevalence rate to be 9.4%.

TOTAL EXPENDITURE ON HEALTH AS % OF GDP (2011)

OUT OF POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH

husband decides whether contraKing Faisal Specialist Hospital &

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

GENERAL GOVERNMENT EXPENDITURE OF TOTAL EXPENDITURE ON HEALTH (2011)

For 55% of Qatari women, their

ception is used or not. 2

Research Center in Saudi Arabia Out-of-pocket health expendi-

is ranked in the top 5% of hospi-

tures account for 59% of total

tals worldwide for safety, quality

health financing in Egypt – the

of care and efficiency. 5

0.4–77.4 Somalia–Qatar

8 1– 37 Iran – Libya

healthcare. 6

hospitals in Iran determined the

tons of medical waste every

11.4

Jordan, Iran and Turkey to receive

A study of 4,350 patients at 8

Palestine generates about 512.6 month.

Due to instability caused by war,

THE HEALTHCARE SYSTEM

EASTERN MEDITERRANEAN

PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)

$195

$36 – $1,738 Pakistan– Qatar

4.2%

1.9% – 8.8% Qatar – Jordan

51% 19% – 82.4% Afghanistan – Kuwait

88.9%

58.8% – 100 Saudi Arabia– Iraq, Libya, Syrian Arab Republic

highest in the Region, and 4% in the Saudi Arabia, the Region’s

100% of the population in the

lowest. 9

of the population live less than

to local health services, while this

5 km from a healthcare facility,

The rate of antiretroviral

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

figure is only 57% in Afghanistan. 3

treatment (ART) coverage for

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

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

LIFE EXPECTANCY AT BIRTH IN YEARS (2012)

United Arab Emirates has access

HEALTH IN SOCIETY

In urban areas of Morocco, 100%

53 – 80 Somalia –Lebanon

52%

DEATHS CAUSED BY NCDS 1 (2008)

19% – 85% Somalia – Lebanon

UNDER-FIVE MORTALITY RATE DEATHS PER 1,000 LIVE BIRTHS (2012)

57 7 – 147 Qatar – Somalia

PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)

EUROPE

Only 7.7% of the healthcare 11.5 – 71.7 Albania – Monaco

facilities in Russia are capable of using electronic health histories or electronic medical records. Less

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

than 3% are equipped with the means to use telemedicine.

25 – 138 Andorra, Turkey – Monaco

In 2011 administrative costs in Scotland accounted for 12% of total hospital expenditures while in the Netherlands this

In Georgia, pharmacies and doc-

figure was 19.8%.7

tors are incentivized to dispense brand name drugs in preference to generics. By contrast, studies in

Scotland, which has been a test

Kyrgyzstan and Tajikistan show a

bed for telehealth innovation

high level of generic prescription,

since 2006, currently has approx-

about 70% in both countries. 8

imately 180,000 people signed up to its telecare services, delivered through 32 local partnerships. 5

THE HEALTHCARE SYSTEM

10 facts about healthcare in the region

33.1

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

TOTAL EXPENDITURE ON HEALTH AS % OF GDP (2011)

GENERAL GOVERNMENT EXPENDITURE OF TOTAL EXPENDITURE ON HEALTH (2011)

100,000 people waited over 12

$2,370

$48 – $9,908 Tajikistan – Norway

2.1% – 11.9% Turkmenistan – Netherlands

73.9% 18.1% – 88.6% Georgia – Monaco

months for an outpatient appointment at public hospitals in Ireland

Hospital in-patient medicines, all

during April of 2013. 9

cancer medicines, and medicines

OUT OF POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH

prescribed by family doctors are free of charge to patients in Turkey.

In the Netherlands, almost 70% of the population return their unused

In Latvia only 6% do the same.11

The average waiting times for a hip replacement in 2012-13 was less than 40 days in the Netherlands, but around 150 days in Spain and Hungary.10

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

WHO Regional Office for Europe. Better noncommunicable disease outcomes: challenges and opportunities for health systems. Country assessment: Turkey. 2014. 2

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

is 82% in Cyprus – the highest in The cost of unnecessary Cae-

Europe, and lowest is Austria at

sarean sections in Italy was $101

21%. 3

million in 2008 – the highest in Europe. This cost was lowest in Bulgaria, at $2.3 million. 6

WHO. The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage. 2010.

Himmelstein D, et al. “A Comparison of Hospital Administrative Costs in Eight Nations: US Costs Exceed All Others By Far.” Health Affairs 2014; 33(9): 1586-1594.

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.

Health Care Without Harm. Unused Pharmaceuticals Where Do They End Up? A Snapshop of European Collection Schemes. Undated. 11

HEALTH IN SOCIETY

harmed by healthcare services

hazardous waste collection point.

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

LIFE EXPECTANCY AT BIRTH IN YEARS (2012)

The perceived likelihood of being

medicines to the pharmacy or a

68.8%

63– 83 Turkmenistan – Andorra, Italy, San Marino, Switzerland

87%

DEATHS CAUSED BY NCDS 1 (2008)

62% – 95% Tajikistan – Serbia, The former Yugoslav Republic of Macedonia

UNDER-FIVE MORTALITY RATE DEATHS PER 1,000 LIVE BIRTHS (2012)

12 2– 58 Iceland, Luxembourg – 58 Tajikistan

In 2010 North Korea spent less

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

than $1 per person on healthcare. This was less than any other country in the world. 8

29% of Indonesians have mobile internet access, making them

10 facts about healthcare in the region

5.9

0.7 – 14.2 Timor-Leste – Maldives

prime candidates for mobile health apps. 5

THE HEALTHCARE SYSTEM

SOUTHEAST ASIA

PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)

A project at the cardiology outpatient department of a large

About 10% of hospitalized

university hospital in India was

patients in Indonesia suffer an

able to significantly reduce wait-

adverse event and 5–10% acquire

ing times. In 2011, 64% of patients

a healthcare associated infection. 6

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

TOTAL EXPENDITURE ON HEALTH AS % OF GDP (2011)

GENERAL GOVERNMENT EXPENDITURE OF TOTAL EXPENDITURE ON HEALTH (2011)

waited 3 hours or more for their

10 6– 59 Bangladesh, Myanmar – Timor-Leste

$69

$19 – $525 Myanmar – Maldives

3.7%

1.8% – 8.1% Myanmar – Maldives

36.7% 15.9% – 83.9% Myanmar – Bhutan

consultation, while after the OUT-OF-POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH

project’s completion, in 2013, this number had dropped to just 8%. 9

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

While Bangkok has about 1 doctor 510 tons of medical waste is pro-

per 1,000 people, the poorer

duced in the Maldives each year.11

northeast region of Thailand has only 1 doctor per 8,000 people. 3 LIFE EXPECTANCY AT BIRTH IN YEARS (2012)

In 2010 Sri Lanka had a maternal mortality rate of only 39 deaths per 100,000 live births – an

In their first 1.5 years of operation, dedicated telemedicine centers in Bangladesh provided over 5,800 consultations. 4

exceptional achievement for a developing country.7

Pfizer. The Global Burden of Noncommunicable Diseases. 2011.

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

OECD. Structural Policy Country Notes: Thailand. 2013. 3

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

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

new mothers in Myanmar had difficulties in raising necessary funds to cover the cost of safe

Village Health Volunteers in

birth practices. 17% even forewent

Thailand provide essential basic

essential food in order to cover

healthcare services to 65 million

these payments. 2

Thai villagers, all free of charge.10

Peerapakorn S & Jayawickramarajah PT. “Role of Medical Education in patient safety.” South East Asian Journal of Medical Education 2008; 1(1). 6

Commonwealth Health Online. Health in Sri Lanka. Undated. 7

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

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

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).

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

HEALTH IN SOCIETY

67% of pregnant women and

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

with chronic conditions can be expected to secure same-day access

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

spending for many countries in the Western Pacific are among the highest in the world. In the Philippines, household spending accounts for 58% of health spending. 2

MRSA (methicillin-resistant Staphylococcus aureus )were reported in the Philippines (38.1%) compared to the Republic had very high prevalence rates of 77.6% and 74.1%, respectively. 8

Region. It is estimated that air

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

TOTAL EXPENDITURE ON HEALTH AS % OF GDP (2011)

GENERAL GOVERNMENT EXPENDITURE OF TOTAL EXPENDITURE ON HEALTH (2011)

of Korea and Vietnam, which

2012 lived in the Western Pacific

The levels of out-of-pocket

Lower rates of hospital-acquired

killed by air pollution globally in

0.5 – 32.7 Papua New Guinea – Australia

5 – 137 Philippines – Japan

10 facts about healthcare in the region

40% of the 7 million people

15.3

to a healthcare provider.7

THE HEALTHCARE SYSTEM

WESTERN PACIFIC

PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)

About 65% of Japanese patients

pollution caused 350,000 to

$679

$35 – $5,991 Lao PDR – Australia

6.6%

2.2% – 17.6% Brunei – Tuvalu Darussalam

65%

22.6% – 99.9% Cambodia – Tuvalu

400,000 premature deaths in China alone.11,12,13

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

6.3% of admissions into Ministry Initiatives to address financial bar-

of Health non-specialist hospitals

riers to accessing care in Cambo-

in Malaysia had an adverse event

dia include Health Equity Funds

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

(AE) and 78.8% of the AEs were

which now cover 80% of the

due to errors. 5

poorest people in the country. 3

A skilled birth attendant was pres77.2% of Singaporeans rated their overall satisfaction levels with public healthcare institutions as “excellent” or “good”. 6

The healthcare system in

50% of patients who had been

Singapore was ranked “most

placed on a public hospital

efficient in the world” by

ent at only 37% of births in Lao PDR. The number is 100% for Fiji. 4

elective surgery waiting list in

Bloomberg Rankings in 2014.

Australia waited 36 days or less.10

The city-state’s life expectancy is 82.1 years and healthcare costs account for just 4.5% of GDP. 9

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

Pfizer. The Global Burden of Noncommunicable Diseases. 2011.

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

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

PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)

AFRICA

THE AMERICAS

EASTERN MEDITERRANEAN

EUROPE

SOUTHEAST ASIA

WESTERN PACIFIC

2.6

20.8

11.4

33.1

5.9

15.3

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

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)

$99

$3,482

$195

$2,370

$69

$679

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

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

OBESITY RATE TOTAL EXPENDITURE ON HEALTH AS % OF GDP (2011)

6.2%

14.1%

4.2%

3.7%

6.6%

AMONG ADULTS OVER 20 YEARS OLD (2008)

11.1%

women

ALCOHOL GENERAL GOVERNMENT EXPENDITURE OF TOTAL EXPENDITURE ON HEALTH (2011)

48.3%

49.5%

51%

73.9%

36.7%

65%

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

56.6%

30.1%

88.9%

68.8%

84.3%

78.4%

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.

CHINA

FROM EAST TO WEST

China faces some unique challenges in terms of sustainable healthcare provision in the coming decades. Its demographic and economic transitions have resulted in a massively expanding healthcare system, even outpacing the country’s economic growth. While government reforms in 2009 have acknowledged the need for a more personcentered healthcare system, the country is still struggling to institute such changes

From China over Europe to the United States of America, healthcare systems are under pressure to fulfill their task of delivering quality healthcare.

across the board. Drastic differences in access to quality healthcare between rural and urban populations is a major challenge, as are safety and hospital payment structures that incentivize over- and under-treatment of patients. Although the challenges China faces in relation to healthcare quality and sustainability

This chapter gives three of the largest and most prominent healthcare

are significant, certain bright spots, such as hospital coordination improvements and

systems in the world a check-up in order to describe some of the systemic

the Essential Drug List, could have the potential to help transform China’s healthcare

challenges that are holding them back from becoming safer, smarter and

system into one that is more equitable, person-centered and sustainable.

more sustainable. By giving an objective diagnosis of the healthcare sysPAGES 46-65

tems in China, Europe and the United States of America, we can begin to discuss the differences as well as the common healthcare denominators for the world today. The state of healthcare is uncovered by examining how the seven dimensions of quality in healthcare – adapted from the Institute of Medicine –

EUROPE

measure up with the reality on the ground.

The healthcare systems of Europe are a microcosm of the region as a whole: constantly evolving and increasingly coherent, yet still fragmented in many respects. The Euro Debt Crisis and subsequent financial instability has put a serious strain on the region’s healthcare systems.

THE SEVEN DIMENSIONS OF HEALTHCARE QUALITY ARE: EFFECTIVENESS

growing burden of NCDs have only exacerbated these challenges. Despite national autonomy, the

SAFETY

region’s countries are intertwined and deeply

TIMELINESS

connected. Citizens have an increasing choice in where to live, work and seek healthcare.

PERSON-CENTERED CARE

ENVIRONMENTAL SUSTAINABILITY

COST-EFFICIENCY

under serious pressure due to high costs, the growing burden of NCDs, and the extreme variation in care quality. The country’s inefficient payment model has led to healthcare costs that

Yet still, the care received by many Americans is of a markedly lower quality than many of their Western counterparts. Such inefficiencies are compounded by the increasing problem of NCDs and the growing divide between wealthy and poor citizens. Progress is being made1, as

Such interconnectedness has led the region

recent healthcare reforms have been designed

to adopt European-wide healthcare initiatives,

to address some of these disparities and

aimed at providing all of Europe with more

challenges. 2

equitable, safe and person-centered care in the years to come.

There remains, however, a long road ahead for the country in terms of equalizing access to care,

The analysis is coupled with insights from the three roundtables conducted

lowering healthcare spending, and cultivating

in the regions, where professionals, patients, policy makers and researchers

an all around more sustainable and efficient

discussed the future of healthcare and pointed us towards challenges and

PAGES 66-91

opportunities.

healthcare system.

PAGES 92-113

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

The healthcare system of the United States is

far outpace any other industrialized nation.

Social factors such as aging populations and the

EQUITY

THE UNITED STATES OF AMERICA

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

CHINA RECALIBRATING A SYSTEM FOR NEW DISEASE PATTERNS In 2009, the central government in China announced that a series of reforms would be implemented in an effort to provide safer, more convenient, and more affordable care to its population of 1.3 billion. The reforms affect nearly every aspect of healthcare, from insurance and primary care, to hospital management, medications, and public health. There are also some positive developments, as

recent decades, serious challenges remain in

programs are seeking to help balance healthcare

The reforms underline the fact that the health-

are more likely to live longer. In 2010, people

the country’s approach to healthcare delivery.

resources between rural and urban populations6,

care sector has become an economic and

aged 60 and over accounted for 13% of the total

As explained in the analysis below, the divide

and new reforms like the redesign of the Essen-

strategic priority for China. Healthcare spending

population and it is expected that this will further

between wealthier urban residents and poor-

tial Drug List have the potential to provide more

in China is expected to near $890 billion a year

increase to 24% by 2030. 2

er rural citizens is apparent in their respective

equitable and safer access to pharmaceuticals.7

by 2017, growing by an average rate of 13.8%

While China has made remarkable progress in

healthcare access. Corruption is a serious issue

annually in local currency terms from 2013-2017.

As the country’s demographics and citizen

and person-centered care, while gaining traction,

Total spending is forecast to reach the equivalent

lifestyles have changed, so have the diseases

remains almost entirely absent in some regions.4

of 5.9% of GDP by 2017, up from an estimated

which afflict them. The rate of non-communica-

5.3% in 2012.1

ble diseases (NCDs) has increased dramatically in

Due to major structural problems, safety for

Deloitte. Global healthcare outlook: Shared challenges, shared opportunities. 2014. 1

China, and today more than 85% of the country’s

both patients and doctors alike is a concern. 5

China has made impressive strides since the mid-

mortality is attributed to NCDs. While NCDs have

The healthcare sector is growing at a rapid pace,

20th century in terms of healthcare. Notably, life

become the primary disease burden, communi-

consuming more economic resources, but the

expectancy at birth rose from 35 years before

cable diseases remain a problem in some western

allocation and use of such funds is, at times,

1949 to 75 years in 2010. This increase has also

provinces, illustrating the often extreme divide

wasteful and inefficient.

resulted in a rapidly aging population, as people

between urban and rural livelihoods in China. 3

WHO. Health sector reform in China. 2015. 2,3

Ministry of Health, China. “Counterpart Technical Support between Urban Tertiary Hospitals and Rural Hospitals in China.” WHO – Global Health Workforce Alliance. 2011. 6

IMS Consulting Group. New Game. New Opportunities. New Direction. 2013. 7

Yip W & Hsiao W. “The Chinese Health System At A Crossroads.” Health Affairs 2008; 460-468. 4

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

CHINA

/ EQUITY

DIVIDED BY PHYSICAL AND SOCIAL INEQUALITIES While more Chinese citizens than ever now have health insurance, ensuring equal access to high quality care is still a major challenge for China’s healthcare system. The country’s physical and social divides continue to lead to inequality in terms of access to healthcare.

Third-level hospitals are more likely to be in large

ruption has become extremely widespread in the

cities, while first- and second-level hospitals are

healthcare sector and exists at multiple levels. 20

more often located in local townships and smaller

Patients offer bribes, or as it is called in Chinese

cities.13 In 2011, China had 1,350 public third-level

hongbao, to doctors in the hopes of getting the

hospitals, 6,034 second-level hospitals and 2,908

best treatment possible. Drug companies and

first-level hospitals.14

medical manufacturers are also complicit in these schemes, as seen in the high profile case of Brit-

Rural China also has a drastically low supply of

ish pharmaceutical giant GlaxoSmithKline’s 2013

doctors, due in large part to their hospitals’ less

$488 million bribery fine for channeling nearly

technologically advanced equipment, physicians’

that same amount of money through conduits to

lower salaries, as well as lower prestige.15 As Law-

physicians and other medical staff to prescribe

ton Burns, a healthcare management professor at

their drugs at inflated prices. 21 Such practices

the Wharton Business School notes; “Why would

worsen an inequitable system as access to care

a doctor move from a class three urban hospital

becomes a matter of wealth rather than respond-

to the lower pay of a class one or two hospital in

ing to a clinical need.

a rural area? Doctors lose prestige and money by going outside the cities.” 16 Despite these challenges, rural hospitals have made substantial strides in providing better quality care in recent years. From 2005 to 2008,

5 KEY PRIORITIES OF THE CHINESE HEALTH REFORM OF 2009

as part of a WHO project, 10,000 physicians from well-respected urban third-level hospitals were Stark differences between rural and urban China have cultivated a system in which urban dwellers have greater access to care than rural residents. As China’s Ministry of Health reports through the WHO, while 70% of China’s population is located in rural areas, only 20% of total health resources are allocated to the rural population. 8 Physically separated from care, and often with low incomes that restrict travel abilities, rural Chinese tend to receive lower quality care. 9,10 Large, well equipped Chinese hospitals are typically only located in large cities, meaning rural residents must travel great distances or utilize lower quality health centers.11

THE URBAN/RURAL CHASM While healthcare in China has improved dramatically in recent years, it has not improved equally across the entire country. Where a Chinese citizen lives, particularly whether it is in a city or the countryside, impacts that person’s access to care. According to the WHO, at the end of 2011, China had an average of 3.5 medical institution beds per thousand residents – with a total of 877,727 medical institutions. However, there is a striking difference between urban and rural areas, with 6.24 medical beds per thousand people in urban areas, but only 2.80 in rural areas.12 The divide is also evident in the types of hospi-

This section will focus on the division between urban and rural China and corruption as barriers for creating equitable healthcare.

assigned to work at rural county-level hospitals and township health centers. These doctors agreed to work in rural areas for one year, also providing training for healthcare workers in these communities, in exchange for higher wages and guarantees of future promotion.17 Additionally, a World Bank project in the rural Henan Province restructured hospital payment schemes and subsequently discouraged over-prescription, increased patient satisfaction, and increased physician salaries.18 To read more about alleviating healthcare treatment gaps in rural China, head to

depending on their size and capabilities, with first-level hospitals being the smallest and least well-equipped and third-level hospitals being the largest and best equipped.

identified five priority areas and established a committee across ministries to coordinate their policy formulation and implementation. The five priorities are: • Accelerating the establishment of the basic medical security system • Establishing a national essential medicines system • Strengthening health services at grass roots level • Promoting the equalization of basic public health services • Promoting pilot projects for public hospital reform 22

page 148 of our Change Makers chapter to learn

Pilot project in practice: In June 2014,

about LifeSeeds.

China announced that 17 new pilot cities will fully implement hospital

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

The Chinese government’s 2009 reforms

reforms, intended to strengthen policy interpretation, provide training for

CORRUPTION IS A FACTOR

relevant management personnel and

Given the sensitivity of the subject, little data

heads of pilot hospitals, and improve

exists concerning corruption in China’s healthcare

management. They will also work to

system. But according to Transparency International’s annual corruption perception index, China

publicize and communicate changes to the community. 23

ranks 117 out of 175 nations.19 By all accounts cor8

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

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

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 THE CASE OF LEE MEGNAN

SAFETY AN ISSUE FOR PATIENTS AND PROFESSIONALS

The case of Li Megnan, a 17-year old boy who attacked and killed hospital intern, Wang Hao, in 2012, drew national attention in China. Megnan’s story came to symbolize the collapse of doctor-patient and a fundamental dysfunction in China’s healthcare system, plagued by high costs, questionable diagnose, and poor care provision. Experiencing severe leg pain in his village, Megnan travelled 6 times over the course of 2 years to doctors in larger city hospitals, as those closer to home were unable to properly treat his condition. However, his care in Beijing and Harbin were hardly improvements. Faced with repeated bureaucratic hurdles, incorrect diagnoses, late detection of secondary ailments that necessitated pausing care for his leg pain and raising the cost of treatment through additional prescription drugs, Megnan reached a breaking point. While condemning his actions, many in China sympathized with Megnan’s utter

Safety is perhaps the most basic component of any healthcare system, but it is one in which China still struggles.

he have a history of violence. He was a man whom society had failed so completely that he was impelled to lash out.” 37

According to the limited information on the

EDUCATION AND TRAINING LEVEL OF

subject, the rate of hospital-acquired infections

DOCTORS VARIES

MORE DATA NEEDED ON HOSPITAL ACQUIRED

WHEN THE SYSTEM ATTACKS

appears to be relatively low in China. The educa-

Having adequately educated and skilled care

INFECTIONS

When most of us think of safety in the healthcare

tion and training of doctors, however, is a public

providers is one of the most vital components of

Generally speaking, little data exist on the issue

sector, we think primarily of patient safety. Yet,

health concern, particularly for lower-income pa-

ensuring patient safety. China had about 2.3 mil-

of healthcare associated infections in China. 30

in China, safety and treatment of patients has

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

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

Therefore, knowledge on this burden comes from

become increasingly tied to the safety of doctors

cent phenomenon of patient attacks on doctors

Western medicine. However, the level and quality

small scale studies in various regions and cannot

and other healthcare providers. A survey by

illuminates another side of the safety challenge

of training varies a great deal. Many doctors have

be regarded as representative of the country as

the China Hospital Management Association

in China, as frustrations with poor and danger-

only a 3 year post-secondary certificate and the

a whole. Still, the different studies can give the

found that violence against medical personnel

ously inefficient treatment has been blamed for a

typical 8 year MD training of Western institutions

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

increased an average of 23% each year between

drastic increase in the number of incidents where

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

patients attack doctors. 26

ties. 27

2002 and 2012. 33 By then, Chinese hospitals were One such study surveyed nearly 400,000

reporting an average of 27 attacks a year, per

patients in 398 ICUs of 70 hospitals in Shanghai

hospital. 34

Qualification of doctors and hospital acquired

Additionally, lacking a history of primary care,

from September 2004 to December 2009 and

infections are highlighted below as indicators

China has very few GPs. As such, most doctors

determined that the rate of device-associated

The survey identifies four primary contributing

of the state of patient safety in Chinese health-

working at Community Health Centers (CHCs)

healthcare-associated infections was 5.3%. 31

factors to this phenomenon in China, name-

care. In addition, the aspect of physician safety

are not trained as GPs and are not necessarily

Another report from 2014 – a one-day point

ly a deteriorating doctor-patient relationship,

is presented as a unique propensity in Chinese

equipped to diagnose and treat common diseas-

prevalence study of HAIs in the Yijishan Hospital

caused by the shortcomings of the health system;

healthcare.

es and chronic ailments experienced by patients

of Wannan Medical College – found that the

seeking high level specialist care even for minor

at those facilities. 28,29

prevalence rate of such infections was 3.53%

conditions, leading to unrealistic expectations;

among a survey of 2,434 patients. 32 While these

physician unhappiness and low morale; and inef-

studies act as examples of large and small

fective and inefficient legal channels for handling

scale surveillance of HAIs, the lack of a wider

malpractice disputes. 35 Solving this problem will

breadth of knowledge at a national scale results

take structural changes, such as improved insur-

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

in a significant knowledge gap. More extensive

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

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

studies on HAIs in China would therefore be

better system of legal redress, and an increase in

needed before firm conclusions about their

the use of primary care facilities. 36

Tao X et al. “Hospital-acquired infection rate in a tertiary care teaching hospital in China: a cross-sectional survey involving 2434 inpatients.” International Journal of Infectious Diseases. 2014; 27: 7-9. 24

Q & Lu Y. “Medical Education Reforms in China.” Asia Pacific Biotech News 2014; 10(15): 805-808.

Wannian L & Chan D. “Community Healthcare Reform and General Practice Training in China – Lessons Learned.” Medical Education Online 2004; 9(10). 28

McKinsey & Company. China’s Healthcare Reforms. 2010. 29

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

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

frustrations. As the New Yorker reported in 2014, “Li Mengnan wasn’t a lunatic, nor did

Tao L et al. “Device-associated infection rates in 398 intensive care units in Shanghai, China: International Nosocomial Infection Control Consortium (INICC) findings.” International Journal of Infectious Diseases 2011; 15(11): 774-780. 31

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

35, 36

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

prevalence and impact can be made.

CHINA

/ PERSON-CENTERED CARE tion exists in the Chinese hospital system. Appointment booking, for example, often includes bureaucratic hur-

THE PATIENT IS A RESOURCE

dles, with patients typically unable to book consultations over the phone, instead needing to appear in person at their hospital of choice to wait in line in order to receive an appointment time.42 Some great strides are being made in this area though, as explained in the Journey Toward Opportunities chapter on p. 133. A small, qualitative 2014 study on the care of older adults with chronic illness from two general hospitals, two nursing homes,

China’s approach to person-centered care has made significant strides in recent years. Yet, while some mindsets have changed, many structural practices have not. Person-centered care, therefore, remains a goal rather than an achievement.

one community hospital and one clinic in the city of Tianjin found that nurses may lack an understanding of continuity of care for patients.43 Though limited, there are some indications of efforts to improve coordination at some large, busy hospitals. An initiative began in 2013, piloted in several major municdepartments so that beds could be utilized in an inte-

Person-centered care has been discussed in

to create patient organizations. According to

grated and coordinated manner, with greater efficiency

China’s healthcare system since at least 1997, and

the Stockholm Network’s report “Patient Power

and exploitation.44 Currently, some hospital departments

has, since the 2009 blueprint for future health-

– what it takes for patient associations to help

are at full capacity while others, in the same building,

care, been an official consideration of the govern-

shape public policy,” China is among the nations

have vacant beds, but due to restrictions they cannot

ment. 38 The approach to person-centered care

least conducive to the inclusion of the patient

share beds between divisions. This restructuring plan

has been top down, with policy makers imposing

voice in health policy, when compared with seven

could potentially allow more patients to be admitted.

new rules on practitioners, such as to improve

other key emerging markets. There is no formal

communication with patients, respect privacy,

process of incorporating patients’ views.41 Although China’s constitution officially includes freedom of speech and of assembly, there are

Studies at the University of Technology in Sydney

certain barriers preventing patients from exer-

and expert in Chinese healthcare, reports, the

cising their rights. According to the Stockholm

person-centered care reforms “provided some

Network’s report, the existing legislation on the

change in the way doctors and patients interact –

rights of patients still suffers from inconsistencies

and helped to create a culture that focuses more

and there are difficulties in organizing patient

on patients, but the Chinese healthcare sector is

associations. Some patient groups also suffer

not patient-centered through and through.”40

discrimination e.g. those that advocate for HIV/ AIDS awareness. As long as these structural

As described below, person-centered care is

barriers are in place, China will have tremendous

beginning to be seen in coordination efforts

difficulties in developing a truly patient-centered

at certain hospitals, but in other areas, such as

healthcare system.

patient involvement and eHealth, it still has some

contribute a great deal to person-centered care, as they make it easier for both patients and care providers to access and share health information. Both have been expanding in China since the early 2000s, but the systems have been afflicted by numerous problems preventing optimal use and coordination. These include insufficient funds to create a widespread and meaningful system; a lack of unification and coordination, resulting in the simultaneous creation of over 100 electronic record keeping systems in various regions and cities regulation; reluctance toward information sharing, particularly with large metropolitan hospitals not willing to share information with smaller Community Health Centers (CHCs), nor likely to recognize a diagnosis or test from such facilities due to concerns of personnel’s proficiency and the accuracy of their equipment.45 Additionally, access to eHealth material can be difficult for many Chinese – especially rural residents who are furthest from medical centers – due to low internet penetration throughout the country. While internet use has skyrocketed in recent years, from 10.5% in 2006 to 46% in 2014, over half of the country still remains without home- or mobile device-based access.46 See figure 1.

treat patients with dignity, and smile more. 39 Jingqing Yang of the Institute for International

eHealth and the use of electronic medical records

without interoperability; a lack of legislation and

ipal hospitals, to break down barriers between hospital

Still, these reforms have yet to truly take hold. As

E-HEALTH LANDSCAPE STILL FRAGMENTED

FIGURE 1.

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.

way to go.

2004

2006

2008

2010

2012

2014

SMALL STEPS TOWARDS CONTINUOUS CARE Ensuring smooth transitions between different NO TRADITION FOR INVOLVING PATIENTS

stages of care and providing patients with a

A strong indicator of patient engagement is the

seamless experience between nurses, doctors

opportunity for patients to be a part of health-

and hospitals is a central aspect of person-cen-

care policy development, as well as their ability

tered care. As it stands now, very little coordina-

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

Huang E. “It Isn’t Getting Any Easier to Get a Doctor’s Appointment in China.” The Atlantic. 2013. Cheng S.L, Zhao JZ, Bai J & Zang XY. “Continuity of Care for Older Adults with Chronic Illness in China: An Exploratory Study.” Public Health Nursing 2014.

Gao X, Xu J, Sorwar G & Croll P. “Implementation of E-Health Record Systems and E-Medical Record Systems in China.” The International Technology Management Review 2013; 3(2): 127-139. p131 45

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

Without an effective primary care system in

ESSENTIAL DRUG LIST IS LOWERING COSTS AND IMPROVING ACCESS

place, and without well-functioning CHCs, China’s hospitals are likely to remain overcrowded, with resources spent on minor, easily treatable conditions rather than on patients in the most need.

Maintaining quality care while lowering costs is a difficult challenge for all healthcare systems. While China’s legacy of a lack of primary care exacerbates this burden, administrative problems are also to blame.

The Essential Drug List (EDL) is a list of

FRAGMENTATION IS WASTING RESOURCES

drugs approved for use in China’s primary healthcare facilities and is one of 5 central

The 2013 report, “China’s Healthcare System –

components of the Chinese government’s

Overview and Quality Improvements,” conducted

2009 healthcare reforms. The goal of

by the Swedish Agency for Growth Policy Analy-

the EDL is to establish a “comprehensive

sis, found that China’s insurance system is deeply

system which facilitates access and ensures

fragmented, leading to inefficiencies and wasted

affordable care for all citizens by 2020.” 51

resources. While the insurance schemes designed

Hospitals are banned from applying their traditional 15% mark-ups on sales of EDL

to serve urban residents are managed by the

drugs to patients, ideally ensuring that low-

Ministry of Human Resources and Social Security, Keeping costs low while maintaining a high

A LACK OF GATE KEEPING LEADS TO

the plan meant for rural residents is operated by

quality of treatment is a fundamental challenge

CROWDED CITY HOSPITALS

the Ministry of Health. Information on insured

for healthcare systems across the world. In China, the concrete results of these efforts appear quite mixed. The country’s lack of gate keeping with use of primary care facilities places an enormous and unnecessary burden on hospitals, and thus overcrowding can lower the quality of care. Certain political reforms implemented in the last couple of years, such as the reform of the essential medicines system including the Essential Drug List, provide some hope that funds in the near future can and will be better managed from the top down. This section will hone in on the level of gate keeping in Chinese healthcare and the system’s administrative fragmentation.

In healthcare, a gate keeper is “a primary-care provider... who coordinates patient care and provides referrals to specialists, hospitals, laboratories, and other medical services.” 47 This role is helpful in addressing conditions early on and deferring non-serious ailments from emergency rooms so hospitals can treat those in most urgent need. The lack of gate keeping and utilization of community health centers

income patients can gain affordable access to these basic medicines. 52 While the initial 2009 EDL system was

individuals in the different systems is not shared

afflicted by inconsistencies and poor

between departments and some people take part

enforcement, the 2012 reincarnation shows

in both urban and rural schemes, which increases

great improvements. The number of

the burden on both the government and the indi-

Western drugs increased from 205 to 317 and coverage broadened to include more

vidual. A report by the Central Auditing Bureau in

treatments. 53 While the national list was

2011 showed that 5.47 million people take part in

expanded to include more drug options,

both resident medical insurance schemes, forcing

greater restrictions were placed on regional

the government to spend an additional nearly

supplementations, thereby ensuring greater

$150 million in subsidies. 50

consistency across geographic locations. 54 These new policies have the potential to

contributes to overcrowded and inefficient care

improve both safety and cost-efficiency, by

at hospitals in large cities.48 Patients travel long

balancing expanded coverage with restricted

distances to these hospitals, unsatisfied with

supplementations.

the care they would receive closer to home, or

they are referred to these facilities by their local Community Health Centers (CHCs). While the CHCs were designed and implemented to act as gate keepers, treating common ailments that require less intensive care and procedures, the poor quality of care they offer has prevented them from relieving the burden of overcrowding at the better respected city hospitals.49

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

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

IMS Consulting Group. New Game. New Opportunities. New Direction. 2013. 51

Yang H et al. “Determinants of Initial Utilization of Community Healthcare Services among Patients with Major Non-Communicable Chronic Diseases in South China.” PLOS One 2014: 9(12). 49

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

McKinsey & Company. An essential strategy for the essential drug list. 2013. 53

IMS Consulting Group. New Game. New Opportunities. New Direction. 2013. 54

McTiernan R. “China’s EDL release a positive for patients, pharma firms to face pricing pressure.” IHS Life Sciences Blog. 2013. 52

CHINA

/ EFFECTIVENESS

EFFECTIVENESS IS IMPROVING, BUT IS NOT INCENTIVIZED

FIGURE 2.

THE INCENTIVE TO OVERTREAT Hospital income structure in China 91% of hospital income comes from drug sales and medical treatments, thus incentivizing overtreatment and overprescription of medications. Sale of drugs

Other

POOR INCENTIVES PROMOTE INAPPROPRIATE

This combined with a fee system, in which

TREATMENT

hospitals are reimbursed by the government for

The double-edged challenge of over- and under-treatment contributes negatively to the effectiveness of healthcare in China. Since the and 80s, the central government has cut vast

insurance. Total health expenditures were $156 billion and per capita costs were $119. By 2011, these numbers had dramatically changed, with 95% of the population now covered under some form of health insurance, and total health expenditures more than doubling to $357 billion. Per capita expenditures also more than doubled, to $261. 55 Despite these improvements, out-of-pocket healthcare costs remain very high due to the fact that insurance often does not cover the full amount of many treatments. Additionally, due to poor incentive structures and systemic corruption many patients pay for tests and procedures they do not need, thus increasing their bill and wasting resources. 56,57,58 Conversely, under-treatment is also a problem, with patients unable to receive needed care due to cost, insurance status, or hospital constraints. The current magnitude of underinsurance and status of over- and under-treatment are indicators of the challenges that the Chinese healthcare system is faced with in terms of providing effective care.

UNDERINSURANCE IS WIDESPREAD The drastic increase in the number of insured

amounts of public money for hospitals. As such, these facilities have had to fund themselves, ultimately redirecting costs to patients.

citizens does not necessarily translate into better or less expensive care for patients. 59

Another method of obtaining revenue is by

Hospital bills are enormously high in China, and

increasing the cost of pharmaceuticals, and as

insurance rarely covers the full amount, meaning

such, hospitals can charge a 15% mark-up on the

patients must pay a great deal out-of-pocket

price non-EDL drugs, and sometimes higher,

or forego care. Costs of care also vary a great

which often encourages physicians to prescribe

deal depending on both the type of insurance

more expensive medicines and more of them.

someone has and where they live. Ultimately,

For example, 75% of patients suffering from a

China has one of the highest ratios of out-of-

common cold are prescribed antibiotics, as are

pocket payments to total health expenditure

79% of hospital patients – over twice the inter-

of any Asian country, and in 2012, 78% of all

national average of 30%.62 Given the extremely

private expenditures on health came in the form

low salaries of Chinese doctors – officially about

of out-of-pocket payments.60 Additionally, over

$7,500 a year – this incentive to over-prescribe is

one-third of households have reduced their

particularly great.63

services performed, regardless of necessity or quality of care, provides doctors an incentive to perform unnecessary tests, prescribe unnecessary medicine and recommend unnecessary treatments.64 See figure 2. Under-treatment is an equally serious problem in Chinese healthcare, as patients are rushed through the system in order for doctors to see as many people as possible. The Economist reported in 2013 that budget caps at certain hospitals caused doctors to keep the cost of treating each patient under a certain amount. Should that amount be exceeded, the remainder would be deducted from the physician’s own paycheck.65 This misguided tactic incentivizes rushed care and early discharges, and can be extremely dangerous for patients. While over- and under-treating patients may at first glance appear to be opposing problems, they in fact operate in tandem and signify numerous flaws in the healthcare system.

consumption or been impoverished by healthrelated expenditures.61 Such a high amount indicates that while a 95% insurance coverage rate is impressive, it may mask more systemic problems with the quality and depth of that coverage.

McKinsey & Company. Healthcare in China: Entering ‘uncharted waters’. 2012. 55

Huang C. “Healthcare Is So Corrupt In China That Patients Have To Bribe Doctors For Proper Care.” Business Insider. 2014. 56

Beech H. “How Corruption Blights China’s Healthcare System.” Time. 2013. 57

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

liberalization of China’s economy in the 1970s

In 2006, only 45% of the population had health

42%

Government subsidy

Medical treatment income

In many respects, China’s healthcare system has made immense strides in productivity and effectiveness in recent years, with reforms improving how healthcare operates and serves its citizens. Still, there exists a great deal of waste and poorly managed care, due in large part to distorted incentive structures.

49%

Fan R. “Corrupt Practices in Chinese Medical Care: The Root in Public Policies and a Call for Confucian-Market Approach.” Kennedy Institute of Ethics Journal. 2007; 111-131. 58

McKinsey & Company. Healthcare in China: Entering ‘uncharted waters’. 2012.

The World Bank. “Out-of-pocket health expenditure (% of private expenditure on health)”. Data. 2015. 60

The Economist. “Feeling your pain.” The Economist. 2013. 64, 65

Yip W & Hsiao W. “The Chinese Health System At A Crossroads.” Health Affairs 2008; 460-468. 61, 62

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

CHINA

/ TIMELINESS FIGURE 3.

WAITING TIMES AND PATIENT DISSATISFACTION

WORTH THE WAIT?

Long wait time

Sources of dissatisfaction with hospital care in Beijing, Shanghai, and Chengdu hospitals

Poor personnel attitude

High price or overcharge Poor physical environment

Qualification of physicians Other

For patients in Beijing, Shanghai, and Chengdu that were dissatisfied with their hospital experience, long waiting times were the most common reason for this dissatisfaction.

Long waiting times have been a wellknown aspect of the Chinese healthcare system. While many hospitals show no sign of change in this regard, others are taking strides to boost efficiency and cut waiting times in the process.

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

BEIJING 7.3%

75.6%

SHANGHAI

43.9%

7.3% 32.6%

64%

46.3% Crowded conditions in China’s largest and best

Since the 2009 healthcare reforms, though, wait-

hospitals – due in large to inadequate or per-

ing times are beginning to go down in a handful

ceived inadequate care at smaller, community

of hospitals. In 2012, Beijing Friendship Hospital,

hospitals – mean that long waiting times are a

for instance, was part of a pilot program de-

norm. Anecdotes abound of hours-long lines that

signed to improve the patient experience. As part

stretch outside just to receive a doctor’s appoint-

of the program, patients would pay more to see a

ment.66, 67, 68, 69 A 2010 PricewaterhouseCoopers

doctor, but drugs sold by that hospital would be

survey of Shanghai, Chengdu and Beijing found

much cheaper, lowering the total bill.71 This also

that while patients are generally satisfied with

resulted in shorter waiting times. Such a program

their choice of hospital, 75% of those dissatisfied

indicates how small changes in hospital income

with the service at their hospital of choice in

models (paying more for doctors rather than

Beijing indicated long waiting times as the pri-

drugs) can serve to improve the patient experi-

mary reason for dissatisfaction.70 This figure was

ence, lower costs, curtail corruption, disincentiv-

also high in Shanghai and Chengdu, at 64% and

ize over-prescription, and reduce long waits.

35.5%

9.8%

CHENGDU

54.1%

22.7% 86.7%

40%

11.6%

86.7%, respectively. See figure 3.

20%

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

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.

20%

53.3%

PricewaterhouseCoopers. Emerging Trends in Chinese Healthcare. 2010 70

Einhorn B & Loo D. “China Raises Doctor Fees, Lowers Drug Bills to Ease Anger.” Bloomberg Business. 2012. 71

CHINA

/ ENVIRONMENTAL SUSTAINABILITY

IN NEED OF A BREATH OF FRESH AIR

ADDRESSING THE WASTE CHALLENGE Some regions are attempting to address the

Air is not the only natural element in China being degraded by rapid industrial development. In

medical waste problem, such as Guangxi’s

2014, Chinese state media reported that 60%

Qinzhou City, which invested $3 million in a

of the country’s underground water was pol-

medical waste disposal center outside the city.

luted.79 It was also reported in 2013 that about

Results, however, are not meeting expectations,

one-third of China’s water resources are ground-

as particularly rural hospitals still choose to burn their hazardous waste rather than recycle

The relationship between healthcare and environmental sustainability is an often-discussed issue in China. While the impact of the environment on healthcare is well documented and discussed, the healthcare industry’s impact on the environment is less so.

...NOT A DROP TO DRINK

water-based, and that only 3% of the country’s

and process it properly.72 It remains to be seen

urban groundwater can be classified as “clean”. 80

whether these efforts can make an impact on the

Some regions are worse than others, with the

actions of hospitals and medical centers in terms

land ministry reporting that 70% of groundwa-

of their medical waste disposal protocols.

ter in the north China plain – an area that covers approximately 400,000 sq km and is some of the world’s most densely populated land is unfit for human touch, let alone consumption. 81 In 2007 The World Bank estimated that the health cost of cancers and diarrhea associated with water pol-

An increasingly important aspect of the health-

without compliance with national or international

of Europe and the United States. This reflects

lution reached approximately $8 billion in 2003 in

care system in China is its environmental impact.

standards of pollution control.72 According to a

their inability to reach what is elsewhere consid-

rural areas of China. 82

Medical waste is a serious concern in China,

recent study in the Shandong Province, a great

ered safe and healthy pollution levels.

and as the world’s largest developing country it

deal of disparity exists between urban and rural

produces a lot of it. Another connection between

hospitals in terms of generation of medical waste.

Pollution has drastic consequences for China’s

source from which they are coming. The fact

healthcare and the environment in China is the

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

healthcare system. The OECD reported that in

that Chinese state media are voluntarily produc-

impact that pollution – of both air and water – has

the average waste generation rate was 0.74kg

2010 the health impact of air pollution in China

ing such alarming information about their own

on the health of Chinese citizens. This leads to a

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

was approximately $1.4 trillion.76 With data from

pollution habits appears to be a sign of increasing

less healthy population with greater healthcare

rural community hospitals this rate rose to 1.53 kg

a Global Burden of Disease study, the New York

transparency and accountability. Additionally, in

needs and higher healthcare costs.

per bed per day.73

Times reports that air pollution contributed to 1.2

2013 the government announced plans to invest

million premature deaths in China in 2010, nearly

$277 billion to curb air pollution, aiming to reduce

40% of the global total that year. Nationally, this

air emissions by 25% by 2017 compared with 2012

In the following, medical waste, air and water pol-

One positive element of these reports is the

lution are presented as primary indicators of the

AIR POLLUTION IS OFF THE CHARTS

means China lost 25 million healthy years of life

levels. 83 Such transparency and financial invest-

current status of sustainability and the environ-

Pollution is undoubtedly an enormous concern

from the population.77 Beijing’s Center for Disease

ment are positive signs that the Chinese govern-

mental challenges the Chinese healthcare sector

of China’s, and one that severely impacts both

Control and Prevention recently reported that an

ment is serious about addressing its pollution

is faced with today.

its health and environmental sustainability. Air

average 18 year old living in the city can expect

problems.

pollution is particularly apparent, with stories of

to spend as much as 40% of their remaining life

China’s dense, grey air making headlines around

in less than full health, suffering from cancer, car-

MEDICAL WASTE IS PILING UP

the world. Typically, air pollution is measured by

diovascular disease, arthritis, and other ailments

While most of the discussion around sustainabil-

the concentration of particulates in the atmo-

related to the city’s extremely poor environmen-

ity in China’s healthcare sector revolves around

sphere, and WHO guidelines state that anything

tal conditions.78

environmental hazards that impact public health,

over 10 micrograms per cubic meter (PM2.5) of

another serious concern is the negative effect

these particulates is considered dangerous to

that the healthcare industry has on the environ-

human health. To put in perspective how bad Chi-

ment. As a rapidly growing developing country,

na’s pollution problem is, we can compare notori-

safe and efficient disposal of medical waste is

ously smog-filled Los Angeles, which averages an

of serious challenge in China. In 2007, the State

16.2 PM2.5, with the Chinese city of Xingtai, with

Environment Protection Administration reported

a population of over 7 million, which averages a

that China produces about 1,800 tons of med-

truly astounding 155.2 PM2.5.75 China has even

ical waste a day, much of which is disposed of

adapted its own air quality scale, relative to that

International Finance Corporation – World Bank Group. IFC Investment in Medical Waste Treatment Plants in China is Expected to Benefit 120 million people. 2007. 72

Gai R et al. “Hospital medical waste management in Shandong Province, China.” Waste Management & Research 2009; 27(4): 336-42.

China Daily. “China’s medical waste piles up.” China Daily. 2013.

Minter A. “Why Living in Beijing Could Ruin Your Life.” Bloomberg View. 2014.

Kan H. ”Environment and Health in China: Challenges and Opportunities.” Environmental Health Perspectives 2009; 117(2): 530-531.

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.

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

To spur discussions, Dr. Duan Tao, President of Shanghai First Maternity

of care

& Infant Hospital and Mr. Alex Lam, Vice Chairman of Hong Kong Alliance of 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

The roundtables were in the format of one-day interactive workshops that gathered key

Shanghai, Brussels, and Washington DC to gain insights for this publication and start

stakeholders from across the healthcare system, including patients, professionals, providers,

a conversation on challenges and opportunities for improving the quality of care in

policy makers and researchers, with the aim of identifying possible trajectories for change

the healthcare systems of China, the EU and the USA. The guiding question for the

by spurring dialogue and discussions based on the various perspectives from the different

roundtables was: HOW DO WE IMPROVE THE QUALITY OF CARE?

stakeholders.

CHINA

/ EXPERT INSIGHT

one example: there have been sever-

within healthcare. We have to see

al cases of patients or family mem-

the patient as the starting point of

bers hurting hospital professionals

healthcare and have their interests at

because they have not received

the center of all we do.

correct or timely treatment. There is no way of expressing

Participant at the Shanghai roundtable

HOW CAN THE CHINESE HEALTH-

CHALLENGE FACING THE CHINESE

CARE SYSTEM OVERCOME THE

HEALTHCARE SYSTEM?

CHALLENGES OF AN AGEING

China’s large population is a big

POPULATION?

Patients should be willing to receive care outside of their home because it is in their own best interest, both socially and physically. In the future, when the Chinese

challenge but it is also an oppor-

Ageing is stressing the system

anger or dissatisfaction within the

views and have a say in choice of

tunity, as fixing the problems that

and there is a need for a new mind-

care is provided in other parts of the

system as the formal channels for

treatment through dialogue before

afflict the healthcare system has the

set from patients and their families.

world, I believe that we will see the

complaints are not working.

and after treatment. Currently the

potential to improve the lives of a lot

In China, it is part of the culture that

needed mindset shift.

approach of the Chinese healthcare

of people.

families take care of their elderly

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

professionals is more paternalistic,

portunities for patient organziations

Another challenge we are seeing

members. This is, in many instances,

with doctors telling patients what

is that the Chinese population is age-

not a good solution because the care

treatment they will be given without

ing, which will change the healthcare

puts great strains on families and

listening to patients’ needs.

system considerably in the future.

in some cases means that elderly

Today, we are already seeing more

patients do not receive the right

patients with diseases related to

treatment.

Currently there are limited opto champion the voice of patients

WHAT ARE SOME TANGIBLE WAYS

HOW CAN PATIENT ORGANIZATIONS INFLUENCE THE POLITICAL DECISION-MAKING PROCESS IN CHINA? My organization has good access to the government, but we are not

change the mindset of families and

a large group and have problems in

patients to accept that nursing

regards to resources. We are trying

homes and other facilities that can

our best to push for a mindset where

deliver care to the elderly are op-

patients and families are at the

complaint committee within the

tions that benefit all parties involved.

center of care. We have suggested

is that Chinese people are becoming

Hospital Authority. The commit-

The government will have to show

that the government sets up more

are small scale and not yet seen as

more aware of their rights. When

tee includes a representative from

leadership and establish health-

healthcare facilities that can provide

important institutions in the Chinese

they pay their taxes, they also want

patient organizations, making the

care facilities that can provide care

the care that is needed for the

healthcare system. It is very difficult

to receive high quality services in

committee more representative and

to elderly patients and treat their

elderly.

to form patient organizations be-

the healthcare system. This push

impartial in terms of considering

diseases.

cause they are seen as challenging

may result in service providers within

complaints.

the system, and we do not have a

healthcare becoming more aware

strong history of service users ques-

of patients’ needs. In the future, I

established for patients to express

tioning the way in which healthcare

think the government may be more

their views and it is important to

is delivered or being involved in the

willing to accept the existence of

stress that these views will include

co-design of services. The result is

patient organization but they would

both complaints and appreciation.

probably still ask for a high degree

Patients are very grateful when they

of monitoring of activities.

receive the right treatment.

HOW DO YOU SEE THE

ROLE OF PATIENT ORGANIZATIONS IN CHINA? Currently patient organizations

“Without patients, healthcare professionals don’t have a job to do.”

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

spected or recognized as it could be. The lack of focus on their inter-

COME MORE ACTIVELY INVOLVED

HOW CAN THE MINDSETS OF CHINESE HEALTH PROFESSIONALS BE CHANGED TO FOCUS MORE ON THE PATIENT AS AN ACTIVE PARTICIPANT OF THEIR OWN

dementia.

IN THEIR HEALTHCARE? In Hong Kong we have a public

the number of people expressing gratitude is four times higher than

Professor Weiwei Zhang Board Member of the Beijing Association of Alzheimer’s Disease Participant at the Shanghai roundtable

HOW CAN PATIENTS AND FAMILIES BE INVOLVED IN THE TREAT-

that focus solely on providing care to Alzheimer’s and dementia patients.

MENT OF ALZHEIMER’S? Alzheimer’s patients are mostly elderly. The Government provides their medicine for free, but patients have to stay in their homes and be cared for by their families. There are no specialized nursing homes for

complaints. That is also why it is

patients with Alzheimer’s, which is a

important to find a balance between

risk factor because their treatment

the negative and positive feedback.

and medicine are not managed by

We need to not only focus on com-

health professionals.

plaints but also start to integrate ap-

Alzheimer’s is on the rise in

proaches where patient appreciation

China. We must think of new ways

professionals don’t have a job to

is used actively to improve quality in

of treating the disease, but it is very

do. A mindset has to be devel-

the Chinese healthcare system.

important that the patients and their

Without patients, healthcare

This could also be done by establishing departments within hospitals

I hope that more platforms will be

In Hong Kong, for instance,

CARE? that the patient voice is not as re-

THAT CHINESE PATIENTS CAN BE-

age, such as Alzheimer’s disease and

have become aware of how health-

My organization is working to

as they are seen by medical service

WHAT IS THE BIGGEST

allow for patients to express their

Mr. Alex Lam Vice Chairman of the Hong Kong Alliance of Patients Organizations

The healthcare system needs to

ests has resulted in a lot of anger

oped where the patient’s interest is

families are involved in this process

and frustration from patients. Take

seen as pivotal for all professionals

and that we respect their culture.

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

EUROPE SHARING A HEALTHCARE GOAL The 53 countries that make up the WHO European Region represent healthcare systems that are located within different social, economic, political and cultural contexts. Even though it is easy to view Europe as a fragmented region, 28 states are already coordinating health and healthcare policy through their participation in the European Union. Common challenges, such as ageing populations, increases in chronic diseases, and greater demand for healthcare for less money call for more coordination in the future – not less.

Recent years have been has characterized by

The healthcare challenges and solutions of tomor-

a growing body of common guidelines and

row are not staying within country borders but

cross-border healthcare initiatives in Europe.

demand transnational collaborations and knowledge sharing.

One concrete example is the “Communication on Effective, Accessible and Resilient Health Systems,”

Although the policies, organization, and delivery of

which came from the European Commission in

healthcare remain the responsibilities of individual

2014. It advocates the use of performance assess-

governments, the EU plays a role in helping to set

ment results, improved patient safety and develop-

new standards, promoting change, and exchanging

ment of integrated care.

best practice across borders.

Another cross border initiative is the European

Through the seven dimensions of quality in health-

health policy framework, Health2020, which was ini-

care, this chapter gives you an insight to the chal-

tiated by the WHO and adopted by the 53 member

lenges that the European healthcare systems face.

states of the Region in 2012. It urges governments to cooperate in fulfilling two strategic objectives: 1) improving health for all and reducing health inequalities, and 2) improving leadership and participatory governance for health.

EUROPE / EQUITY

PROTECTING UNIVERSAL CARE

According to sociological monitoring carried out in Russia for problems with the nations’ health systems,

ROMANIA IS STRUGGLING TO PROVIDE EQUAL ACCESS

high drug prices and out-of-pocket payments are two of the most crucial problems facing the country’s healthcare system, according to

In Romania, access to healthcare is a serious concern, especially for low income groups.

Despite the economic crisis, access to healthcare is still considered a fundamental right in European countries. This does not mean that all healthcare needs in the region are met – especially for low income groups.

70% and 35% of respondents, respectively.

According to a review of the Romanian Health

Additionally, nearly half of the respondents men-

Sector by The World Bank from 2011, many poor

tioned that they would have to limit their food

individuals who are in need of healthcare do not

spending and purchase of staple goods to pay for

seek care.

medical services.12 High healthcare costs are there-

This is the case for almost 10% of the population. 8

fore having a significant impact on the quality of life

This gap is particularly large in the treatment

of many Russian citizens.

of chronic disease, as 42% of the poor with a chronic condition do not seek care, compared with 17% of the rich.

CRISIS CREATES VULNURABILITY IN

The true gap is likely even larger, as, according

Access to healthcare constitutes a basic right

UNMET CARE – PARTICULARLY FOR

according to the Charter of Fundamental Rights

THOSE MOST IN NEED

of the European Union.¹ This right, however, has been challenged by the recent economic crisis where health expenditures fell in half of the EU countries and growth significantly slowed in the other half. The crisis meant cuts in health workforce and salaries, reductions in fees paid to health providers, lower pharmaceutical prices, and increased patient co-payments.² These measures have had a negative effect on patients’ abilities to access the health system.³ Universal (or near universal) health coverage in most EU countries has remained the norm during and after the crisis.⁴ Still, The Euro Health Consumer Index from 2014 states that the financial crisis has resulted in a “slight but noticeable increase in inequity of healthcare services across Europe” and detects the biggest equity gap between wealthy and less wealthy European countries in the nine year history of the index.⁵

In all European countries, the large majority of the population does not experience unmet care needs, according to the 2012 EU Statistics on Income and Living Conditions Survey.⁶ However, in Latvia, Poland, Romania and Bulgaria, for

to the World Bank’s report, many low income individuals with chronic conditions are not aware

Most European countries have universal or near-uni-

of their need for care. Simulations that assume

versal coverage for a core set of healthcare services

that the need for care for chronic conditions

– exceptions are Bulgaria, Greece and Cyprus where

is similar between wealthy and poor people

a significant proportion of the population is unin-

estimate that a whopping 85% of the poor who need medical care are not getting it. In March 2014, the World Bank approved a loan to Romania of $338.8 million for the objective of

example, more than 10% of the respondents had

improving access to, and quality and efficiency of

unmet needs for a medical examination, and this

public health services in Romania.10

burden fell unevenly on low income groups.

The reforms include the streamlining of hospital services; enhancing primary care services,

On average across EU member states, more than twice as many people in low income groups reported unmet needs as did people in high income groups.

HEALTHCARE

sured. In Bulgaria, public insurance is not automatic for the unemployed and self-employed. Instead, they have the option to buy it. In Greece, coverage is reduced after 24 months of

particularly at the community level; and

unemployment. Both systems, and the people they

increasing sector governance and stewardship

serve, are very vulnerable to economic crises that

in order to improve management, strengthen

cause high unemployment rates.

departmental communication and better incentivize primary care.

The main reason for people in low income groups to report unmet healthcare needs was that care

These reforms are expected to improve the performance of the health system as a whole and reduce existing inequities in terms of access to

was too expensive. The proportion of people

quality care amongst the population. The World

in low income groups reporting unmet needs

Bank program will run until 2020.11

for financial reasons is two times greater than that of the population as a whole and over four times greater than among people in high-income groups on average across EU countries.⁷

⁶ European University Institute. EU Statistics on Income and Living Conditions. 2015. ⁷ OECD & European Commission. Health at a Glance: Europe 2014. 2014. ⁸ The World Bank Europe and Central Asia Region. Romania Functional Overview – Health Sector. 2011.

The World Bank. Romania – Health Sector Reform – Improving Health System Quality and Efficiency Project. 2015. 10

The World Bank. Project appraisal document on a proposed Loan in the amount of Euro 250 million to Romania for a health sector reform – improving health system quality and efficiency project. 2014. 11

European Observatory on Health Systems and Policies. Health Systems in Transition – Russian Federation: Health system review. 2011. 12

This section will hone in on coverage of healthcare costs, unmet care needs and doctor consultations examining the overall question: How equitable are the European healthcare systems?

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

¹ European Parliament. Charter of Fundamental Rights of the European Union. 2000.

⁴ European Commission. Health at a Glance: Europe 2014 Executive Summary. 2014.

² European Commission. Health at a Glance: Europe 2014 Executive Summary. 2014.

⁵ Health Consumer Powerhouse. Euro Health Consumer Index. 2014.

³ Health Consumer Powerhouse. Euro Health Consumer Index. 2014.

EUROPE / SAFETY

FIGURE 4.

COUNTRIES INTRODUCING COSTS FOR ACCESS TO HEALTHCARE

Greece

In 2011 copayments increased from approximately $3 to $5 for outpatient hospital care and health centers.

Ireland

Portugal

In 2008, it cost about $65 to access emergency care and $65 per day for hospital care, capped at 10 days per year ($650). By 2013, this was increased to over $100 to access emergency care and $80 per day for hospital care, capped at 10 days per year ($800). These fees are waived for people with a medical card (40% of the population in 2013).

The 2014 Eurofund report, “Access to healthcare in times of crisis,” which explores the impacts of the financial crisis on access to public healthcare services, also found that economic crises are contributing to the emergence of new types of vulnerable groups which have difficulties accessing healthcare.13 Job loss – and the loss of work-associated health insurance – is creating new groups of Europeans that struggle to access quality healthcare. At the same time, though, several countries have recently introduced measures that increase the cost of healthcare or restrict access to it. Spain, for instance, passed a measure in 2012 denying universal healthcare entitlements to nearly

From 2007 to 2013, copayments for both inpatient and outpatient care were raised, with the largest increase occurring in 2012. Exemptions for chronically ill patients were restricted to consultations/ treatments for their specific condition.

Source: European Foundation for the Improvement of Living and Working Conditions. Access to healthcare in times of crisis. 2014.

CREATING A CULTURE OF PATIENT SAFETY Over the last decades patient safety has moved far up the political agenda in Europe. But despite a line of common guidelines aimed at improving patient safety, fragmentation still rules. Some countries have made patient safety a top priority while others remain reluctant to take on the challenge.

UNEQUAL USE OF HEALTHCARE SERVICES Throughout the region, there are income-related differences in the use of healthcare services. According to the OECD report, “Health at a Glance” from 2012, there is evidence of inequity in terms of doctor consultations by income group in European counties.

Looking at the EU in general, patient safety remains an unresolved issue in healthcare. An estimated 8-12% of patients admitted to hospitals in the EU suffer from adverse events while receiving healthcare. 25% of these adverse events are healthcare-associated infec-

The probability of a generalist visit is equal in most countries and lower income individuals actually consult a GP more frequently. In regard to specialist visits, however, a different story emerges. In nearly all countries, high income individuals are more likely to see a specialist than those with low incomes and also do so more frequently.15

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

• The establishment and development of national policies and programs on patient safety • Making patients part of the process • Education and training of healthcare workers

failure to act on the results of tests.16

• Sharing knowledge, experience and best practice at community level

In 2009, the European Council put forward 13

• Prevention of healthcare associated infections

recommendations for patient safety measures, including the prevention and control of

Variation in the implementation of the EU

900,000 non-registered residents and intro-

HAIs, and invited the Commission to report

recommendations, the state of HAIs, and a

duced copayments for drugs on the grounds of

on progress and further action.

lack of healthcare professionals are discussed

austerity.14 These simultaneous phenomena are

below as indicators of the development of

placing a double burden on vulnerable Europeans seeking healthcare. Figure 4 shows three examples.

patient safety in the Europe. European Foundation for the Improvement of Living and Working Conditions. Access to healthcare in times of crisis. 2014. 13

14 Legido-Quigley H. Erosion of universal health coverage in Spain. The Lancet 2013; 382(9909): 1977.

The overall recommendations include:

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

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

FIGURE 5.

HARMED BY HEALTHCARE

WHAT IS STANDING IN THE WAY OF PATIENT SAFETY RECOMMENDATIONS?

ECONOMIC CRISIS AND RESULTING CONFLICTING PRIORITIES

LACK OF POLITICAL WILL

Every year an estimated 4.1 million patients acquire

There is still room to improve information provided

a HAI in the EU, and at least 37,000 die as a result.

to patients and their involvement in HAI prevention.

The financial cost of HAIs in Europe is approximately

According to the Eurobarometer survey on patient

$6.2 billion annually.20

safety and quality of care from 2014, only 39% of the respondents that had been hospitalized or admitted

Economic strain, technology and fragmentation are among the main reasons for the lack of implementing patient safety recommendations among the EU countries Source: European Commission. Report on the Public Consultation on Patient Safety and Quality of Care. Undated.

FRAGMENTATION OF PROVISIONS AND ORGANIZATION

BARRIERS DOMINATING “BLAME CULTURE”

LACK OF PATIENT SAFETY CULTURE

Although HAIs are a challenge, the solutions are

to a long term facility in the past 12 months report-

within reach. It is thus estimated that 20-30% of

ed that they had received information on the risk of

HAIs can be prevented by intensive hygiene and

HAI – the majority of those who did came from the

control programs.21

western and northern areas of the EU.23 The Eurobarometer report also notes that there has been an

According to a report from the European Com-

increase in how many adverse events are reported,

mission based on member states’ reports on the

from 28% in 2009 to 46% in 2014. At the national

implementation of the Council Recommendation on

level there have been even more dramatic changes,

patient safety, about two out of three EU countries

for instance in France (+61% points), Spain (+40) and

had defined a national strategy and/or action plan

Luxembourg (+32).

for the prevention and control of HAIs in 2011: Sadly, 37% of the respondents report that the most • More than 80% of national action plans included

likely outcome of reporting an adverse event was

hospital implementation of: infection prevention

that nothing happened. 20% received an apology

and control programs; appropriate organizational

from the professional and only 17% received an ex-

PUSHING SHARED PATIENT

governance arrangements and qualified infection

planation for the error.

SAFETY GUIDELINES FORWARD

control staff; surveillance of targeted HAIs; surveil-

The report from the European Commission from

Over the last couple of years, some progress has

lance of particular events for timely detection of

During the past few years, the EU has funded further

2012, which analyzes Member countries’ imple-

been made in regards to the 13 recommenda-

alert microorganisms or HAIs; and high quality mi-

projects aimed at improving the state of HAIs, such

mentation of the 13 recommendations, indicates

tions.

crobiological documentation and patient records.

as the Third Health Programme 2014-20, which aims

that while some countries focus intently on pa-

to improve patient safety and reduce HAIs in Euro-

tient rights, patient safety strategies, and patient

An evaluation from 2014 shows that most

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

inclusion policies, others take a more passive

pean countries.24 This program focuses specifically

countries have implemented at least half of the

tional level had set up mechanisms to encourage

on the control of healthcare-associated infections

stance and place the burden on individual hospi-

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

its implementation.

through exchanging good practices on quality

tals to introduce patient safety measures.

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

assurance systems, developing guidelines and tools • 15 countries had considered nursing homes and

to promote quality and patient safety, increasing

Similarly, some EU member states have instituted

actions implemented. On the other end of the

healthcare institutions other than acute care hos-

the availability of information to patients on safety

official legislation on these strategies, while oth-

scale, Romania and Slovenia only have 3 out of 13

pitals when designing their action plans.22

and quality, and improving feedback and interaction

ers rely on less formal networks and platforms.17

actions implemented.19

between health providers and patients.25 Despite this development, the latest evaluation from

From 2013-2014 the European Commission con-

EU “Patient safety and Health-Associated Infections”

ducted an online survey on patient safety in the

from 2014 concludes that HAIs continue to be a

EU, particularly in order to highlight the barriers

problem in Europe.

to implementing the 13 Council Recommendations for patient safety measures. Economic strain, lack of political will, limited technology and fragmentation were among the primary barriers.18 See figure 5.

17 European Commission. Detailed analysis of countries’ reports on the implementation of the Council Recommendation (2009/C 151/01) on patient safety, including the prevention and control of healthcare associated infections. 2012. 18 European Commission. Report on the Public Consultation on Patient Safety and Quality of Care. Undated.

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

21 European Center for Disease Prevention and Control. Healthcare-associated infections. 2015. 22 European Commission. Detailed analysis of countries’ reports on the implementation of the Council Recommendation (2009/C 151/01) on patient safety, including the prevention and control of healthcare associated infections. 2012.

24 European Commission. Patient Safety and Healthcare-Associated Infections. 2014. 25 Official Journal of the European Union. Regulation (EU) No 282/2014 of the European Parliament and of the Council. 2014.

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

EUROPE / PERSON-CENTERED CARE

DOCTORS WITHOUT BORDERS All across Europe, the shortage of healthcare professionals is a reality. In 2012, on average across EU countries, one in three doctors was over 55 years of age, up from one in six in 2000. This aging workforce, combined with other factors,

SHORTAGE OF HEALTHCARE PROFESSIONALS IN FINLAND In Finland, the demand for healthcare services is increasing, while there are not enough applicants

will likely cause an estimated shortage of 1 million

for the vacant positions. The primary reason for

health workers in Europe by 2020.26

this shortage is not a lack of sufficient training at educational institutions, but rather that a

The healthcare sector is clearly affected by these shortages and the 2014 Care Quality Commission

significant proportion of the qualified labor works in sectors other than healthcare. For example, there are 20,000 qualified practical

report assessing the UK’s National Health Service

nurses working outside the healthcare sector,

(NHS) and social care services stated that short-

meaning that their skills and training are not

ages of doctors and nurses posed safety risks for

being properly utilized. Partly to blame for this

patients.27

TOWARDS CO-CREATION AT DIFFERENT SPEEDS The idea of putting the patient in the center of healthcare is gaining momentum – and becoming an integrated part of care delivery in European countries. Still, a shared understanding of the term is missing. The focus on and interpretation of personcentered care varies within the region of Europe.

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

According to the Euro Health Consumer Index

study also identified different levels of

The 2014 European Commission report, “Map-

unfavorable.31 Reconciling this challenge will

patient rights legislation and involvement in

person-centered care in what they define as

ping and Analysing Bottleneck Vacancies in

be critical if Finland is to fulfill its demand for

policy-making became standard in Europe

Eastern and Western Europe.

EU Labour Markets,” examines the occupations

healthcare workers in the coming years.

by 2013, and only 2 countries have not yet

where there is evidence of recruitment difficul-

introduced healthcare legislation based on

In Russia, patient rights, as outlined in the

ties. In total, 21 of 29 European countries reported

patient rights.32

WHO’s “Declaration of Patients’ Rights in

vacancies in their healthcare workforce.

Europe,” have not been actively implemented Despite the positive development, Europe

and patients typically lack the information

The findings show different reasons for the short-

still faces challenges in terms of delivering

needed to fully understand their illness or

age of healthcare professionals. For instance, in

person-centered care. The “Eurobarometer

potential treatment options. Without such

most EU1528 countries not enough people are

Projects and organizations are being developed

qualitative study” conducted for the Europe-

information, it is hard for patients to make

training as health professionals, whereas the

in an effort to alleviate the problems caused by

an Commission in 2012, which was based on

informed choices about their medical care.

challenge in newer EU states is that healthcare

cross border migration of professionals. The

interviews in 15 EU member states33, revealed

professionals seek employment in other coun-

European Joint Action on Health Workforce

that the meaning of the term “patient involve-

In the following dimension, we examine the

tries, where the salary and the working condi-

Planning and Forecasting, for instance, gathers

ment” was not clearly understood by either

state of integrated care, eHealth and health

tions are better.

experiences and best practices in planning and

practitioners or patients.34

literacy as three indicators of person-cen-

assessing health workforce needs. Their work

tered care in Europe, as they help to gauge

Furthermore, mitigation strategies used by

seeks to uncover sustainable solutions to the

In fact, it was often perceived by both groups

how well patients understand their involve-

some countries to actively fill the gaps in their

challenge of the growing demand for healthcare

“as medical compliance and following doc-

ment in their own health and healthcare

recruitment of healthcare professionals can have

workers throughout Europe.30

tors’ orders,” which is quite the opposite of

system.

a detrimental impact on other countries in the

the co-creation approach that person-cen-

region. For example, Norway is attracting labor

tered care is meant to evoke.35 The same

from neighboring countries, which consequently further depletes the supply of labor in those nations.29 26Joint Action Health Workforce Planning and Forecasting. Leaflet. Undated.

27 Campbell D. “NHS staff shortages pose risk to patients, warns watchdog.” The Guardian. 2014.

28 Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain, Sweden and the United Kingdom

29 European Commission. Mapping and Analysing Bottleneck Vacancies in EU Labour Markets. 2014.

30 Joint Action Health Workforce Planning and Forecasting. Welcome page. Undated.

31 European Commission. Mapping and Analysing Bottleneck Vacancies in EU Labour Markets. 2014. 32 Health Consumer Powerhouse. Euro Health Consumer Index. 2014. 33 Austria (AT), Belgium (BE), Czech Republic (CZ), Finland (FI), France (FR),

Germany (DE), Greece (EL), Hungary (HU), Italy (IT), Latvia (LV), Poland (PL), Romania (RO), Spain (ES), Slovakia (SK) and the United Kingdom (UK).

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

European Commission. Eurobarometer Qualitative Study – Patient Involvement. 2012.

37,38

34,35

Center for Strategy and Evaluation Services & Oxford Research. Final Evaluation of the Lead Market Initiative. 2011.

FIGURE 6.

DIFFERENT APPROACHES TOWARDS MORE INTEGRATED CARE From E-health records in Estonia to integrated HIV treatments programs in Ukraine, integrated care is unfolding in different settings FIGURE 7.

ESTONIA

UKRAINE

GERMANY

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

AIM

OUTCOMES

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

Efficiency gains via the direct communication between institutions and providers. More patient empowerment via personal health records, virtual medical centers and mobile patient applications.

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

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

To develop integrated services for people with a history of injection drug use through innovations including pharmacy-based needle exchanges, overdose prevention services and improved case management services.

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

Inadequate health literacy Sufficient health literacy

Problematic health literacy Excellent health literacy

AUSTRIA BULGARIA GERMANY GREECE

Across countries in Europe, health literacy continues to pose a great challenge in healthcare. The results vary significantly between countries. For example, inadequate health literacy was present in 2% of the population of the Netherlands, but 27% in Bulgaria.

SPAIN IRELAND NETHERLANDS POLAND TOTAL

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

90 100

Improved user satisfaction.

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

In 2007, the European Commission selected eHealth

Aside from a promising economic potential, eHealth

as one of six promising lead markets, meaning that

can empower patients through greater transparen-

it is innovative, responds to customers’ needs, has a

cy, access to services and information, and the use

strong technological and industrial base in Europe

of social media for health.39 Furthermore, patient

A EUROPEAN VISION FOR INTEGRATED CARE

To help address some of these barriers, WHO

and depends on public policy actions to create

empowerment is mentioned as part of the vision in

In the common policy framework – Health 2020 –

launched “Framework for Action towards Coor-

favorable framework conditions.

the eHealth Action Plan 2012-2020, put forward by

that the 53 member states in the WHO European

dinated/Integrated Health Services Delivery" in

Region have agreed on, people-centered health

2013, which supports countries with policy options

The European Commission was proven right in their

systems are defined as a shared goal. Figure 6

and recommendations that target key areas for

prediction, since the market potential of eHealth has

However, eHealth is still not a common standard

shows a selection of different nations’ integration

strengthening the coordination/integration of

remained strong, despite the economic crisis.

in the region. The study, “Overview of the national

initiatives. While they are very different cases, they

health services.

do illustrate that steps towards more integrated

the European Commission.

laws on electronic health records in the EU member The global telemedicine market, for example, has

states and their interaction with the provision of

The framework focuses on ensuring the participa-

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

cross-border eHealth services,” from 2013 concludes

tion of partners, including a network of focal points

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

that, “there are major disparities between countries

One of the barriers standing in the way of further

in member states, external experts and leading

billion in 2016.38 This increase indicates a growing

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

expanding people-centered initiatives is that ad-

organizations in the field, such as the International

potential for the use of eHealth measures through-

erable infrastructure that allows different healthcare

vocating coordination and integration of services

Foundation for Integrated Care.

out the world, including Europe.

providers to access and update health data in order

health systems are being taken.

takes a backseat to other political priorities in

to ensure the continuity of care of the patient”.41

times of economic crisis.36

EUROPE / COST-EFFICIENCY

Another disconcerting finding from the study is

Unfortunately, according to WHO’s Health Litera-

the fact that EHR systems use very different ter-

cy Survey, nearly half of all Europeans have inad-

minology and coding methods depending on the

equate and problematic health literacy skills, and

country in which they operate, and this semantic

as such have difficulties in accessing, understand-

diversity is considered one of the main barriers

ing, appraising and applying information to make

to the transfer of health data making it difficult to

healthcare decisions.43 See figure 7. This poses

ensure continuity in care.

a threat to the future of person-centered care in Europe, as low health literacy makes it difficult for

LOST IN TRANSLATION

patients to take their health in their own hands,

Health literacy is a key dimension of Health 2020

thereby leaving professionals as the only experts

– the European health policy framework adopted

in health.

by member states in 2012 – and it remains a chal-

GROWING DEMAND AND SHRINKING BUDGETS Economic strain is the reality and the future for healthcare systems throughout the European region. These constraints will hopefully pave the way for a delivery of healthcare where cost-efficiency is named king – not through reductions in healthcare, but through new models, new priorities and new incentives.

lenge in the region. According to WHO, low health literacy is strongly

The healthcare sector accounts for 8% of

associated with more hospitalization and less

the total EU workforce and 10% of the GDP.

self-management. An individual’s level of literacy

According to the 2013 report, “Investing in

directly affects his or her ability to access health

Health,” from the European Commission,

information, learn about disease prevention and

the high healthcare costs in the EU pose the

health promotion, follow healthcare regimens and

question of “cost efficiency and the finan-

communicate about health messages with other

cial sustainability of the region’s healthcare

people.42

systems.”44 The pressure for finding a sustainable healthcare model is rising. On one hand, the economic crisis caused enormous reductions in public health spending. In Iceland, Ireland and Greece public expenditure on health was reduced by 9.3%, 9.9% and 10.8%, respectively, between 2009 and 2010. On the other hand,

39 Center for Strategy and Evaluation Services & Oxford Research. Final Evaluation of the Lead Market Initiative. 2011. 40 Electronic Health Records 41 Health Programme of the European Union. Overview of the national laws on electronic health records in the EU member states and their interaction with the provision of cross-border eHealth services – Final report and recommendations. 2014. Page 7.

42 WHO. Working document for discussion at the 7th Global Conference on Health Promotion, “Promoting Health and Development: Closing the Implementation Gap”, Nairobi, Kenya, 26-30 October 2009.

Focusing on disease prevention can reduce high long-term treatment costs and improve health outcomes by avoiding tens of thousands of premature deaths.46 However, little relative importance is currently given to health promotion in budgetary terms. Between 70% and 80% of healthcare budgets across the EU is currently spent on treating chronic diseases, and 97% is spent on treating patients with both acute and chronic conditions. But only 3% is spent on prevention, with chronic diseases being among the most preventable illnesses.47 See figure 8.

ageing populations and the prevalence of chronic diseases are also stressing the need for better quality care for less money.45 In the following, healthcare promotion and

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

PRESCRIBING PREVENTION

costs of pharmaceuticals will serve as measurements of cost efficiency within European healthcare.

European Commission. Investing in Health. 2013. 44,45,46

47 Spongenberg H. “Chronic diseases: forcing change in EU healthcare management.” EU Observer. 2014.

48 Friends of Europe. Healthcare in Times of Austerity: Boosting Cost-Effective Prevention. 2013.

EUROPE / EFFECTIVENESS

FIGURE 8.

PREVENTION IS NOT TOP PRIORITY Current health expenditure by function, 2012 (or nearest year)

In-patient care

Outpatient care

Medical goods

Prevention and adminstration

100 90 80 70 60 50 40 30

Prevention efforts are taking

20 10

One example of the benefits of prevention is

EFFORTS TO CUT

the flu vaccine. According to the WHO, season-

PHARMACEUTICAL SPENDING

al influenza can cost $6.5 million per 100,000 residents each year in countries like France and Germany. If vaccination rates in Europe went up to 75%, 1.7 million more cases of flu could be prevented. In addition, achieving this target would reduce the number of visits to GPs by approximately 770,000 annually.48

Between 2000 and 2009, pharmaceutical expenditure grew by 3.2% annually in EU member states, an increase that exceeded GDP growth.49 As the economic crises hit Europe, this picture changed and the pharmaceutical sector was targeted by governments seeking to cut costs without harming patient outcomes. A range of measures has been introduced across the EU member countries, including price cuts, centralized public procurement of pharmaceuticals, promoting the use of generics, reduction of package sizes,

50 OECD & European Commission. Health at a Glance: Europe 2014. 2014. 51 Deloitte Center for Health Solutions. Impact of austerity on European pharmaceutical policy and pricing: Staying competitive in a challenging environment. 2013.52 OECD & European Commission. Health at a Glance: Europe 2014. 2014.

53 European Federation of Pharmaceutical Industries and Associations. Annual Review of 2011 and Outlook for 2012. Undated.

reduction in coverage, and increases in co-payments by households.50 In terms of the increasing use of generics, Germany has introduced systems to benchmark prices and started to link reimbursements to the lowest available price of the drug as a way to reduce public spending.51 The result of these initiatives has been falling annual growth rates of spending on pharmaceuticals of 2.7% in 2011-2012 across EU member states.52,53

ICELAND

SWITZERLAND

NORWAY

SPAIN

SLOVAK REPUBLIC

HUNGARY

PORTUGAL

SWEDEN

LUXEMBOURG

DENMARK

LATVIA

CROATIA

GERMANY

ESTONIA

FINLAND

SLOVENIA

NETHERLANDS

EU23

CZECH REPUBLIC

CYPRUS

LITHUANIA

POLAND

Source: OECD & European Commission. Health at a Glance: Europe 2014. 2014.

AUSTRIA

0 GREECE

Region.

ROMANIA

spending across the European

FRANCE

up a small part of the overall

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

EU GUIDES THE WAY TO MORE EFFECTIVE CARE

Long-term care

Policy recommendations from the EU are trying to promote effectiveness in healthcare in the region. In recent years, a line of improvements has taken place, but there are still shared challenges and great variations when it comes to effectiveness between established EU countries and new additions to the Union.

In 2014, the European Commission issued the “Communication on Effective, Accessible and Resilient Health Systems” which addresses the effectiveness of EU healthcare systems by calling for member states to apply performance assessment results, improve patient safety and develop integration of care.54 The Communication also acknowledges that assessing the effectiveness of health systems is a complex process and states that, “healthcare measures may only show their effects after a long period, and comparability and reliability of data is a challenge.”55

From 2000 to 2010 virtually all EU member states have succeeded in reducing the rate of ‘amenable mortality. However, the distribution of the rate of amenable mortality across the EU member countries shows a clear divide between the ‘old’ Western member countries and the ‘new’ Eastern member countries and highlights a trend towards large variations in the effectiveness of healthcare systems in the EU28. See figure 9.

While it can take many years to collect the data needed to assess a healthcare system’s effectiveness, this section examines two indicators that offer more immediate feedback on a system’s effectiveness, namely the rate of premature deaths (deaths that should not have occurred if timely and effective healthcare was provided) and the underuse and overuse of healthcare.56, 57 These indicators give insight into how well a healthcare system is performing its primary job: properly and safely treating those in need.

STATE OF AMENABLE MORTALITY

54 European Commission. On effective, accessible and resilient health systems. 2014. 55 European Commission. On effective, accessible and resilient health systems. 2014. Page 7. 56 European Commission. On effective, accessible and resilient health systems. 2014. 57 Amenable mortality combines the standardized mortality rates for a selected set of diseases on which healthcare is estimated to have a direct impact.

58 Measuring the effectiveness of EU healthcare systems is challenged by the lack comparable data across the 28 member countries of the union. 59 EU Health & Consumer Protection Directorate-General. European guidelines for quality assurance in breast cancer screening and diagnosis. 2006. 60 European Commission. European guidelines for quality assurance in breast cancer screening and diagnosis. 2006.

Amenable mortality, standardized death rates per 100,000 inhabitants, 2010

FIGURE 9.

BIG DIFFERENCES IN AMENABLE MORTALITY

Despite improvements in all EU countries, there are still great differences in the amenable mortality in the region. France and the

EU GUIDELINES FOR THE FUTURE ACTION ON HEALTH SYSTEMS ACCORDING TO MARIA IGLESIA GOMEZ FROM DG SANTE

Netherlands are at the top, while Latvia and Lithuania are at the bottom. Data for Greece not available. 600

Female

Source: Eurostat (2010)

Males

500 400

In April 2014, the Commission adopted the “Communication

ACCESSIBILITY

on effective, accessible and resilient health systems,” which

“Access to healthcare is a multidimensional phenomenon; we

presents some overall guidelines for the future action on

can identify at least four dimensions of it: share of the popu-

health systems. Ms. Maria Iglesia-Gomez from DG Sante

lation that is covered, the basket of care, the affordability of

explains key elements of the recommendations:

care and the availability of care. Measuring access to health-

EFFECTIVENESS “Health systems should improve the health of the population.

300

The challenge is to measure improvements in the health status that are due to the health system, and not for instance

200

to better nutritional habits, or safer roads and cars. The 100 0

Commission is currently supporting member states with using health system performance assessment, through an expert FR NL

ES LU BE DK SE PT

CY DE MT AT

UK PL CZ HR BG EE SK HU RO LT

group that started in the framework of the reflection process on modern, responsive and sustainable health systems, initiated by the Council in 2011. The goal of this process is to improve the coordination on health systems performance

CHALLENGE: ENSURING APPROPRIATE CARE

assessment at EU level.”

care encompasses significant difficulties. Available indicators allow for the measurement of self-perception of unmet needs for care but not for objective measurement of access; indicators for coverage, waiting times and affordability are either non-existent or inadequate." RESILIENCE “Resilience is the ability to adapt effectively to changing environments, tackling significant challenges with limited resources. member states’ future ability to provide high quality care to all will depend on making health systems more resilient, more capable of coping with the challenges that lie ahead. And they must achieve this while remaining cost-effective

Overall figures for comparing under- and overuse

Antibiotic use is an ideal indicator of medication

of treatments and medicines across the European

overuse, as the volume of antibiotics prescribed

be cost-effective; we give a great importance to increasing

Union are hard to come by, and instead breast

at a community level and prevalence of resistant

co-operation on Health Technology Assessment.”

cancer screenings and the use of antibiotics will

bacterial strains are linked. Infections caused by

serve as examples of under- and overuse re-

resistant microorganisms often fail to respond to

spectively. All though not drawing the complete

conventional treatment, resulting in prolonged

picture, these two cases will serve as inspiration

illness, greater risk of death, and higher costs.62

for further comparisons.

Hence, it is essential that antibiotics are prescribed based on evidence-based needs and not

In the case of breast cancer screening, a num-

for viral conditions like a mild throat infection.63

ber of European countries are underusing

and fiscally sustainable. Clearly, innovation in health must

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

However, variations across countries are prevalent.

certain treatments and thus not living up to

The volume of antibiotic use varies substantially

tion through an effective primary care system. Looking

Asthma-related admissions in the Slovak Republic and

EU guidelines.58, 59 The European Commission

across EU member countries with the Nether-

at chronic diseases such as asthma, chronic obstruc-

Latvia were more than double the EU average, where-

has established the “European guidelines for

lands and Estonia reporting the lowest volumes

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

as Italy, Portugal, Germany, Sweden and Luxembourg

quality assurance in breast cancer screening and

and Greece, Cyprus and Belgium reporting

performing primary care system could, to a significant

report rates that were less than half the EU average.

diagnosis”, which promotes a desirable breast

volumes around 1.5 times the European Union

extent, avoid acute deterioration for people living with

Hospital admission rates for uncontrolled diabetes

cancer screening target of at least 75% of eligible

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

these diseases and prevent admission to hospital.66

vary 8-fold across the EU member countries with Italy,

women in European member states.60 Despite all

reducing antibiotic use is a pressing, yet complex

countries having uniformly established programs

problem in the European Union. Improvement

These are all conditions that affect EU healthcare

and Austria and Hungary reporting rates that are near-

according to the guidelines, only six countries

of this issue should involve multiple coordinated

systems substantially with e.g. COPD accounting for

ly double the OECD average.69

had reached the target of 75% in 2010.

initiatives that include surveillance, regulation and

approximately 3% of total deaths in the European

education of professionals and patients.65

Union and diabetes resulting in an estimated 10% of

Participation in the programs also varied consid-

United Kingdom and Spain showing the lowest rates,

total adult deaths in Europe.67, 68

erably across EU member countries, ranging from 8% in Romania and 16% in the Slovak Republic, to over 80% in Finland, Denmark, Austria and the Netherlands.61

61 OECD & European Commission. Health at a Glance: Europe 2014. 2014.

EU member countries have reported a reduction in admission rates for each of the three aforementioned conditions over recent years.

62 OECD & European Commission. Health at a Glance: Europe 2014. 2014.

68 International Diabetes Federation. IDF Diabetes Atlas, Sixth Edition.2013.

63 Cochrane Collaboration. The Cochrane Acute Respiratory Infections Group.2013.

69 OECD & European Commission. Health at a Glance: Europe2014. 2014.

OECD & European Commission. Health at a Glance: Europe 2014. 2014. 64,65,66

67 World Health Organization. Background Paper 6.13: Chronic Obstructive Pulmonary Disease (COPD). 2013.

EUROPE / TIMELINESS

TIMING IS EVERYTHING Bringing down waiting lists has been a main target in European countries in recent years. But there are still challenges when it comes improving the timeliness of healthcare in Europe, and with strains on the healthcare budgets they do not seem to be overcome just yet.

An efficient way to measure crowdedness is through the number of hospital beds per citizen. If the demand for care outpaces the resources to handle patients, long wait times can ensue. Over the past 10 years, the number of hospital beds per population has decreased in all European countries except Greece. On average across EU member states, the number fell by close to 2% per year, coming down from 6.5 beds per 1,000 people in 2000 to 5.2 beds in 2012.73

In the survey Eurobarometer “Patient Safety and Quality of Care” from 2013, one in five of the respondents point to the waiting time to be seen and treated as crucial in their evaluation of a hospital.70

LOST IN THE CROWD Overcrowded hospitals are an important hindrance to the provision of timely and high quality care. An array of issues are identified as reasons for crowding: increased patient

Improving the timeliness of care – reducing waiting times, avoiding crowding and ensuring the right treatment in due time – demands resources, but it also calls for great changes in areas such as hospital processes, culture, technology use. In the following, hospital crowding and wait times for elective procedures are presented as indicators for the state of timeliness in European healthcare.

acuity, hospital bed shortage, increasing ED volume, radiology delays, insufficient ED space, laboratory delays, consultation delays, nursing shortage, physician shortage, and managed care issues. International studies have also shown that delays caused by overcrowded EDs can lead to adverse effects on patient care.71 A Danish study from 2014 found that high bed occupancy rates were associated with a significant 9% increase in rates of in-hospital mortality and thirty-day mortality, compared to low bed occupancy rates.72

70 European Commission. Special Eurobarometer 411: Patient Safety and Quality of Care. 2014. 71 Jayaprakash N, et al. “Crowding and Delivery of Healthcare in Emergency Departments: The European Perspective.” Western Journal of Emergency Medicine 2009; 10(4): 233-239.

72 Madsen F, Ladelund S & Linneberg A. “High Levels of Bed Occupancy Associated With Increased Inpatient And Thirty-Day Hospital Mortality In Denmark.” Health Affairs 2014; 33(7): 1236-1244. 73 OECD & European Commission. Health at a Glance: Europe 2014. 2014.

74 The NHS defines major incidents as any occurrence that presents serious threat to the health of the community, disruption to the service or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by hospitals, ambulance trusts or other acute or community provider organizations”.

Although the reduction in beds could signify that more patients are seeking care at primary care facilities rather than hospitals, it can also be a safety hazard if the number of patients seeking care in hospitals does not decline alongside the number of beds. Illustrating the latter, in December 2014, 15 hospitals in England declared major incidents74 because of pressures on A&E department bed capacity.75, 76

PUTTING A PRICE ON TIME Elective – but often very necessary – procedures are also prone to long wait times, and these vary a great deal between European countries. For example, in 2012-13, the average waiting time for cataract surgery was just over 30 days in the Netherlands, but about three-times longer (100 days) in Spain and Finland.78 Over the past decade, waiting time guarantees have become the most common policy tool to tackle long waiting times in several European countries. This has been the case in Finland, for example, where a National Healthcare Guarantee was introduced in 2005 and led to a reduction in waiting times for elective surgery. In Denmark, a key policy is the “free choice” of hospital provider for patients. If a hospital can foresee that the maximum time cannot be

Long wait times can also discourage people from utilizing hospital services, as a 2007 study in Ireland reported that out of 45,000 surveyed

fulfilled, the patient can choose another public or private hospital, either within or outside Denmark – and the money follows the patient.79

ED patients, 35% said that the prospect of a prolonged stay affected their willingness to come to the ED or to return.77

75 The Guardian. Eight more hospitals declare critical incidents as demand surges. 2015.

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

76 The Independent. NHS in critical condition as A & E waiting times are worst in a decade. 2015.

78 OECD & European Commission. Health at a Glance: Europe 2014. 2014.

77 Jayaprakash N, et al. “Crowding and Delivery of Healthcare in Emergency Departments: The

79 Siciliani L, Moran V & Borowitz M. “Measuring and comparing

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

EUROPE / ENVIRONMENTAL SUSTAINABILITY

A HEALTHY ENVIRONMENT Sustainability is moving up the agenda in all European countries – not only as an economic phrase, but also in terms of the effects of climate change on the region’s healthcare sector and vice versa.

DIAGNOSIS: CLIMATE CHANGE

INNOVATIVE THINKING CAN SAVE ENERGY

Not only does the healthcare sector affect the environment, but the reverse is also true. Climate change has an enormous impact on health and

At the Royal Free Hospital in the UK, the

healthcare in Europe, in terms of public health,

implementation of a Combined Heat and Power

safety, and the associated healthcare costs

plant and the installation of three new boilers –

of both. It affects human health both directly In the coming years the European healthcare sector will be forced to reduce its own negative effect on the environment and also be prepared for meeting and coping with a new pathological picture created by climate change. Within the EU, sustainability in the healthcare sector is becoming a focus area and an important element of the region’s ambitious green targets for the coming years. One example is the EU Green Public Procurement Policy aimed at making public authorities go green and push the market towards a more sustainable production, in which a main focus area is green procurement of medical devices – currently one of the top five of most energy intensive products in Europe.80

HEALTHCARE IS HEATING UP The healthcare sector is a contributing factor to the climate change experienced in Europe. The healthcare sector is a major energy user, as European hospitals consume on average 300 Kw of thermal and over 100 Kw of electrical energy per square meter per hour. Considering that there are approximately 15,000 hospitals in Europe, this represents an expense of 10% of the GDP and accounts for 5% of CO2 emissions.81 The NHS Sustainable Development Unit in the UK has calculated its carbon footprint at more than

plus a number of smaller adjustments such as low

through extreme heat and damage to health

voltage distribution boards and lighting updates

service delivery infrastructure in times of envi-

– resulted in annual energy savings of $1.9 million. The project provided a return on investment after

ronmental disaster and indirectly through forced

just seven years and allowed the site to increase

migration, flooding, and lifestyle changes.83

its energy security and meet its sustainability targets.

Additionally, temperature-sensitive infectious diseases, such as food borne infections are likely to grow. Recent studies show that the disease burden caused by climate change in Europe could be significant, with 20,000 potential extra cases of

The European Commission has outlined that the

food borne diseases per year by the 2030s, and

greatest concern in terms of climate change and

25,000 to 40,000 extra cases per year by the

its effect on health is heat-related mortality and

2080s.84

morbidity due to increases in annual temperature. In EU countries, it is estimated that mortality

18 million tons of CO2 each year — 25% of total

increases by 1–4% for each one-degree rise in

public spending.82

temperature, meaning that heat related mortality could rise by 30,000 deaths per year by the

Despite initiatives like this, there is still a long

2030s and by 50,000 to 110,000 deaths per year

way for a common green goal within healthcare

by the 2080s.85

in the European region. Great challenges remain, and the healthcare sector in general continues to be a ‘black industry’. Energy use and the effect of climate change on healthcare are outlined as primary challenges when it comes to sustainability and climate change in regard to the healthcare sector in Europe. 80 Swedish Competition Authority. The EU GPP criteria for medical devices. 2014. Healthcare Without Harm. Climate change and Health. Undated. 81,82

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

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

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

86 KPMG International. Improving energy and resource efficiency. 2012.

BRUSSELS ROUNDTABLE The roundtable discussion in the European Parliament in Brussels marked the second stop on our journey to co-create better healthcare systems worldwide. The roundtable participants represented a broad range of European healthcare stakeholders and provided their insights concerning the common challenges and opportunities across the healthcare systems in the 28 member countries of the EU. To inspire the discussion, the Danish Member of the European Parliament,

CHALLENGES FOR HEALTHCARE IN EUROPE

OPPORTUNITIES FOR CHANGE

There is much variation in the quality of healthcare services and access to treatment

Change the mindset of health professionals to see themselves as guests in patients’ lives, not the hosts

Increased demand for healthcare services and strained budgets are stretching healthcare

systems at both ends

Demographic change with an ageing population

Make organizational data public in order

in most EU countries is increasing the need for

to increase learning across the member

integrated long-term care

countries

There is an inability to properly manage long term

and chronic illnesses

Enhance coordination and incentivize collaboration on all levels

Improve quality of care for chronic diseases Empower patients to self-care and harvest the

There is a lack of focus on how to manage the

benefits of a more efficient use of healthcare

“mobile patient” that is moving across the open

professionals’ time

EU borders

Ms. Christel Schaldemose (profiled in an interview on page 90), presented her perspective on what the political priorities for healthcare in the EU should be; Dr. Francesco De Lorenzo, President of the European Cancer Patient Coalition (profiled in an interview on page 91), provided a status update on the European healthcare systems from a patient perspective with a special emphasis on the role of accreditation and Ms. Maria Iglesia Gomez, Head of the Strategy and Analysis Unit in DG SANTE (profiled on page 83), outlined the European Commission’s priorities and policy initiatives for healthcare.