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Complex patients Healthcare and IT Waste control The trouble with AMR No 309 Q1 2017 Halving road deaths as a health imperative Pensions roundtable Olof Palme and Sweden’s inequality challenge

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CONTENTS No 309 Q1 2017


Sustainable cities; International trade; Sense and big data; Twitterings


Our health systems must put people at the centre Angel Gurría, Secretary-General of the OECD

NEWS BRIEF 4 Migration follows beaten track; R&D funding at risk; Mainstreaming biodiversity; Soundbites; Economy; Country roundup; Clara López; Other stories; Plus ça change

BLOGS 6 BlogServer 7 March on gender

ECONOMY 9 Inequality: Can Sweden reconquer utopia? Jon Pareliussen 11 Going for inclusiveness and productivity; China’s economy


13 Towards sustained progress in global healthcare Jeremy Hunt, Secretary of State for Health, United Kingdom, and Chair of the 2017 OECD Health Ministerial Meeting 14 The PaRIS initiative: Helping healthcare policies to do better for patients Stefano Scarpetta 15 The challenge of antimicrobial resistance: The hidden “fil rouge” for healthcare policy Mark Pearson 17 Healthcare systems: Tackling waste to boost DATABANK resources Francesca Colombo 19 Governing data for better health and healthcare Jillian Oderkirk and Elettra Ronchi 21 Complex patients: How healthcare must adapt to their needs Martin Wenzl, OECD, Mossialos, at large Trendand in theElias number of doctors London Selected EU countries, 2000 to 2012 (or nearest year) School of Economics and Political Science CD area are living longer es. Improved lifestyles 23 People-centred healthcare: What empowering as are better medical could the number of policies are needed a contributing factor? Olivia Wigzell, Director General, National Board of t European countries at Health and Welfare, Sweden te number of doctors has en 2000 and 2012. Overall, 24 Business Brief: Johnson & Johnson ntire period, there were doctors in 2012 compared 26 An agenda for robust healthcare 2000 to 2012, there were Xavier Prats Monné, Director-General for Health rs in the United Kingdom, many, 40% more in Spain, and Food Safety, European Commission n Portugal and in the

11). The exceptions are Czech Republic, where octors has remained over the period, while life also improved.

27 Why patient-centred approaches are important Nicole Denjoy, Secretary General of COCIR and Chair of the BIAC Health Committee 27 Patient-centred policies must be centred on healthcare workers too Jocelyne Cabanal, Member of the Executive Committee, Confédération Française Démocratique du Travail (CFDT), France 29 Casting light on dementia’s shadow Tim Muir 30 The healing power of information technology Interview with David Blumenthal, President and CEO, The Commonwealth Fund 32 Managing new health technologies Jonathan Skinner, Geisel School of Medicine and Department of Economics, Dartmouth, and Amitabh Chandra, Harvard Kennedy School of Government, Harvard 34 Designing value-based health systems for patients: The example of pain control and palliative care Felicia M Knaul, Professor, Department of Public Health Sciences at the Miller School of Medicine, and Director, Miami Institute for the Americas, and Afsan Bhadelia, Visiting Scientist, Harvard T.H. Chan School of Public Health 35 Business Brief: Faculty of Medicine, Université Paris Descartes 36 Our patients have changed, our healthcare must now follow Dr Samir K. Sinha, Director of Geriatrics, Sinai Health System and the University Health Network Hospitals 37 People-centred healthcare: Don’t forget the nurses! Judith Shamian, President, International Council of Nurses 38 Healthcare: Pouring a little cold water on crowdfunding Claire MacDonald 39 Business Brief: HES-SO University of Applied Sciences and Arts Western Switzerland 40 Can healthcare policy and technology heal ruralurban divides? Rory Clarke and Claire MacDonald

erform administrative es from about 70% in mark to less than 20% in rkey and Italy.

differences in internet

BOOKS 49 Reviews: Dare to share; Making Africa healthy 50 New publications 51 Focus on healthcare 52 Review: A more violent world?; Crossword

DATABANK 53 Can more social spending curb emigration?; The race for excellence in scientific publishing 54 Main economic indicators 56 Addressing high costs of specialty drugs

Tackling waste in healthcare systems, page 17

Complex patients, page 21

Index 2000=100








Czech Republic




SOCIETY 42 OECD Observer roundtable on pensions 45 Halving road deaths by 2020: A global health priority HRH Prince Michael of Kent UK Netherlands Germany France


Spain Portugal Czech Republic

OECD roundtable on pensions, page 42









Source: OECD 2014

stabilised or slowed in countries hard hit by the crisis. Despite this upward trend, with a third of doctors over 55 years of age, many European countries could face a shortage of doctors in future, particularly in rural areas.

OECD (2014), Health at a Glance: Europe 2014, OECD Publishing. eur-2014-en

Published in English and French by the OECD EDITOR-IN-CHIEF: Rory J. Clarke EDITORIAL ASSISTANT, WRITER: Neïla Bachene EDITORIAL INTERN: Balázs Gyimesi ment generation ©OECD% ofMarch 2017 Using e-governments services LAYOUT: Design Factory, Ireland individuals obtaining information and sending completed forms on government websites in the last 12 months ols simplified our public authorities? From ILLUSTRATIONS: David Rooney, Sylvie Serprix ing to downloading ofISSN 0029-7054 administrative procedures, WRITER: Clara Young, Claire MacDonald Tel.: +33 (0) 1 45 24 9112 most of OECD countries ADVISERS: Emily Hewlett and Luke Slawomirski, range of online services. Fax: +33 (0) 1 45 24 82 10 ed. Most people in OECD Health Division -government services ADVERTISING MANAGER: Aleksandra Sawicka n on administrationFounded in 1962. The magazine of the Organisation though many also use it ADVERTISING SALES: LDMD ms, such as tax returns. for Economic Co-operation and Development rvices are used on PRINTERS: SIEP, France; Chain of Custody certified. than 45% of individuals OECD Publications 2 rue André Pascal ation, but users show a Applications for permission to reproduce or translate all or parts propensity to use them 75775 Paris cedex 16, France o filling in a document of articles from the OECD Observer, should be addressed to: % do. Editor, OECD Observer, 2 rue André Pascal, 75775 Paris, usage rates: in 2013, 90% and more of In any case, companies are one The step ahead: e of individuals

e trend clearly rose both the 2008 world economic there were over 10% doctors in 2012 compared ver, the number has

OECD.ORG 46 Healthcare for patients; OECD wins international publishing award; Affordable housing database; Effectopedia, chemical risks and health 47 Recent speeches by Angel Gurría; List of OECD Ambassadors 48 Calendar; Frankie

% 90


Sending filled forms, 2013

Getting Information, 2013

Sending filled forms, 2010






All signed articles in the OECD Observer express the opinions of the authors and do not necessarily represent the official views of the OECD or its member countries. Reprinted and translated articles should carry the credit line “Reprinted from the OECD Observer”, plus date of issue. Signed articles reprinted must bear the author’s name. Two voucher copies should be sent to the Editor. All correspondence should be addressed to the Editor. The Organisation cannot be responsible for returning unsolicited manuscripts. The statistical data for Israel are supplied by and under the responsibility of the relevant Israeli authorities. The use of such data by the OECD is without prejudice to the status of the Golan Heights, East Jerusalem and Israeli settlements in the West Bank under the terms of international law.


10 0


Source: OECD, ICT database and Eurostat, Information Society Statistics

the adult population had access to the internet in the Nordic countries, but less than 60% in Turkey. Despite a high internet usage rate, the Germans do not seem eager to perform administrative requirements online.

cedex 16, France.

e-governments services are used by more than 80% of businesses in OECD countries.

OECD (2014), Measuring the Digital Economy: A New Perspective, OECD Publishing.

OECD Observer No 302 April 2015


This document, as well as any data and map included herein, are without prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area.

Readers’ views We welcome your feedback. Send your letters to or post your comments at or

any meaningful way? Learning can’t be “measured,” but it can be assessed. Parents do this every day as they watch their children grow and develop. Of course, that doesn’t generate the “data” that society has come to believe is “more true” than qualitative observation. Sadly, the data now being used to decide the fate of our children is totally invalid, both in statistical methodology and in what it claims to measure.

Judy Yero, commenting on “How does big data impact education?”, from, posted on, January 2017

Sustainable cities Great to see that OECD is joining forces with C40 “to identify knowledge gaps, advance research, and ultimately promote best practices and policy solutions for achieving more inclusive, sustainable cities.” Partnerships like this– or like the newlyestablished Global Covenant of Mayors for Climate & Energy, a merger between The Compact of Mayors and the EU Covenant of Mayors – are key to protect the future of our planet.

Andreas Sandre, commenting on “Climate, inequality and cities: How the world’s mayors can make a difference”, from OECD Observer No 307 Q3 2016, posted on

International trade I would point the figures on the purpose of world trade depending on what sort of future we expect for the world trade: a world of peace and justice, based on the sustainable development goals and OECD responsible business conduct, and other similar “values”? Or a world of anger, prejudice, war, unfairness, based on the astonishing amount of the big business of military industry in the world. Thus, as society is becoming more and more networks of networks, Gross National Product Index are obsolete to measure quality of living. Better if OECD country members consider the need for several other indexes to measure happiness, wellbeing, quality of life. For a new future, a transformative future, we need new, transformative measures to evaluate success of countries. For sure, the Netherlands is a benchmark for the world, as well as other leaders promoting policy coherence for sustainable development, at least nationally, both horizontal and vertical policy coherence. However, what about the Netherlands promoting a clear voice in the world towards sustainable


development policies for investment and trade internationally, not only expecting the voice of multinationals, but clearly embracing in all international agreements?


Twitterings Mairita Luse @mairitaluse

G20 has opened the path towards coherence with the Agenda 2030, as well as the OECD. Now it is time for policy coherence among UN, G20 and OECD country members.

Reading a report on #criticalminerals by @OECD. How can we still have so many important materials with recycling rate of 0? #circulareconomy

Patricia Almeida Ashley, Associate Professor, Instituto de Geociencias – Universidade Federal Fluminense, and Former Prince Claus Chair in Development and Equity (ISS/EUR – 2009-2011)

John Kirton @jjkirton

Extract from letter on “What is key for the OECD in 2017? An open economy perspective”, see http://oecdinsights. org, January 2017 for full comment.

Sense and big data Data is only valuable when it actually measures something important. One would think that, in education, the most useful data would be a measurement of how much learning is taking place. Standardised tests claim to do this, but they largely test a learner’s ability to memorise largely context-free facts that can be used to generate multiple choice questions with one right answer. Yet the results of these tests are being used to determine whether students, teachers, and schools are successful or failing! The obsession with data – numbers, quantitative assessment – has all but eliminated authentic and ongoing formative assessment that is actually useful in understanding and facilitating the learning of each individual – something that standardised tests can’t and were never meant to do! Learning is so much more than memorising easily testable facts and rules that can be regurgitated on a test. Could anyone sum up their learning as a single test score? A single number? If not, why has the public become convinced that tests measure learning in

We count on the @OECD to bring the best analysis to enrich the G20 work, including on fossil fuel subsidies @g7_g20 @g20rg @CLMannEcon Fernando M. Reimers @FernandoReimers I greatly enjoyed conversation w @A_Gurria and his colleagues @SchleicherOECD @OECD Dave O’Connor @oconnear Interesting #health views at the @OECD Health Ministerial Meeting. Chiara Samele @chiara_samele @OECD #futureofhealth. Excellent forum and impressive speakers. Let’s however hear more from patients and informal carers. Howard Catton @HowardCatton #FutureOfHealth @OECD Congrats & thanks 4 excellent Forum; next time contributions from more healthcare staff on panels not just docs b gr8 Ed Fitzgerald @DrEdFitzgerald Interesting new @OECD report on tackling wasteful spending in health. #OECD #health #healthcare #patientsafety

Follow us on Twitter @OECDObserver Comments and letters may be edited for publishing. Send your letters to or post your comments at these portals:,, or at the other OECD portals on this page.


Our health systems must put people at the centre We need to change how we provide care and how we measure health systems today

care. And data on seven OECD countries from the Commonwealth Fund shows that at least one in four high-need adults experience poorly coordinated care. More worrying still, high-need adults express low-levels of confidence in the care provided to them: in six OECD countries, more than 10% of high-need adults thought that a mistake had been made in their treatment or care in the previous two years. These challenges point to an urgent need to recalibrate health systems and put people squarely at their centre. There are three areas for action: First, we need models of care that deliver what matters to patients. Too often, clinicians deliver what they think is in the interests of patients, rather than listening to what patients want; for example, less intrusive healthcare.

Angel Gurría Secretary-General of the OECD

Looking back at what we have achieved over the past few decades in the health sector, in many ways the future is looking quite bright. People are living longer, healthier lives. Health data continues to grow exponentially. New health technologies, such as fitness trackers, wearables and remote monitoring systems, are breaking down the information walls of hospitals and clinics, empowering people to assess and monitor better their own health in real time. And new drug treatments tailored to the genetic profile of each individual–precision medicine–have the potential to revolutionise healthcare. But delivering high-quality, inclusive healthcare remains a major challenge. These are exciting new frontiers, but important challenges remain as suggested by the targets underlying UN Sustainable Development Goal 3 to “ensure healthy lives and promote well-being for all at all ages”. Universal health coverage continues to elude many emerging and developing countries. In Europe, poor people are 10 times more likely to report unmet medical needs for financial reasons than rich people. In many advanced and even emerging economies, health budgets are struggling to cope with the simultaneous pressures of an ageing population with multiple chronic diseases, and new high-cost treatments. Many health systems are ill-equipped to capitalise on the opportunities provided by new innovations and technologies. And while health systems across the world are data rich, most are very poor at making use of data to inform policy, practice and patient choices. The quality of care is also uneven, including for those who need it most. Across the OECD, one in ten patients is adversely affected by preventable errors caused by sub-standard or inappropriate

Second, we need to ensure that patients and providers are equipped with the right skills and infrastructure to take advantage of new technologies. Third, we need to understand better what matters to people in their healthcare experiences and outcomes. The Patient-Reported Indicators Survey (PaRIS) will serve as a ‘‘PISA for health’’, so that policymakers, providers, and patients can understand how health systems make a difference to people’s lives. We plan to work with other institutions to systematically survey patient-reported outcomes. We will no longer only assess health system performance on the basis of what they do–for example, the quantity of operations or appointments–but also on whether medical care leads to people being in less pain, more mobile, and in better physical and mental health. People-centeredness means treating people, patients, their loved ones, carers and others with compassion, dignity and respect. It means involving them in decision-making about their health and their care. It means doing things with people, not to them. It means involving people in system design and in policymaking. To deliver the people-centred health systems of tomorrow, we need to change how we provide care and how we measure health systems today. These changes will position us to achieve health outcomes that matter to people, rather than focusing simply on those that providers can deliver. Extract adapted from opening remarks to the OECD Policy Forum and Health Ministerial Meeting, People at the Centre: The Future of Health, 16-17 January 2017. The full version is available at For more on the PaRIS initiative, see @A_Gurria

OECD Observer No 309 Q1 2017


News brief

ŠMarko Djurica/Reuters

Migration follows beaten track

Despite growing economic dynamism in many emerging regions, international migration flows are not being diverted towards these new alternative poles, according to a new OECD Development Centre report. The share of developing country migrants heading to high-income countries has jumped from 36% to 51% of the world total over the last 20 years. For the countries migrants are leaving, the loss of labour can relieve pressure in over-crowded labour markets, propping

R&D funding at risk A decline in public funding of R&D research in a number of countries could pose a threat to innovation at a time when global challenges like climate change and ageing populations demand solutions, according to a new OECD report. Spending on R&D in government and higher education institutions in OECD countries fell in 2014 for the first time since the data were first collected in 1981.

up wages and easing unemployment. Moreover, migrants send home remittances and bring knowledge as they return. But emigration also can come with economic and social costs, such as labour shortages, a loss of educated and skilled workers and repercussions for family members left behind. Countries of destination can benefit from migration to make up for worker shortages. However, immigrants are less likely to have formal labour contracts than native-born workers, the report warns. The need for greater international co-operation to address migration may also grow, the report says. See more on Perspectives on Global Development 2017: International Migration in a Shifting World, on page 56. See

The latest OECD Science, Technology and Innovation Outlook warns that a backlash against globalisation and migration in some countries could also become a cause for concern: indeed, innovation is increasingly driven by cross-border co-operation and the ability of scientists, students and entrepreneurs to move about and work in different countries over their careers.

Soundbites Rather than seeking refuge in nationalism and isolationism, we believe that a better response to globalisation lies in localisation. Michael Bloomberg and George Osborne, The Times, 27 February

We need leaders who remember the dangers of a fragmented Europe. Europe can slip back into war. Jacques Attali, French economist and former minister, in an interview on, 20 January

The ability of statistics to accurately represent the world is declining. In its wake, a new age of big data controlled by private companies is taking over-and putting democracy in peril. William Davies, The Guardian, 19 January

La robotisation ne tue pas le travail, elle le transforme. Headline, Le Monde, 19 January

Mainstreaming biodiversity The world must ramp up its efforts to use natural resources more sustainably and conserve biological diversity and the ecosystems on which we depend for human life, the OECD told participants at the COP13 Convention on Biological Diversity held in Cancun, Mexico, on 7 December. Countries are doing more to preserve biodiversity. Yet billions of dollars are still spent each year subsidising fossil fuels and agriculture that put pressure on natural services like water purification, climate regulation and insect pollination.



anticipate trends and turning points in the economic cycle. Though there are signs of growth picking up in a few countries, stable momentum is anticipated in the OECD area as a whole.

December 2016. Excluding food and energy, annual inflation picked up only marginally, to 1.9%.

Economy Global economic growth is expected to pick up modestly next year to some 3.6% from a projected 3.3% in 2017, but risks of rising protectionism, financial vulnerabilities and potential market volatility hang over the outlook. The OECD’s composite leading indicators continue to point to growth momentum picking up in several economies. By using data from the likes of order books, building permits and long-term interest rates, these leading indicators help


In fact, real GDP growth in the OECD area decelerated slightly to 0.4% in the fourth quarter of 2016, compared with 0.5% in the previous quarter. OECD-area inflation jumped to 2.3% in January 2017, compared with 1.8% in

The unemployment rate in the OECD area fell by 0.1 percentage point to 6.1% in January 2017 after two consecutive months of stability. Some 38.3 million people were out of work, 5.7 million more than in April 2008, before the crisis. The unemployment rate was stable in the euro area at 9.6%. Outside Europe, the unemployment


Other stories

The Swedish economy is growing strongly, with unemployment trending downwards and living standards still among the highest in the world. But further policy actions will be needed to continue delivering inclusive, resilient and green growth, the latest OECD Economic Survey of Sweden says.

Current policies to mitigate carbondioxide emissions from global transport will not be enough to achieve international climate ambitions, a study from the International Transport Forum finds. The ITF Transport Outlook 2017 shows transport emissions rising sharply by 2050, and even under its optimistic scenario emissions remain around 2015 levels.

Portugal’s economy is recovering from a deep recession, thanks to a broad structural reform agenda that has led to falling unemployment and an improved export performance, a new Economic Survey says. Comprehensive reforms to Portugal’s labour market between 2011 and 2015 have helped create jobs and reduce the country’s high unemployment rate, according to Labour Market Reforms in Portugal 2011-2015: A Preliminary Assessment. Reforms are starting to bear fruit in Mexico, but further action is needed to boost productivity and ensure more inclusive growth, the latest OECD Economic Survey of Mexico argues. The US has maintained foreign aid volumes through the aftermath of the global economic crisis and has visibly improved the focus and effectiveness of its development assistance. These trends should be maintained and reforms to the US Agency for International Development should be consolidated, according to the latest DAC Peer Review of the United States. Denmark should boost benefit coverage for low-skilled and low-wage workers and improve the support available to blue-collar

rate increased by 0.1 percentage point in the US to 4.8%, while it fell by the same percentage point to 6.8% in Canada, 3% in Japan and 3.6% in Mexico. Export growth picked up strongly to 1.5%, compared with 0.3% in the previous quarter. Imports increased by 0.8%, marginally up on last quarter’s 0.7% growth. Merchandise trade still remains around 10% below its pre-crisis levels.

©OECD/Hervé Cortinat

Country roundup

Minister of Labour Clara López, with OECD Secretary-General Angel Gurría, during a visit to the OECD in February, where she spoke about developments in Colombian labour policy and the Peace Agreement. Colombia is currently in accession discussions with the OECD. Visit colombia/

workers as part of a series of reforms to help laid-off workers get back into work more quickly, according to Back to Work: Denmark. Despite a challenging global environment, the growth prospects of Southeast Asia, China and India remain robust over the medium term, according to the OECD Development Centre’s Economic Outlook for Southeast Asia, China and India. Governments in Latin America will need to improve public sector management and capacity–including budget allocation–to relieve the pressure on public finances from sliding commodity prices, according to Government at a Glance: Latin America and the Caribbean 2017.

See Nearly one in five mobile phones shipped internationally is fake, as a growing trade in counterfeit IT and communications goods weighs on consumers, manufacturers and public finances. An OECD report, Trade in Counterfeit Goods, finds that batteries, chargers, memory cards, video game consoles and music players are also being counterfeited. See New international guidance on fighting corruption in the development sector went into effect on 9 December 2016, backed by more than 40 countries, with progress on agreed recommendations to be monitored by the OECD Working Group on Bribery and the OECD Development Assistance Committee (DAC). See and

All OECD reports can be found at

Consumer prices, selected areas January 2017, % change on the same month of the previous year % OECD total 8.0

8.5 All items

6.0 4.0 2.0 0.0



1.9 0.4


Plus ça change… Over the next 50 years, the twin engines of population ageing and changing health technology may substantially increase health spending. “Health spending: its growth and control”, by George J Schieber, in Issue No 137, November 1985

All items non-food, non-energy


OECD Observer No 309 Q1 2017


BlogServer Turning groundwater into farmers’ underground insurance against climate change Robert Akam and Guillaume Gruère

Despite the recent drought in California, farms have continued to supply water-intensive crops such as fruits and nuts to consumers both in the US and around the world. Doing so has not always been easy for farmers–or for the environment. From OECD Insights. More here:

From economic crisis to crisis in economics Andy Haldane

It would be easy to become very depressed at the state of economics in the current environment. Many experts, including economics experts, are simply being ignored. But the economic challenges facing us could not be greater: slowing growth, slowing productivity, the retreat of trade, the retreat of globalisation, high and rising levels of inequality. From OECD Insights. More here:

Borders and networks: The forgotten elements of development Laurent Bossard

The latest SWAC/OECD publication Cross-Border Co-operation and Policy Networks in West Africa addresses the crucial but often overlooked issue of cross-border co-operation, employing an analytical approach sparsely used in the development field and in West Africa in particular–social network analysis. From OECD Insights. More here:

Does growth lead to inequality? It depends Orsetta Causa, Mikkel Hermansen and Nicolas Ruiz

Widespread increases in inequality over the past three decades have raised the question of whether growth in itself is a driver of income inequality. Considering that correlation often tells little about causation, this question is less trivial than may appear at first glance. Indeed, the concomitant rise in GDP per capita and income inequality does not, per se, imply any causal relationship from the former to the latter. Research efforts have offered mixed conclusions so far and the growth and inequality question has been at the centre of a long-standing controversy among economists. From OECD Ecoscope. More here:

Migration: An overlooked tool for local development Cécile Riallant

The global approach to migration and development is typically framed at the national level, whereby policies are conceived by national governments and mostly implemented with national fiscal resources and by national actors. This is in line with the common perception that migration is subject to national sovereignty, involving country to country agreements and adherence to international conventions. Yet, this national level approach fails to acknowledge the diversity of development and migratory contexts that exist within countries. From OECD “Development matters” platform. More here:


The Walking Dead: Zombie firms stifle economic recovery prospects Müge Adalet McGowan, Dan Andrews and Valentine Millot

With the global economy stuck in a low growth trap, it is crucial to understand the factors behind the weak recovery in potential output growth, and particularly the barriers to productivity growth. New research shows that this dynamic can be partly understood in terms of the increasing survival of zombie firms– those firms that would typically exit in a competitive market but are being kept alive by creditors or policy weakness. From OECD Ecoscope. More here:

Human migration, environment and climate change Daria Mokhnacheva, Dina Ionesco and François Gemenne

Environmental migration is a fact. Most countries experience some form of migration associated with environmental and climate change, or forced immobility for those populations that end up trapped. Sudden-onset disasters as well as slow-onset environmental change taking place around the world, whether natural or manmade, profoundly affect migration drivers and migration patterns, even though the relationship between concrete environmental factors and migratory response is seldom direct and linear. From OECD “Development matters” platform. More here:

What is key for the OECD in 2017? An open economy perspective Noe van Hulst

As we start a year that Ian Bremmer, President Eurasia Group, has coined as entering “the geopolitical recession”, it is worth asking what the OECD focus could be in 2017. I see two key issues worth highlighting in this context. From OECD Insights. More here: extracts from blogs are courtesy of OECD Insights, OECD Education & Skills Today, OECD Ecoscope, Wikigender, Wikiprogress and other content and social media platforms managed by the OECD.


March on gender Catch up with the OECD’s initiatives on gender, including for International Women’s Day 8 March, by visiting

representative of the societies that they serve and enables courts to understand the real-world implications of their rulings. Enhancing gender diversity in the justice system helps maintain public confidence, reduces barriers to women’s access to justice, such as stigma associated with reporting violence and abuse, and ensures a more balanced approach to enforcing the law. A higher presence of women jurists is vital to ensuring the implementation and safeguarding of equality rights. Courts that operate free of gender bias and other forms of discriminatory practices can be powerful drivers of social change. Read full blog at

Female breadwinners sweep the crumbs, too Valerie Frey and Lucy Hulett, OECD Directorate for Employment, Labour and Social Affairs

It’s 11:00 on Saturday morning. Both you and your partner had exhausting weeks at work, and so far the day has been spent preparing and cleaning up breakfast, wrangling children out of pyjamas and into real clothes, and running to the store for yogurt and bananas. Your kids are finally playing quietly with Lego bricks in the living room. At last, a break! Do you: (a) Relax on the couch with an iPad? (b) Go tidy up the bedrooms? (c) Gather laundry to toss a quick load in the washing machine? (d) Start meal prep for the week ahead? If you answered b, c, or d, odds are good that you’re a woman. But don’t just take the word of two working parents. Survey data tell us so.

©Jeff FIsher

Read full blog at

Statistical insights: Large inequalities in longevity by gender and education in OECD countries OECD Statistics Directorate

Women in the judiciary: What solutions to advance genderresponsive and gender-diverse justice systems? Kate Brooks, OECD Directorate for Public Governance and Territorial Development

In recent decades, the number of women in the judiciary has significantly increased worldwide. In many countries around half of law students are women, and 2014 data shows that women in OECD countries make up more than 54% of professional judges. But women are still vastly underrepresented in top-ranking judicial positions including on High Court benches and other senior roles in the legal profession. What are the obstacles to women’s legal leadership? How can we overcome them? In 2015 the UK’s only female Supreme Court judge, Baroness Hale, criticised all-male appointments. Hale has been a strong advocate of improving diversity, questioning whether an element of positive discrimination may eventually be needed to redress gender imbalance. Increasing gender balance on high court benches helps to preserve the legitimacy of the courts as

Measures of inequalities in longevity show that, on average, the gap in life expectancy between high and low-educated people is equal to 8 years for men and 5 years for women at the age of 25 years; and 3.5 years for men and 2.5 years for women at the age of 65. Cardio-vascular diseases, the primary cause of death for the over 65s, are the primary cause of mortality inequality between the high and low-education elderly. Read full blog at

Gender equality in West Africa: Actions speak louder than words Julia Wanjiru, OECD Sahel and West Africa Club (SWAC) Secretariat

Respect of the fundamental rights of women and girls remains a serious, sometimes life-threatening, concern in many developing countries. Several decades of gender debates, special events and development goals dedicated to the empowerment of women, add up to only modest improvements on the ground. Read full blog at

OECD Observer No 309 Q1 2017


SODEXO HEALTHCARE Safe, Caring, and Effective Our single minded focus on Quality of Life enables healthcare providers to achieve efficient and sustainable health outcomes for patients and their families


Inequality: Can Sweden reconquer utopia? conquered anew.” These words by Sweden’s late former prime minister, Olof Palme, in July 1965, remain pertinent today. They reflect a deeply held commitment to egalitarianism, which is shared throughout Swedish society and which has won admiration, if not the envy, of countries around the world. But the Swedish model is constantly being tested.

Jon Pareliussen, OECD Economics Department

Today Sweden boasts a vibrant, resilient economy, but powerful forces, some which policy can control, others not, have driven wedges into the income distribution of a

Incomes at the top end of the distribution have outpaced middle-class earnings in recent years, thanks mainly to capital income country that used to be the most equal in the OECD area. Policy actions can reduce those new inequalities, though it will not be easy.

“Equality is a utopia (…) that must be constantly redefined and constantly

So, what has caused inequality to widen? For a start, incomes at the top end of the

©Sabine Weiss/OECD

promote equality again. What are the options and can those policies work?

More than simply resulting from social policies of redistributing from rich to poor, the origins of Sweden’s income equality is to be found in the actual labour market. Wage differences are relatively narrow, and reflect the fact that wage bargaining is centrally co-ordinated among sectors, which pivots wage deals towards equality and fairness, as well as international competitiveness. Skilled and highly qualified people might not have the wage premiums seen in some other countries, but they do enjoy a higher probability of finding steady employment than those with only basic education and low functional skills. Even in cases where people struggle to find jobs, solid activation policies are there to help them. This mix of compressed wages, high skills and high employment, with active labour market policies for the unemployed, is a cornerstone in Sweden’s efforts to hold back inequality and to generate the tax revenue needed for redistribution.

The late Olof Palme, former Swedish prime minister, at the OECD in 1968. Income inequality is relatively low in Sweden compared to the OECD average, but a rapid rise from the 1990s has threatened this hallmark of Swedish society and has led to calls for policies to

OECD Observer No 309 Q1 2017


distribution have outpaced middle-class earnings in recent years, thanks mainly to higher capital income from the likes of stocks, investments and property, rather than normal wage increases. Meanwhile, people at the bottom end of the distribution, including those on welfare, saw their incomes drift behind other earners, in large part due to the slow uprating of their benefits. There are demographic and structural factors that have played a role too, as our analysis highlights. Educational attainment has increased, pulling up median earnings and therefore increasing the gap with bottom earners. On the other hand, non-labour immigration has risen, and Sweden’s population has been ageing, so more people than before receive a pension, which is typically lower than wages. More single, and single parent households with typically low incomes, as well as more working couples without children and typically higher incomes, have also widened the gap between those at the top of the income distribution and those at the bottom. The combination of such trends can explain more than 40% of the increase in the Gini coefficient, which is a metric of inequality, from 1987 to 2013. What can policymakers do? Redistribution from top to bottom earners is challenging, especially as taxes on wage income are already relatively high. Taxing capital income is already not an easy task either, and has been complicated further as the collection of wealth statistics was discontinued when the wealth tax was abolished in 2007. As this makes it harder to monitor wealth concentration and capital incomes, we recommend that collecting such wealth data be resumed from other sources. Another way to address the widening income gap between those with and without jobs is through working-age benefits, which have been lagging behind wages since the early 1990s when Sweden was in deep recession. Decades of slow uprating have led to a gradual decline of


benefits relative to earnings, which should be addressed. Particular policy attention should also be given to disadvantaged groups, notably migrants who are in Sweden for humanitarian reasons or to be with their families. These migrants usually have lower incomes and worse housing conditions than native Swedes. Segregation between poorer and wealthier neighbourhoods leads to school segregation as well. This further affects education and job prospects, adding to language and other cultural difficulties that such migrants experience. Sweden’s relatively well-developed integration policies can be strengthened by learning from several successful local experiences, as well as stepping up action to promote upskilling. Other measures, such as shortening the time it takes to get residence and work permits, and simplifying wage subsidy schemes, would also help. Another area for policy action is to improve housing conditions for the least well-off. This can be done by addressing inefficiencies in the housing market, for instance, by tightening the generous tax treatment of owner-occupied housing to improve affordability, and easing strict rental regulations while protecting tenants against abuse, as this would enable mobility among those who cannot afford to buy. Moreover, measures to improve the

supply of rental housing would lead to a better utilisation of the housing stock, while the rules governing the allocation of municipal housing could be better designed to help low-income households and limit residential segregation as well. With Sweden facing new realities, the current government has taken steps to reverse the trend of widening inequalities, with stronger social protection and ramped-up budgets for integration and adult education, for instance. The government has also expressed its intention to consider other OECD recommendations, including more systematic benefits uprating. Olof Palme’s words about redefining and conquering utopia have not been forgotten after all. Share article at References Bussi, M. and J. Pareliussen (2015), “Skills and labour market performance in Sweden”, OECD Economics Department Working Papers, No. 1233, OECD Publishing, Paris. 5js0cqvnzx9v-en. OECD (2015), OECD Economic Surveys: Sweden 2015, OECD Publishing, Paris. surveys-swe-2015-en. OECD (2017), OECD Economic Surveys: Sweden 2017, OECD Publishing, Paris. surveys-swe-2017-en. Robling, P. and Pareliussen, J. (2017), “Structural inequality: The case of Sweden”, OECD Economics Department Working Papers, forthcoming, OECD Publishing. See

Stagnating working-age benefits widened inequality 1991=100 180 Workers

Unemployed and sick

Other non-working

160 140 120 100 80 60 1991 1996 1998 2000 Source: OECD Economic Surveys: Sweden 2017.


2004 2006 2008 2010 2012 Note: Median income within each group after taxes and transfers


Going for inclusiveness and productivity

©Amir Cohen/REUTERS

drive long-term growth, competitiveness and jobs. It reveals an uptick in policymaker attention to reforms to lift employment, particularly measures aimed at helping women, young people and low-skilled workers enter and thrive in the labour market, and these have delivered results. However, the report detects a worrisome slowdown in reforms that influence labour productivity, such as those in education and innovation policy, which is of particular concern in light of the persistent and widespread decline in productivity growth, which is the key to boost wages and living standards. Inclusiveness should be a prime objective of growth-oriented policies, alongside productivity and employment, Going for

Growth 2017 argues. The report provides a comprehensive assessment of policy reforms that can be packaged together to

China’s economy

in the short run to ensure greater stability over the longer run, with a wider spread of the benefits of growth across society and less stress on a highly polluted environment.

As it enters the 13th Five-Year Plan period (2016-20), the Chinese economy continues to grow fast by international standards. While growth is slowing gradually, GDP per capita remains on course to almost double between 2010 and 2020. As a result, the Chinese economy will remain the major driver of global growth for the foreseeable future. Notwithstanding the economy’s impressive performance and unprecedented poverty reduction , imbalances have built up. China’s growth has long been driven by capital accumulation, supported by high savings. However, the growth model has led to misallocation of capital and falling investment efficiency, and to excess capacity in some manufacturing industries and in the real estate sector, which needs to be worked off. High enterprise investment was financed by debt, fuelled by interest subsidies and implicit guarantees for state-owned enterprises (SOEs) and other public entities. Effectively addressing sources of risk, such as excessive corporate leverage, real estate bubbles and leveraged investment in asset markets will help keep growth on a sustainable path. The authorities may need to forgo some growth

Against this backdrop, rebalancing of the economy towards consumption is key. Progress has been made, with growth slowing only gradually. Consumption is supported by stable income growth, in particular in rural areas, which will help reduce the urban-rural divide and make growth more inclusive. Consumptiondriven growth will also help rebalancing from manufacturing to services, and from external to internal demand. Slowing growth implies lower profits for enterprises, and therefore greater pressure

For more on Going for Growth, see economy/goingforgrowth.htm

to improve efficiency. It also translates into slower growth of incomes and limits the fiscal resources available to make growth more inclusive. Improving corporate performance by boosting innovation activities and entrepreneurship, enhancing the standards of corporate governance and reforming SOEs by exposing them to market mechanisms would raise efficiency and boost household incomes, improve employment opportunities and raise people’s overall well-being. Extract adapted from Overview of OECD Economic Survey of China 2017, available at http://www.oecd. org/eco/surveys/china-2017-OECD-economic-surveyoverview.pdf See and The report is also available in Chinese.

Ensuring inclusive growth by enhancing opportunities Disposable income of the top 20% over that of the bottom 20% of the income distribution, 2016 or latest available Ratio 12 10 8 6 4 2 0




Source: OECD Economic Survey of China 2017






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How do you measure

a Better Life? For nearly a decade, the OECD has been working to identify societal progress – ways that move us beyond GDP to examine the issues that impact people’s lives. The OECD’s Better Life Index is an interactive tool that invites the public to share their thoughts on what factors contribute to a better life and to compare well-being across different countries on a range of topics such as clean air, education, income and health. Over five million visitors from around the world have used the Better Life Index and more than 90 000 people have created and shared their personal Better Life Index with the OECD. This feedback has allowed us to identify life satisfaction, education and health as top well-being priorities. What is most important to you?

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Towards sustained progress in global healthcare Jeremy Hunt, Secretary of State for Health, United Kingdom, and Chair of the 2017 OECD Health Ministerial Meeting

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For everyone working in the healthcare sector, 2017 arrives with much to celebrate and a great deal to ponder. On the one hand, we can look back on decades of sustained progress, with universal coverage of healthcare rising and people enjoying generally healthier and longer lives than ever before. Funding is increasing and the OECD’s figures on the state of play show the number of doctors and nurses has grown significantly across most OECD countries since 2000. This has been accompanied by some great leaps forward on efficiency and productivity. In surgery, clinical advances are transforming the proportion of day cases and reducing average length of hospital stay. Changes in prescribing habits have helped

High quality care and financial discipline are two sides of the same coin to offset the spiralling cost of modern treatments. And reducing avoidable harm in our hospitals has become a shared, global mission–and I’m proud of the singular contribution the UK is making to this debate. But amidst the sunshine, there are storm clouds looming over international healthcare systems. Our systems are now dealing with populations that are older, sicker and with more complex healthcare needs than ever before. With demand outpacing supply, how do we develop the right systems, cultures and policies to ensure every pound goes further for patients and communities? In the UK, our central purpose is to create the safest, highest quality care in the world. In doing so, we also aim to make it the most efficient. High quality care and financial discipline are two sides of the same coin, and it is only by improving quality and productivity that we will deliver truly sustainable change. It is not only a financial imperative, but a moral one, that every single investment, and every clinical intervention should deliver maximum value in terms of patient outcomes. So the OECD’s excellent study on waste makes challenging reading, and it’s salutary to reflect on its hard truths: that up to a fifth of spending on health is being used ineffectively; that significant variations in standards and clinical practice expose too many patients to avoidable harm; and that healthcare systems remain

too slow to learn, adapt and refine their clinical, information and management practice. So, what is the UK’s response? The National Health Service (NHS) is already recognised as one of the most efficient healthcare systems in the world, but we believe we can go even further. Firstly, we’re making some profound change in how the NHS collects, shares and uses data, mirroring the outstanding results that ‘intelligent transparency’ has shown in Sweden, for instance, as well as challenging the NHS to embrace a fully digitised future. Secondly, we’re pushing ahead with efforts to tackle variations in clinical practice–from looking at referral and antibiotic prescribing in primary care, through to a Getting It Right First Time programme ( targeting surgical practice, which we will be expanding to other specialities this year. Thirdly, we’re targeting cost-savings, bearing down on exorbitant management and agency fees, and exposing variation in how we procure vital goods and services, guided by Lord Patrick Carter’s world-leading efficiency study, which showed that up to £5 billion (US$6.2 billion) could be saved by adopting best practice in these areas. Finally, and most significantly, we are devolving power to local NHS and government organisations to develop radical proposals for the future. Authorities in every part of our country are now developing long-term plans that improve integration, bolster prevention and dissolve the boundaries between hospital and community care. This is a challenging time for the world’s health services–arguably the most challenging in their histories. It is therefore more important than ever that international policymakers pool their intellectual capital and explore the innovations, small and large, that can help us tackle the rising tide. I applaud the OECD’s work in facilitating this process, and I hope the discussions we have at the OECD Policy Forum and Health Ministerial Meeting will be an important contribution to our shared aim: that is, to deliver renewed and sustained progress in global healthcare, on the same scale and significance as the last quarter of a century. @Jeremy_Hunt References and links OECD (2015), Health at a Glance: OECD Indicators, OECD Publishing, Paris OECD (2017), Tackling Wasteful Spending on Health, OECD Publishing, Paris Carter, Patrick (Lord Carter of Coles, 2016), “Operational productivity and performance in English NHS acute hospitals: Unwarranted variations”, February, independent report available at For links and more sources, see online version of this article at

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The PaRIS initiative: Helping healthcare policies to do better for patients Stefano Scarpetta, Director, OECD Directorate for Employment, Labour and Social Affairs

independently. PREMs complement this information by asking people about their experience of being treated, for instance, whether the treatment was properly explained to them, or if they felt involved in decisions about their care.

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This challenging project will depend on close collaboration with international partners

When is healthcare successful? All too often, the answer is that we don’t really know. Although healthcare consumes almost a tenth of GDP in the OECD, our understanding of the value and outcomes that this large and often growing spending achieves remains limited. Health systems collect vast amounts of data–how many patients were treated, what services were delivered, whether clinicians followed guidelines, and how much was spent. We typically measure survival rates, or rates of cure after treatment, as a marker of success. But these indicators do not tell us enough about people’s recovery and ability to get back to their usual activities which, ultimately, is what we expect from healthcare. In the last decade, for example, knee replacements have doubled from 60 per 100,000 people to 120 on average in OECD countries. But not all these interventions may be justified if a patient’s ability to work, look after their family, or do whatever matters to them, is


no better after the operation compared to before. Collecting data on clinical outcomes, like mortality and complications, is essential, and the OECD is contributing in providing comparable indicators on them. But we also need to know about the outcomes that matter from a patient’s point of view if we are to strengthen the capacity of clinicians and policymakers to provide health services shaped around patients’ needs. And this can only be done by asking the patients themselves what they think of healthcare quality. Progress has recently been made on this front and a number of health systems, particularly at local level, are starting to collect “patient-reported outcome measures” (PROMs) and “patient-reported experience measures” (PREMs). PROMs systematically ask people to report back on outcomes that matter to them, whether treatment reduced their pain, for example, or helped them live more

However, work in this area faces hurdles. For instance, although validated data sets of the most important outcomes by disease have been developed by the International Consortium for Health Outcomes Measurement (ICHOM), each health system continues to pursue its own path, leading to fragmentation which greatly narrows the scope for crosscountry comparative analysis of outcomes. This means that opportunities to identify excellence, support poor performers and drive improvements across the board will inevitably be missed. Moreover, there is a glaring gap to fill, too, in that the biggest users of healthcare–people with multiple, long-term conditions–are typically not included in PROMs and PREMs initiatives at all. The OECD can play an important role in addressing these issues. In particular, by emphasising the substantial benefit from standardising PROMs and PREMs across countries, and recognising the OECD’s leadership in reporting health system performance measures, the OECD is well placed to take forward international work to extend and deepen the benchmarking of health system performance through patient-reported indicators. Indeed, after in-depth discussions with a high-level reflection group, involving leading experts in measuring and driving health performance improvement, and with member countries, the OECD requested a mandate from health ministers at their meeting on 17 January 2017 to develop an exciting new global initiative, the Patient-Reported Indicators Survey, or PaRIS for short. PaRIS aims to devise new tools to improve healthcare



The challenge of antimicrobial resistance: The hidden “fil rouge” for healthcare policy

This is a challenging, multi-year project that will depend on close collaboration with international partners such as the European Commission, the World Health Organization, the Commonwealth Fund and the International Consortium for Health Outcomes Measurement. All stakeholders stand to benefit, particularly patients, by helping them assessing what treatments are the most likely to benefit them, and clinicians who will have critical data on how to improve the care they provide. Policymakers will also benefit from PaRIS, by having better information on where to focus quality improvement efforts and prioritise spending. So, to return to my opening question, when is healthcare successful? For me, the answer is clear: when patients state that their well-being is better as a result. Through PaRIS, we will capture the vital information required to build successful healthcare systems that are truly responsive to patients everywhere. For further information, contact: Stefano.Scarpetta@oecd. org and visit Share article and sources at Read Ministerial Statement: The next generation of health reforms, at

Mark Pearson, Deputy Director, OECD Directorate for Employment, Labour and Social Affairs

©Andrew Brookes/AB Still Ltd

policy and practice, and build a people-centred view of health system performance. It will be done in two ways. First, in conditions where patient reported indicators are already used, such as in care after a stroke or heart attack, in cancer care, and in hip and knee surgery, PaRIS will work with countries to accelerate the international monitoring of standardised PROMs and PREMs. Second, in conditions where PROMs and PREMs are rarely used, PaRIS will develop new patient-reported indicators. Priority groups in this case are patients with chronic conditions such as diabetes and dementia and, in particular, patients with several conditions at once, as these require complex care. PaRIS will survey both patients and carers directly, and issue new state of the art indicators on health system performance.

Two issues are at the centre of the debate on how to make our health systems more sustainable: tackling unnecessary spending on health, and making sure that medical innovations deliver the right products at the right price. Both of these key issues are epitomised by one of the biggest public health challenges we face today: that of antimicrobial resistance (AMR). When antibiotics (and similar medicines) do not work because diseases have evolved to resist them, people will die from diseases that most people in OECD countries these days only see on the big screen or on stage, like tuberculosis, or infections from wounds. In fact, around 700,000 people die each year because of AMR. Even when the consequences are less serious, the costs of AMR are high: each case of someone having a resistant disease results in an additional US$10,000 to 40,000 having to be spent per infected patient in OECD countries. And there are other economic costs, too, such as absenteeism from work. There is a race between the spread of AMR, and the development of new

medicines, and it is a race that so far we are losing: AMR is growing, but new antimicrobials are not being developed. Companies make money out of selling antibiotics either by selling a lot of them, or by setting a high price. The result is that some people are taking antibiotics when they should not, and others are not taking them when they should. This is a market failure: in either case, the result is growing resistance. In some countries, people consume too many antimicrobials, often when they will not work. For example, we have estimated that in long-term care facilities and general practices in the OECD area, up to 70% and 90% respectively of antibiotics are prescribed for inappropriate reasons. On the other hand, in other countries, people cannot afford to buy the drugs they need. In addition, antimicrobials are also heavily used in agriculture, often for no other reason than to make animals grow more quickly. Such ineffective use encourages AMR. Similarly, the lack of new antimicrobials is largely due to the same market failure

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that triggers ineffective use. The costs of developing a new medicine are enormous, but the returns are very uncertain because they depend on sales which in turn will have to be restricted in order to prevent diseases from becoming resistant even to the new antimicrobials. Consequently, in the last two decades, the pharma industry has preferred to invest in therapeutic categories that are more profitable and for which there is less

Now is the time to scale up global efforts to tackle AMR before it becomes uncontrollable uncertainty. Since 2000, only five new classes of antibiotics have been put on the market and none of these target so-called gram-negative bacteria, which are a leading cause of hospital-acquired infections and may lead to septic shock and death. Now is the time to scale up global efforts to tackle AMR before it becomes uncontrollable. The OECD has developed a framework based on five areas of action to best address AMR and its associated health and economic burden, covering areas such as surveillance, R&D and co-ordination (see references). Since then, we have been working to fill in the knowledge gaps and to identify best practices to help countries meet their aims in each of these areas.

Keeping you ahead of the policy challenges of our time. Since 1962.

Together with the World Health Organisation (WHO) and other international organisations, the OECD is supporting G20 countries in their efforts to encourage more investments in the antimicrobial R&D pipeline. Much progress has been made in promoting basic research into new antimicrobials, often through promising public-private partnerships. However, if the returns to innovation still depend on sales, then the market failure in how we pay for new antibiotics may well stop any new breakthroughs from making it to market. This must be corrected, for instance, by introducing market entry rewards or prizes to recompense and motivate innovators, regardless of their sales. Furthermore, stewardship of any new antimicrobials must be improved to ensure they do not add to the problem, but so that new drugs are only used in an effective fashion. This means ensuring that access to the drug is granted when and where it is needed and that we have in place strong actions to prevent ineffective use. Much modern medicine, from surgery to chemotherapy and treatment for patients with AIDS, depends on effective antimicrobials. If we want to put up our own stiff resistance to AMR, then we need big changes–in the expectations and actions of patients and physicians, the investments of pharmaceutical companies and the oversight of 2016 OECD Yearbook governments. Borders will not defeat AMR, which is a global problem requiring a global response.

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Visit and health/health-systems/antimicrobial-resistance.htm Cecchini, Michele (2016), “Tackling antimicrobial resistance”, on OECD Insights blog, June; see OECD (2015), “Antimicrobial resistance in G7 countries”, OECD Policy Brief, October, see health-systems/Antimicrobial-Resistance-in-G7-Countriesand-Beyond-Policy-Brief.pdf

OECD Observer 1 Volume 2016 Supplement ISSN 0029-7054

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of the key social, focuses on some of the OECD Yearbook arising both from the continuing ts The sixth edition ntal challenges global agreemen Part 1, economic and environme crisis, but also from ambitious climate change. economic development and ty and aftermath of the past year on taxation, explores the declines in productivi s, struck over the there is Productive Economie in recent years and asks whether looks Innovative and making . It also inequality witnessed ty might inform policy the increases in ding of productivi two trends that on our understan both a link between these a range the digital economy, 2, Future Societies, examines at the impact of today, Part of the economy. on the way we live and on the future to make an impact societies and economies, starting already of migrants in our of issues that are barriers , the integration and how we remove including digitisation and support parents, to Action, examines what is children t how we educate Part 3, From Agreements struck in 2015 and looks at to success for women. global agreemen y in combating communit significant al honour the internation needed to challenges facing nt goals and tackling the implementation sustainable developme abuse, meeting international tax climate change. by leaders from experts are joined to examine these Yearbook, OECD and civil society In the 2016 OECD labour, academia today. government, business, facing our societies and other questions



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For example, Greece uses three times as many antibiotics as the Netherlands per head of population, and Turkey nearly four times as many. Differences in the use of “second line” antibiotics–drugs that should be used only when more common antibiotics do not work–are equally dramatic. Some countries have managed to reduce unnecessary use of antibiotics, thanks to the likes of stewardship programmes and educational interventions to change the attitudes of clinicians and patients. Organisational changes, such as better use of diagnostic tests and delayed prescriptions, as well as economic incentives such as pay-forperformance schemes, have sometimes worked. The trouble is, most countries

have implemented these actions in a piecemeal fashion, often only in some regions and often on a voluntary basis. There is a long way to go before antibiotics are used when–and only when–they are truly needed.

Volume 2016 Supplement




Healthcare systems: Tackling waste to boost resources

©Image Source / Alamy Stock Photo

Francesca Colombo, Head, Health Division, OECD Directorate for Employment, Labour and Social Affairs

Is there such a thing as a right amount of health spending? In an ideal world, this would likely mean spending that achieves effective healthcare services, with good outcomes for patients, the right number of professionals with the right skills, and delivers good value for tax payers with little, if any, wastage. Finding that balance is a difficult challenge. Avoiding wasteful healthcare spending has been a public policy goal for decades, but since the global financial crisis started in 2008, the need has gained new

urgency. The US, for instance, spends 16.9% of its gross domestic product on health. Nearly a third could be wasted, according to a 2012 Institute of Medicine study. US healthcare spending as a share of the economy is almost double that of OECD spending of 8.9%–and yet, the country’s citizens can hardly claim to be twice as healthy as people in other developed countries. But the US is not alone: alarmingly, as much as a fifth of health expenditure makes little or no contribution to good

health outcomes. All OECD countries need to free up resources so that healthcare systems can perform better. Far more could be done to sort out what is wasteful from what is not, and possibly even achieve more with less. Consider clinical care. Wasteful clinical care occurs in hospitals when people seek emergency care even when their condition is not urgent. Hospital inpatient care comprises an average of 28% of total health spending in

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OECD countries. Hospital care could be made more efficient if it were devoted solely to essential or acute care. Pressure can be taken off hospital services by focusing resources on alternatives like

OECD countries need to free up resources so that healthcare systems can perform better primary care and community care facilities. Norway has intermediate care clinics that are open out of hours, and the UK is experimenting with GPs who consult seven days a week. Umbrella systems of caregivers can help relieve pressure on hospitals, too. In France, the system called PAERPA (Personnes Agées En Risque de Perte d’Autonomie) coordinates health and social care services for the elderly, for instance. Hospital At Home is another resource currently being expanded. Even when a hospital stay is unavoidable, effectiveness can be improved. Same-day surgery for procedures such as cataracts and arthroscopic meniscectomy has grown over time, yet same-day surgery rates for cataract remain relatively low in Poland, Hungary and Turkey. So-called adverse events can lead to prolonged inpatient stay. They affect between 4% and 17% of admissions, with around 30‑70% judged preventable. The use of checklists, a strategy borrowed from the aviation industry, is an effective way to reduce error. A 2002 study showed that checklists reduced the rate of error from 30.9% to 4.4%. The digitalisation of health records and computerised physician order entries also reduce errors. Systems and protocols need to be upgraded to avoid mistakes. Patient stays can be unnecessarily prolonged when they acquire infections. About 23,000 and 25,000 deaths per year are directly attributable to antimicrobial resistance (AMR) in the US and Europe respectively with a cost of about US$20 billion per year. Inappropriate use represents about 50% of all antimicrobial consumption by humans, but may be as high as 90%


in general practice. Comprehensive strategies to monitor and encourage rational use of antimicrobials include interventions targeted at both the general public and clinicians, among others. Pharmaceuticals constitute a major source of operational wastefulness. In OECD countries, pharmaceutical spending comprises between 6.7 and 30.2% of national healthcare budgets. Two irrefutable ways to tackle waste in pharmaceutical spending is through bulk purchasing and replacing originator with cheaper generic drugs. Swapping originator for generic drugs holds tantalising price-saving possibilities, but requires changes in behaviour. Physicians can be nudged to prescribe cheaper generics with guidelines and incentives. In Greece, public hospitals are required to reach a 50% share of generics in total volume of administered pharmaceuticals, and in Japan pharmacists receive bonuses. Meanwhile, patients can be persuaded to use generics instead of originator drugs if the reimbursement for the former is higher or if, as in Greece and Ireland, people pay the difference in price. Shifting from expensive biologic medicines used in highly-targeted therapies for cancer and rheumatoid arthritis, for example, to their cheaper biosimilar alternatives could yield even larger results: replacing eight key biologics with biosimilars in the US and five European countries could save more than €50 billion (US$54.5 billion) by the end of 2020, according to estimates from the IMS Institute for Healthcare. What about governance? Spending on administration comprises a rather modest share of overall health expenditure–only around 3% on average in OECD countries in 2014–but it is often perceived as a soft target when it comes to cutting clinical waste. There could be areas to look at though, for example reduction in unnecessary administrative systems or the growing use of paperless e-prescription. Fighting fraud and corruption, which are all too prevalent in OECD healthcare

systems, would also generate savings. According to one survey, around 35% of citizens in OECD European Union (EU) countries believe that “giving and taking of bribes and the abuse of power for personal gain is widespread” in health. Meanwhile, loss to fraud and error is estimated in a 2015 report at about 6% of related health expenditure on average. Several OECD countries have recouped millions if not billions thanks to fraud detection in their systems. Policymakers could take a stronger lead in reducing waste from these and other integrity violations, and promoting better practices in healthcare. In short, the rule of thumb for policymakers is clear: encourage healthcare systems to stop doing the things that do not bring value, and swap for equivalent but less pricy alternatives. Targeted action with a surgeon’s scalpel, rather than wielding an axe, would generate large savings and boost healthcare performance, too. Visit References OECD (2017), Releasing Health Care System Resources: Tackling Ineffective Spending and Waste, OECD Publishing, Paris Evans, Robert G. (2013), “Waste, Economists and American Healthcare”, in Healthcare Policy, November, US National Institutes of Health’s National Library of Medicine (NIH/NLM) , Longwoods Publishing, available at PubMed Central, search code PMC3999538 at IMS Institute for Healthcare Informatics (2016), Delivering on the Potential of Biosimilar Medicines: The Role of Functioning Competitive Markets Institute of Medicine (2012), Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, report brief available at https://www.national Share article and sources at



Governing data for better health and healthcare


Jillian Oderkirk, OECD Directorate for Employment, Labour and Social Affairs, and Elettra Ronchi, OECD Directorate for Science, Technology and Innovation

The healthcare sector is awash with data, whose range and volume are growing exponentially. But they will sit unused in data warehouses, often from fear of being misused, unless fundamental action is taken. The OECD Recommendation on Health Data Governance can help countries in managing the risks and harnessing the benefits from health data. Generating data is not a weakness in today’s healthcare sector. Indeed, from doctor and hospital records to insurance claims, surveys, bio-banks, lab reports, pharmacy transactions, research studies and behavioural and environmental monitoring devices and apps, not to mention big data, there is a veritable plethora of information to draw from. But are these data being put to full and proper use for patients and healthcare performance? There is arguably no other sector that generates quite as much data and, at the

same time, fails to coordinate the data in effective, useful ways. In fact, only half of the 35 OECD countries have national policies in place to address how data from electronic health records can inform clinicians, monitor disease outbreaks, conduct research and improve patient safety. Only half of OECD countries regularly link their existing health datasets to monitor healthcare quality. Yet, as several countries show, better governance of healthcare data is possible and can lift performance. For instance, public reporting of healthcare quality indicators gives patients the information needed to identify the best healthcare provider, and acts as a powerful incentive for failing healthcare providers to change for the better. Finland, for instance, has improved hospital services by publishing indicators about performance after hospital care,

including readmissions to hospital, infections, complications and deaths. Or take Korea, which also regularly publishes indicators, focusing on the overuse, underuse and misuse of therapies. Sweden uses health data to assess how clinical care guidelines are working, including if they are being followed by physicians and if patients’ health is improving as a result. Its continuous monitoring allows action to be taken if improvement is required. New technology is a boon to such efforts. The US is building a rapid-response electronic surveillance system to transform how it monitors the safety of medicines and medical devices and to respond in the event of unexpected side-effects among patients taking new drugs or drug combinations, for instance. Health data can also power the discovery of new treatments and help to personalise care in light of the unique

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needs of individuals. The UK now has a biobank of 500,000 adults with biological, behavioural and environmental data that can be linked to healthcare data. More recently, Genomics England was launched for the sequencing of 100,000 genomes among 70,000 adults, with the aim of supporting research to improve the diagnosis and treatment of diseases and advance personalised medicine. Large healthcare organisations that both insure and provide care for patients have been among the quickest to use data to keep patients healthy. Clalit Health Services (CHS), the largest of the four health plan organisations in Israel, uses real-time data mining to flag elderly patients at risk of being re-admitted to hospital before they are discharged, so that they get the support and care that they need in the community. Kaiser Permanente in the US, one of the world’s largest health management organisations, analyses patients’ data to prevent illnesses, hospitalisations, deaths and waste. Clinicians and patients are reminded to practise routine preventative care, and re-fill their prescription medicines if needs be. Data helps with routine monitoring of chronic illnesses, such as blood glucose testing for diabetic patients and cancer screening. By using algorithms applied to patients’ hospital data in real time, clinical care teams can be alerted in advance of a serious deterioration in a patient’s health. This saves resources and lives, and allows for more compassionate care. The need for international consensus on health data governance These are encouraging examples of how data can help policymakers improve patients’ lives, but more needs to be done. Health data are personal and sensitive, and in the wrong hands, can be used to harm patients through a loss of their privacy; discrimination in areas such as health insurance or employment; and identity theft. Such data breaches and misuses weaken public trust, not just in healthcare providers but in policymakers, too. The rising risk of cyber attacks and the growing suite of new technologies to


secure data, make the data protection environment as vital as it is challenging. Uncertainty in the implementation of well-intended laws and policies to protect privacy and to reduce the potential misuse of personal health information has already been known to block data uses that could have helped patients. However, some countries have addressed these governance issues to improve healthcare. There are international and European laws, regulations and guidelines that promote the protection of privacy in

Health data are personal and sensitive, and in the wrong hands, can be used to harm patients the use of personal data in general, such as the OECD Privacy Guidelines and the EU General Data Protection Regulation. But the breadth and scale of data collection practices have given rise to new challenges for protection standards and procedures, such as consent to personal data collection and use. This has to be addressed, alongside complementary measures, such as education and awareness raising, skills development, and the promotion of technical measures for greater security. The OECD Recommendation on Health Data Governance points the way forward. It represents an international consensus about the framework conditions within which health data can be appropriately governed, so that health data processing can take place both domestically and transnationally in ways that can reduce risk and improve benefits for health systems and patients. The Recommendation is based on 12 high-level principles, ranging from engagement and participation of a wide range of stakeholders, to effective consent and choice mechanisms to the collection and use of personal health data, to monitoring and evaluation mechanisms. These principles set the conditions to encourage greater crosscountry comparison and harmonisation of data governance frameworks so that

more countries are able to use health data for research, statistics and healthcare quality improvement. The OECD Recommendation on Health Data Governance, which is the fruit of a multi-stakeholder effort, was endorsed at the OECD Ministerial Meeting on Healthcare in Paris on 17 January 2017. The OECD Health Committee worked alongside the OECD Committee on Digital Economy Policy to develop the Recommendation, and benefited from the advice of experts in privacy, law, ethics, health, government policy, research, statistics and IT. There were also extensive consultations with representatives from civil society, business and labour. We believe that by following the new Recommendation, policymakers will be able to put in place systems that improve not only data collection and governance in patient-centred ways, but healthcare performance too. The OECD will do its part in monitoring the implementation of the Recommendation and ensuring better data governance for better lives. Share this article using References The 2017 OECD Recommendation on Health Data Governance and background information about its rationale and development can be found at www.oecd. org/health OECD (2017), New Health Technologies: Managing Access, Value and Sustainability, available at OECD (2015), Health Data Governance: Privacy, Monitoring and Research available at OECD (2015), Data-Driven Innovation for Growth and Well-Being, Chapter 8: The Evolution of Healthcare in a Data-Rich Environment available at OECD (2013), Strengthening Health Information Infrastructure for Healthcare Quality Governance: Good Practices, New Opportunities and Data Privacy Protection Challenges available at

Complex patients: How healthcare must adapt to their needs Martin Wenzl, OECD Health Division, and Elias Mossialos, London School of Economics and Political Science



his son takes him to hospital. In the last 18 months, Pepe visited the hospital emergency room 39 times. He was admitted to the pulmonology department in eight of these visits. Pepe’s case might sound unusual, but it is all too common. Life expectancy has increased dramatically over the past century but longer lives have also been accompanied by chronic health problems. Non-communicable diseases are now the leading causes of morbidity and mortality in the ageing populations of OECD and upper-middle income countries. Many patients with chronic health problems suffer from several conditions at once. Such multimorbidity likely affects more than half of over 65 year-olds in the OECD area, and there may actually be more under 65s with multimorbidity in absolute numbers. Multimorbidity tends to be concentrated in poorer communities, and the combination of various diseases with disability, social and other non-medical problems makes the healthcare needs of these patients complex.

ŠSylvie Serprix

While a high degree of specialisation in medicine has undoubtedly contributed to progress in overcoming diseases, it has also led to fragmentation. Healthcare is organised by types of disease, corresponding medical specialities, distinct provider organisations, inefficient workflows, budgetary silos, and provider contracts and payment systems tied to activities rather than patients. Hospitals have come to enjoy a special status among providers and consume some 35% of total healthcare expenditure in OECD countries.

Pepe is a 74 year-old widower, who lives with one of his two sons in a small apartment in the Spanish city of Valencia. His son works at night and sleeps all morning. Pepe spends most of his day at home and feels lonely and depressed. He suffers from pulmonary fibrosis,

heart failure, hypertension and dyslipidaemia. He takes corticosteroids, nebulisers and inhalers, as well as drugs against hypertension, statins and anti-coagulants. Pepe is often short of breath and also requires oxygen therapy. Sometimes he feels like he is dying and

Such a structure is poorly suited to the needs of complex patients, who require care from a variety of providers, including generalists, specialists, providers of social care or ancillary services and others. Rather than being treated for a collection of distinct diseases, which can result in contradictory advice from the various well-meaning professionals they see, incompatible treatments and poor health

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outcomes, multimorbid patients require a holistic approach to care that helps them access the right services. At the OECD Policy Forum on the Future of Health in 2017, ten recommendations will be presented to policymakers to help design high-performing healthcare systems for complex patients. These

Multimorbid patients require a holistic approach to care that helps them access the right services recommendations were developed by an expert group under the auspices of the London School of Economics and the Commonwealth Fund. They make not only a strong case for putting people, rather than diseases or providers, at the centre of care, but demand fundamental paradigm shifts in medical practice and the organisation of healthcare. The recommendations call for making care co-ordination a high priority, for instance, and engaging patients in decisions about their care, as well as involving informal caregivers more closely. They also call for integrating health and social care, physical and mental healthcare and for integrating clinical records to facilitate communication between providers and allow information to flow with patients. Using data to identify proactively patients whose care can be improved is another recommendation. A key challenge is how to find costeffective ways of providing care for complex patients. Data from Canada and the US, for example, suggest that some two thirds of total health expenditure is attributable to the top 10% of patients with the highest cost. Many of these high-cost patients have complex needs. More internationally comparable data are needed, but this pattern is likely to be similar in most OECD countries. However, it would be a fallacy to expect easy savings from improving care for all high-cost or all complex patients.


Some complex patients receive care that is entirely appropriate and the evidence suggests that only carefully targeted improvements, aimed at people like Pepe who do not receive the right services, will be effective. Even then, improvement strategies tend to require additional up-front investment or may increase costs through addressing unmet need. Savings can only be achieved by reducing wasteful over- and misuse. While this is a daunting task, there are promising projects in OECD countries that show what can be done. The Integrated Model for Complex Cases within the Chronic Care Strategy in the Valencia region is such an example and has been scaled up since 2011. For Pepe, it sharply improved care and well-being. Electronic health records, which cover nearly the entire population of 5 million, were screened automatically. Pepe was flagged as a “complex case” in this process. The Regional Health Authority employs “nurse care managers”, each of whom has responsibility for a defined number of complex patients. A hospitalbased nurse care manager had Pepe located in the pulmonology department during his last stay. The manager planned Pepe’s discharge and informed a community-based nurse care manager, who reviewed Pepe’s records and performed a case assessment. This multidimensional assessment, which considered Pepe’s medical needs, support available from his son and his living environment, was conducted in co-operation with a primary care doctor and a social worker. The latter managed to convince Pepe’s other son and a granddaughter to support him more actively. A medication review was performed and the family received training on medication management, handling oxygen therapy and inhalers and on identifying early signs of disease exacerbation. Thanks to the care plan, Pepe now receives regular home visits from his nurse and primary care doctor and

hospital-at-home services when needed. The community-based manager stays in touch with him by phone, with Pepe and his family now handling day to day care. Exacerbations have occurred less often and are managed by the primary care team. Pepe has not been to the hospital for six months. Acknowledgements: This article is based on work by the International Expert Working Group on Patients with Complex Needs, supported by a grant from the Commonwealth Fund. The authors would like to thank Juan Gallud at the Regional Health Authority of Valencia for providing information about the Chronic Care Strategy. Any errors and omissions are the sole responsibility of the authors.

References Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B (2012), Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study, Lancet 380(9836):37–43 Blumenthal D, Anderson G, Burke S, Fulmer T, Jha AK, Long P (2016), Tailoring Complex-Care Management, Coordination and Integration for High-Need, High-Cost Patients. A Vital Direction for Health and Health Care, available from: Koné Pefoyo AJ, Bronskill SE, Gruneir A, Calzavara A, Thavorn K, Petrosyan Y, et al. (2015), The increasing burden and complexity of multimorbidity, BMC Public Health 15(1):415 The Commonwealth Fund International Expert Working Group on Patients with Complex Needs (2017), Designing a High-Performing Healthcare System for Patients with Complex Needs: Ten Recommendations for Policymakers, Paris: OECD Policy Forum on the Future of Health McWilliams JM., “Cost Containment and the Tale of Care Coordination”, New England Journal of Medicine 375(23): 2218–20

People-centred healthcare: What empowering policies are needed Olivia Wigzell, Director General, National Board of Health and Welfare, Sweden and Chair of the OECD Health Committee



which is based on respect as equals, with an equal access to and possession of knowledge of different kinds. A patient, or rather a person, cannot be reduced to a disease. People-centred healthcare means that health and capabilities are in focus. How you manage your own life, how you maintain your health, how you function though having pain and, of course, how you might be treated, get better and improve your health. Only this

Patients should no longer just consume care but help produce better health and wellness too way can the term “healthcare” really mean what it says. Health is in focus, but so are patients, who no longer just consume care but help to produce better health and wellness, too.

©National Board of Health and Welfare, Sweden

So what can policymakers do to help? Patient-centred care means changing relationships, which is not easy to do. After all, patients have traditionally tended to look to doctors to cure them, and in return, doctors and other healthcare professionals see patients as clients. To transform this, it is important to provide tools that make it easy and inviting to become an active, or indeed, proactive patient. Such tools include information, creating more opportunities to co-decide, and a respectful way of listening and learning from the patient, as well as clearly acknowledging that patients have active roles and responsibilities within healthcare. The 2015 Swedish Patient Act states the healthcare sector has a responsibility to invite the patient into such a partnership. The Act empowers the patient. Another action is the use of patient-reported measures as a support for improving the outcomes of the health care sector. Patient-reported measures, such as being able to function in your daily life, level of independence, being able to cope with your pain often focus minds on other issues than medical outcomes. It gives us a broader perspective on health and well-being. The word “patient” comes from Latin, and means “the one that suffers”. Healthcare has historically been about “taking care” and “protecting” the patient that suffers. Under this view the patient is more or less helpless. The healthcare professional on the other hand plays the dominant role, as an authority, to be heeded and obeyed. This attitude is all too prevalent today, in that the passive patient is not seen as having useful knowledge or capacities, and so must wait patiently for the doctors’ orders. With people-centred care comes a new, fresher attitude and perspective, which highlight the patients’ capabilities, knowledge and own value-setting. This shift understands that the patient is a person with a unique life and wishes. It helps both carer and cared for alike. Seeing the patient as an active person encourages professionals working in the healthcare sector to create a partnership. Professionals will become more like consultants, and pedagogical skills will be needed. Professionals will seek a relationship with patients,

The digital world, which is largely driven by the public, and that also means by the patients, can open new ways for patients to research, promote, and improve access to new innovative ways of delivering healthcare support and services. One example is cognitive behavioural therapy that has been launched over the internet in Sweden. Another example is our youth-clinic online that has been successful in reaching out to boys in particular. Finally, the Swedish rheuma-registry offers further evidence that for successful approaches to healthcare, an active patient, patient-reported measures and an equal partnership work. @OWigzell Share article and links: References Visit the National Board of Health and Welfare website at Internet Psychiatry website at The Swedish rheuma-registry at Youth clinic online at

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Business brief

The OECD Health Ministerial Conference and the OECD Policy Forum, with the purpose of discussing new ideas and policies to shape health reforms, can help ensure that future generations, and their children, have greater access to healthcare, grow up embracing health and wellness and possibly survive diseases we consider impossible to cure today. At the same time, adequate access to public health services can positively impact broader social and economic factors such as productivity. Meeting these challenges will require new models of collaboration between health authorities, academia and industry, with patient care at the centre. At Johnson & Johnson, we believe that scientific and technological innovation can play a role in achieving the shared goals of better health, better quality and lower costs. “We continue to pursue transformative healthcare solutions and form collaborations

Events such as the OECD Public Forum provide unique opportunities to find common ground on reshaping healthcare for the people and societies of tomorrow that explore the cutting edge of scientific research to achieve our primary goal of improving the quality of patients’ lives,” said Paul Stoffels, MD, Chief Scientific Officer. Innovation in regulatory and financing models, new approaches to care delivery and payment reforms that reward improvements in quality and outcomes, a focus on prevention, early detection and curative treatment, and therapeutic solutions are also critical factors for success. Innovation is at the heart of everything we do Innovations in medicines have contributed to most of the improvements in life expectancy over the past decade and more. “As a healthcare company, we intend to play our part, and innovation is at the heart of everything we do at Johnson & Johnson” for about 130 years, says Liz Fowler Vice-President Global Health Policy. Innovative technology makes possible the development of ever-more effective treatments, less invasive procedures with shorter recovery times, and, above all, improved patient outcomes. It can also help speed sequencing, diagnoses, ensure medication adherence to improve


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Leading innovations for better healthcare treatment outcomes, and allow for personalised real-time tracking to support wellness and facilitate positive lifestyle choices that improve overall health. Today we are investing in the development of approaches to disease interception techniques in order to identify patients most at risk for certain conditions and prevent illness at even earlier stages in the disease cycle. “Employees at Johnson & Johnson’s Pharmaceutical (Janssen), Medical Devices and Consumer businesses are pushing the boundaries of innovation to better serve patients and customers every day,” Fowler said. The importance of collaboration Innovation is only part of the solution, and we cannot tackle the tasks at hand alone. New approaches to innovation require collaboration and engagement in the continuous global debate if we are to make progress in improving health for the populations throughout the world. Johnson & Johnson created a network of Innovation Centers across the globe, bringing together a network of academics, scientists, entrepreneurs, business development specialists, community leaders, patient advocates, and community groups to source the best possible solutions for unmet medical need. “This broad perspective enables us to identify the best ideas, no matter where they originate, that hold potential to revolutionise healthcare and transform patients’ lives.” said Robert G. Urban, Ph.D., Global Head, Johnson & Johnson Innovation. Regulatory bodies play a critical role in the innovation cycle. Newly discovered biomarkers, combined with patient perspectives, real world evidence, disease interception models and innovative diagnostics, can guide healthcare delivery and should be recognised as a priority. We will need a regulatory environment that supports tools to prevent and intercept disease or needed and suited to achieve our goals. “Making all this happen requires greater collaboration between health authorities and public and private capital to ensure that healthcare systems are both providing access to care and are sustainable for the societies in which they operate”, Fowler continues. Innovation in governance and systemic innovation are equally important. And this is why we appreciate events such as the OECD Policy Forum, they are unique opportunities to exchange perspectives with other players in the healthcare field and find common ground on reshaping healthcare for the people and societies of tomorrow.

Investing in better health improves an individual’s well-being and lifestyle Attain a higher education In utero shock of a mother struck by the flu negatively affected socio-economic indicators of the child later in life.1

Children of healthy mothers are 18% more likely to graduate from high school than children of mothers struck by the flu.

Wages of male children of healthy mothers are 5-9% higher than male children of mothers struck by the flu.

Stay in the workforce longer With improved healthcare, people can stay in the workforce longer and continue contributing to the economy.2

Be more productive An effective wellness program reduces sick days by 25% on average.3

We invite the global community to work together to invest in better health for people everywhere


Almond D. Is the 1918 Influenza Pandemic Over? Long-Term Effects of In Utero Influenza Exposure in the Post 1940 U.S. Population. Journal of Political Economy. 2006; 114(4):672-712


Georgetown Public Policy Institute



Chapman, L. Meta-Evaluation of Worksite Health Promotion Economic Return Studies: 2012 Update. The Art of Health Promotion. 2012.

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An agenda for robust healthcare Xavier Prats Monné, Director-General for Health and Food Safety, European Commission

measure successful integrated care systems, built around the concept of patient-centred care respectful of individual patients’ specific needs, expectations and values.

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Among other key EU initiatives with the core aim of improving patient access to effective and sustainable health systems, let me highlight European Reference Networks, an innovative cross-border approach to help cost-effectively use European expertise to diagnose and treat rare and complex diseases; and the work towards strengthening EU co-operation on Health Technology Assessment to efficiently measure the added value of new health technologies.

We often say that in healthcare policy there is no one-size-fits-all solution. But despite the many differences in how countries define, organise and deliver health services and medical care, a number of common challenges can be tackled together. Most national health systems face unprecedented pressures to evolve, be it because of demographics, technological developments, changing epidemiology or patient engagement, and they often struggle to deliver tailored, patient-centred care, while keeping their spending in check. The growing demand for healthcare in an economic climate that calls for cost-containment has led the European Commission to propose an agenda with actions to help EU countries make their national health systems more effective, accessible and resilient. This agenda makes a particularly strong case for better integrated person-centred care, and greater use of primary care, as well as the development of innovative technologybased solutions. These policies will not only help patients with several concurrent diseases live independently with a better quality of life, they will also save precious healthcare resources. To help translate these ideas into reality,


the Commission has set up an expert group on health systems performance assessment (HSPA), with the task of identifying practical, sound policy tools and actions. Its first report in April 2016 recommends more consideration of patient experiences and outcomes, and it is currently working on how to set up and

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The EU is not alone in its aspiration to provide tailored, patient-centred care. No system or organisation can succeed alone, and there are great benefits to learning from one another. I am therefore optimistic that our collaboration with the OECD and other international organisations will bring about better and faster solutions for all. Visit and health_food-safety/index_en.htm Share article and sources at





Why patient-centred approaches are important Nicole Denjoy, Secretary General of COCIR and Chair of the BIAC Health Committee

challenges posed by an ageing society and the increasing burden of chronic diseases and related comorbidities it brings.

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Barriers between hospital, primary, community and social care prevent more person-centred healthcare. Valuable information is not shared efficiently across service providers, leaving citizens to try to integrate services themselves, navigating between different healthcare providers. Yet overburdened patients may face difficulties communicating complex care needs and medical histories across services. At the same time, underdeveloped and fragmented data collection on health outcomes makes it difficult to objectively compare the value of different care interventions.

Significant changes in demographics, epidemiology and lifestyles have created novel challenges for health systems. Recent OECD estimates suggest that the share of population aged over 65 will rise to nearly 30% by 2060. Given existing budgetary constraints, today’s health systems are struggling to meet the

Transforming delivery mechanisms to a more person-centred approach would provide better, safer and more efficient care. To make patients the focus of the next generation of health reforms, governments could: support multi-year funding, stakeholder engagement and education programmes for overcoming barriers in care organisation, finance, technology, regulatory and governance; develop multi-stakeholder collaboration to implement shared care pathways, disease

management and improve health literacy; secure political leadership and develop national and regional evidence-based roadmaps for transforming integrated care delivery systems that are better suited to individual needs. The private sector has outlined these and other recommendations in a vision paper. We encourage governments to look at innovation, nutrition and active lifestyles and investment linked to health policy. As we address health ministers in Paris this January, we look forward to further intensifying our collaboration. Business and Industry Advisory Committee to the OECD (BIAC) is an independent international business association devoted to advising government policymakers at the OECD.

For more information on the work of BIAC at the OECD, contact Ali Karami Ruiz, Business at OECD (BIAC), at Visit Share article and sources References BIAC (2017), “Our Vision and Priorities for the Future of Health”, available at OECD (2016), Health at a Glance: Europe 2016, OECD Publishing

Patient-centred policies must be centred on healthcare workers too Jocelyne Cabanal, Member of the Executive Committee, Confédération Française Démocratique du Travail (CFDT), France

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The OECD Health Ministerial in Paris on 17 January 2017 has the ambition of paving the way to “The Next Generation of Health Reforms” with “people at the centre”. Representing the Trade Union Advisory Committee to the OECD (TUAC) on this occasion, and in close partnership with the Public Services International (representing public sector trade unions), I am bringing the voice of the labour movement to the table. Health is a public good. The right to health is a fundamental human right and its fulfilment is key to achieving the UN Sustainable Development Goals. And yet, even in the advanced economies of the OECD, inequalities in access to health services persist and are being aggravated

by austerity policies. It is essential to address the social determinants of health inequalities and from there to work towards sustainable funding and insurance systems that can be trusted and are inclusive for all. This should be based on public services, social protection and, where appropriate, not-for-profit insurance schemes and cooperatives. It is also critical to maintain a robust healthcare infrastructure that can absorb health shocks and epidemiological peaks. Cost-optimisation strategies aiming at “just-in-time” delivery do not offer a viable future for our hospitals. But we agree that more can be done to eliminate waste in health spending. Monopoly distortions driven by

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pharmaceutical corporations need to be effectively addressed. It is equally necessary to anticipate and invest for the future. Preventive care, awareness campaigns targeted at vulnerable populations and at the youth, and better life-long health monitoring make sense in their own right, but can also offer opportunities to improve control over, and indeed reduce healthcare spending in the long term.

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For trade unions, people-centred means both patient-centred policies and healthcare worker-centred policies together. Both are intertwined. Ensuring

Inequalities in access to health services are being aggravated by austerity policies respectful treatment of healthcare workers by listening to their concerns, including through their representative institutions, is essential both to deliver quality services and to build trust with patients. Social dialogue including healthcare workers and professionals also improves process and organisation. That is particularly true for those personnel who are at the bottom of the pay pyramid, such as nurses, community workers, and healthcare assistants, but who play a vital role in ensuring a balanced working relationship between informed professionals (doctors and insurers) and the patients themselves. The Trade Union Advisory Committee (TUAC) to the OECD is an interface for labour unions with the OECD. It is an international trade union organisation which has consultative status with the OECD and its various committees. Share articles and sources 28



Casting light on dementia’s shadow

ŠSylvie Serprix

Tim Muir, Health Division, OECD Directorate for Employment, Labour and Social Affairs Over 46 million people worldwide are estimated to be living with dementia, with the numbers projected to almost triple to 132 million by 2050. The strong link between dementia prevalence and age means that it is currently more common in OECD countries with older populations, though global population ageing means that the rest of the world is catching up. Between now and 2050, the number of dementia sufferers in high income countries is expected to rise by over 50%, but in low income countries, which have less developed health and social care systems, the number will more than triple. Dementia is a debilitating condition that casts a shadow over the lives of the millions that it affects, including people who develop dementia, and their families and carers. It also has huge financial implications, with the worldwide cost expected to reach US$1 trillion by 2018, which is more than the GDP of most countries. Health systems have yet to find a way to deal effectively with dementia. There is currently no cure and despite billions being spent on research, existing treatments provide only limited symptomatic relief for a brief period. Many people with dementia have other long-term conditions and complex needs, so they are disproportionately affected by the failures in co-ordination that characterise many health systems. Governments around the world are starting to put dementia at the top of their policy agendas and the last few years have seen a step change in international collaboration. In December 2013, the UK hosted the first G8 dementia summit in London. Follow-up events in Canada and Japan kept up the momentum and the first WHO Ministerial Conference on Global Action Against Dementia was held in March 2015. The ultimate aim of this collaboration must be to find a cure. At the London summit, ministers set a target of developing a cure or disease-modifying therapy by 2025. Achieving this ambition will require a collaborative approach between governments, international organisations, research bodies, industry and the public. One resource that may prove crucial to these efforts is the ever-increasing power of information technology, particularly big data. Massive amounts of population-based health and

healthcare data (broad data) are routinely collected by health systems around the world and the ongoing development of electronic health records means that the scope of this data is increasing. If it can be combined with detailed clinical and biological data (deep data) then this can be a powerful tool to accelerate research. However, the use of big data for research is made more difficult by the need to balance research goals with concerns about privacy and data protection, incompatible data systems and academic structures that can sometimes discourage data sharing. Overcoming these challenges will require international co-operation, and the OECD is helping to lead these efforts. Even if these initiatives are successful, it will be years before a cure for dementia is widely available. In the meantime, health and social care systems must help people who have dementia to live better with the condition, and unfortunately, research shows that dementia care is not good enough. The problems start with identifying people with dementia in the first place. In many countries, half or more of all people with dementia have not received a diagnosis, leaving them without

Many people with dementia have other long-term conditions and complex needs the health and social care they need. Many people with dementia living in the community are old and isolated, and rarely leave their homes, while their family and friends who look after them are at risk of falling out of work or developing mental health problems. Long-term care institutions often use antipsychotic drugs to control difficult behaviour, despite this practice being widely condemned. Moreover, hospitals do not always recognise the condition or provide appropriate care, to the extent that people with dementia often come out of hospital in a worse state then when they went in. Improving dementia awareness and care is therefore a policy priority, and the OECD is now working with countries to develop international indicators that can be used to monitor and compare the quality of dementia care and to drive improvements. These may be just the first steps down the road towards better dementia care, but if governments remain committed to international co-operation, then we can begin to cast some light on one of the biggest threats to health and well-being, particularly of older people, around the world. Claire MacDonald contributed. Share article and links: References Anderson, G. and J. Oderkirk (eds.) (2015), Dementia Research and Care: Can Big Data Help?, OECD Publishing, Paris. See review at OECD (2015), Addressing Dementia: The OECD Response, OECD Health Policy Studies, OECD Publishing, Paris. Prince, M. et al. (2015), World Alzheimer Report 2015, The Global Impact of Dementia, An Analysis of Prevalence, Incidence, Cost and Trends, Alzheimer’s Disease International Visit

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The healing power of information technology Interview with David Blumenthal, President and CEO, The Commonwealth Fund

children with cancer or needing blood transfusions. Would you say that your experiences regarding patient relationships are unusual or do a lot of physicians share them? Surely in the end, the traditional relationship between a passive patient and doctor as the dominant player still suits many people, doesn’t it? I am really describing my attitudes and beliefs, rather than my experiences. I have certainly often had patients who very much want to delegate decision-

Information is a fundamental holistic technology

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making to me, patients who say “you’re the doctor, you tell me.” And that’s fine. As long as it is clear that that is what the patient wishes.

OECD Observer: On the OECD healthcare conference website you paraphrase Donald Berwick: “We are all guests in our patients’ lives”.* What exactly do you mean by this eloquent phrase?

health, that patient then has the right to determine what happens to him or her, and to accept or reject my advice.

David Blumenthal: Don, who is a good friend, has a marvellous way with words and analogies. I practised primary care for 35 years, and my view is that physicians are in many ways the servants of their patients, their advisors, their supporters.

If you have a communicable disease, which by your behaviour could affect others, such as Ebola, HIV or tuberculosis. There is a very long history of public health activity that’s related to the containment of infectious illness, and in such cases, people are not just acting for themselves. The state in many countries, recognising such cases, empowers the medical profession to move beyond advice to actions that are coercive, in the interest of a larger society.

The primary ethical duty of respecting patient autonomy means that it is the patient who calls the tune, using the information and advice that we as doctors provide. I find Don’s analogy to being a “guest in their lives” very apt from that perspective. If a patient is competent and speaking for him or herself, as long as his or her decision did not affect the population’s


In what situations can a patient’s decisions affect the population’s health?

Also, when parents speak for children, there are limits to their autonomy, and we recognised that recently in the US in respect of the willingness of parents, for example, to forgo chemotherapy for

Is it a traditional attitude? You know, physicians and other clinicians range across the spectrum in their views. An earlier generation of physicians would have tended to believe that by virtue of their knowledge and their training, they ought to be in charge, people should follow their advice, and that it is a failure of the patient when they don’t. Such attitudes are less prevalent than they were, but they still exist. These attitudes develop in different ways. Sometimes doctors come into training with them, sometimes they’re a response to a mentor, or to particular experiences. But I do think such paternalism or maternalism is less prevalent than it was, in the US at least. You are a strong advocate of using information technology in healthcare, particularly regarding patient data. Can technology really be empowering for patients, and become personal healthcare assets rather than gadgets? There is a train of logic here, which starts with the availability of digitised healthcare information, which is now ubiquitous in the western world. The old truism that “information is power” applies, it’s a huge resource. The question

is whether there are ways we can use this information to empower patients to make better decisions about their healthcare, both where they get it and how they manage their illnesses. I believe there is, but a lot of work needs to be done to make it possible. There are a lot of political, cultural and technical obstacles to sharing that data across boundaries and among institutions. This is true of the US, and for countries like New Zealand, the UK, and even in Denmark, which has worked hard to make it possible for patients to have their data. The US has a peculiar problem: in our capitalistic healthcare system, competing entities, whether vendors or owning

An infrastructure to assist patients with managing their data is needed institutions, don’t like sharing data, which they see as a proprietary advantage. We are fighting uphill against market forces. Privacy is another common concern. In the US there are no patient identifiers, unlike in Europe where there is enough trust in government to allow the creation of these unique patient identifiers for most patients. That makes sharing of information a lot easier, technically. This is the main obstacle we face. One way forward politically in the US is to give patients their data and let them direct its use, because there is legislation here and a moral agreement that patients have the right to access their data and control it. Formal ownership of the data is not as important as access and control. Patients can have it, share it, do what they need to do with it. That is in some ways the ultimate patient-centred use of healthcare data. Most people don’t want to manage the data, but they want to have it available when they need it. So we need an infrastructure to assist patients with managing their data. In the US that infrastructure could take the form of companies doing it for a fee, and there

are ways of adding in technical supports, and decision supports to make the data more useful.

IBM and others are all deep into creating AI to support the work of clinicians and patients.

This all sounds promising, but with all that information in the public’s hands, is there not a risk of a divide building up between those who know what to do with the data and those who are less sure? Are ordinary people set up for this role?

What about concerns over privacy and the abuse of people’s data?

Yes, there are inequalities that are pervasive in our societies, affecting healthcare as well as other areas of life. In every country there are disparities, regardless of how free the care is, and they might affect this aspect of care as well. But to my mind it’s not a reason to forgo change. It really calls for other policies and provisions to reduce the effect of those disparities. You’ve watched a lot of technologies emerge in healthcare. Are there any that leap out as particularly influential or any in the pipeline you are excited about? In the history of modern medicine and technology, it is hard to get past information, as it is the lifeblood of medicine, it always has been. Information is a precious and rare resource that is fundamental to decision-making at every level. Many complex diagnostic technologies like CAT scanning or magnetic resonance imaging and all sorts of laboratory tests are all about generating information that is then processed in the brains of computers, which is to say, the brains of clinicians. So information is a fundamental, holistic technology. Even procedures we do are governed in real time by the information available to manage them. So we increasingly have simultaneous MRI imaging during surgeries so that surgeons can clearly see the full extent of a tumour and remove it. Going forward, I think of information technology as the absolute core of progress in medicine. What we badly need, given so much digitised information, is analytic support for clinicians that enables them to make better decisions in real time, and for patients too. This verges on Artificial Intelligence but falls short of that, but I assure you that Google, Apple,



I had to deal with this problem in government, and I came to the conclusion that privacy is a very strong human public concern, and that trust in whatever information systems we have is vital to their effectiveness. Creating that trust is a complex enterprise that involves educating the public about benefits and risks of collecting and using information, that the process requires action to protect privacy, but also transparency about the limits of our ability to secure absolute privacy. Whenever people share information online, financial, shopping preferences or whatever, they are taking a risk that the information will have some ill effect, that it could be pirated or just misinterpreted. The same will be true for healthcare, but there will be such amazing benefits from sharing it which outweigh these risks for the vast majority of people. There are tens of millions of records that have been breached in the US in recent years, an astounding number. Most of the breaches are the result of what I call bad data hygiene. That could be poor practice by institutions in protecting that information, such as not observing basic security protocol, sharing passwords, being fooled by phishing, and so on. There is a lot to be done to improve this, but there will be hacks. There will be a constant technological battle between criminals and mischief makers, and those who are protecting information, but we will just have to live with it. @DavidBlumenthal Visit Share article and sources: See notes for David Blumenthal’s keynote address, Patient-Centered Care For High-Need, High-Cost Patients, at the OECD Policy Forum on Patient-Centred Health Care, 16 January 2017 *Donald Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement (IHI), was also a guest at the OECD Policy Forum, 16 January 2017.

OECD Observer No 309 Q1 2017




Managing new health technologies Jonathan Skinner, Geisel School of Medicine and Department of Economics, Dartmouth, and Amitabh Chandra, Harvard Kennedy School of Government, Harvard real health benefits for every penny spent. And it is not just about specific treatments or drugs, but about hospitals and medical practices too: such costeffectiveness analysis should be applied to actual delivery systems as much as to new drugs and devices.

©Sylvie Serprix

Consider our chart, for example, which shows US data on treatments for heart attack patients during 2007-11, based on a new unpublished study with Dr Carrie Colla at Dartmouth. We examined the performance of larger hospitals (with at least 400 AMI patients over the period of analysis) in terms of one-year survival and one-year expenditures to characterise the association between spending and health outcomes. Both expenditures and survival are risk-adjusted for both clinical and socioeconomic status.

Countries around the world are struggling with rising healthcare bills. Every introduction of pricey new biologics, surgical procedures, and exotic “precision” treatments causes everincreasing fiscal stress, leading to deficit spending, cutbacks in other government services, and insurance costs shouldered by firms and employees alike. Yet, freezing budgetary allocations is clearly not an option, as citizens in our ageing societies are likely to demand more and better access to new health innovations, and essential healthcare services. What can be done? Good management is key, both for anticipating budgets needed for new treatments, and for assessing any new technological innovations coming on the market. Take the first of these principles, which requires that policymakers make sure that there is sufficient budgetary space to allow for the most valuable new treatments and innovations when they become available. There are a variety of ways of doing this, none easy, and all of which follow the basic logic of costeffectiveness–that is, if a treatment is expensive, we should expect it to deliver


What seems clear is that the best performers are not necessarily the highest spenders. In fact, as the chart demonstrates, there is nearly two-fold variation in spending across hospitals in price- and risk-adjusted expenditures, reflecting different approaches to post-acute treatments such as testing and exams, late stenting, cardiac rehabilitation, and nursing home care. Most of these high expenses reflect the wider use of treatments among patients, regardless of their cost-effectiveness. Notice also the large variation in risk-adjusted survival rates, with striking differences between the lowest and highest-performing hospitals. Some of them (in the northwest quadrant of the graph) provide excellent care at low cost, while others (in the southeast quadrant) are poor performers, with high costs and poor outcomes. While these results are based on US data, a 2014 OECD study shows similar patterns across all OECD countries and among nearly every medical or surgical procedure. The key message from this and other research is that spending more doesn’t guarantee better results. We can certainly learn from these high-performing

hospitals–what’s their secret sauce? But we can take practical action by channelling patients away from poor performers into the high-performing hospitals–for example, by directing ambulances to bypass the low-quality hospitals–which can ease spending pressures, and save lives as well. The hard part is identifying the lowquality health systems, because it requires a national system of data collection with detailed information on patient costs, patient histories and patient outcomes. This is where many European governments have an advantage over the US, whose patchwork quilt of insurers and payers means that it is very hard to measure the performance

Some hospitals provide excellent care at low cost, while others are poor performers with high costs of the overall delivery system and improve it. European governments, on the other hand, will have to show political courage to let underperforming delivery systems fail. The threat of failure encourages improvement in healthcare, while the promise of a government bailout, whether to protect managers or jobs or any interest other than that of patients, does not. Our second general good management principle is to weigh up alternatives by considering the opportunity cost of adopting a new technological advance compared with other choices. Buying a new robotic surgical machine or covering an expensive drug could involve not only imposing higher taxes or out-of-pocket costs to cover the extra expenses, but foregoing an appealing alternative, such as hiring an additional primary school teacher or construction worker for an infrastructure project. This principle underlies cost-effectiveness, that if a treatment or service costs a great deal of money, it should provide considerable health benefits in return across the board. Benefits that are asserted, but cannot be quantified for high-cost treatments, such as protontherapy for prostate cancer, should be viewed with intense scepticism because

the opportunity cost of covering them is high, particularly if to pay for them means cutting spending on the likes of education, whose health benefits are known and substantial. Several new innovations will fail the grade on this basis, for example, very high cost drugs that at best extend median lifespan by several months. Offering to pay on the basis of how well the drug works is one approach to address this problem, since over time, competition and better experience with how best to use new drugs can convert a previously cost-ineffective drug into an effective one. That said, we recognise the excruciating ethical decisions that have to be made in the clinic–how can one really say no to a human patient who sees an expensive (and unapproved) drug as her last-ditch hope to beat a fatal disease? Time and competition can help. An example comes from the recent introduction of Sovaldi and Havarti, initially costing US$84,000 or more in the US for a round of treatment of hepatitis C. These are unusual drugs because even at that very high price, they are still cost-effective, because the lives saved (and future healthcare costs reduced) are so large relative to their higher price. Yet the sheer size of the hepatitis C population led to budgetary pressures

on health ministries around the world, leading to rationing and restrictions for patients who might have benefited from the treatment. Fortunately, however,

Could clamping down on costineffective treatments turn off the tap of new innovations? competition from a new drug, Zepatier, and bargaining at the country level have brought prices down over time, in some cases by as much as two-thirds of the original price. One class of innovations that will prove difficult to achieve such pricing dynamics is novel treatments such as gene and cell-therapies developed for “orphan” conditions (those with fewer than 200,000 patients), so that competition will be less likely because of small market size. Two forces–high benefit and less competition– make high prices inevitable. Still, even here, it may make sense to think about paying off the amount over time rather than in the current year’s budget to ease the cost impact. Could clamping down on cost-ineffective treatments turn off the tap of new innovations? So long as health systems pay when the innovation is cost-effective, the answer is no, though it could be an incentive to shut down cost-ineffective

Spending and 1-year survival, elderly Medicare patients with acute myocardial infarction, 2007-11 Risk-adjusted 1-year survival, fraction

drug development. By paying for such cost-ineffective treatments, the US has inadvertently made it harder for other countries to refuse these budget-busting drugs, particularly in smaller countries with less bargaining power and alternatives of their own. So, to control costs and improve effectiveness for the long term, policymakers should first think carefully about how to make room in the healthcare budget for new and effective treatments, and clearing out old closets by speeding up the “exnovation” of outmoded technologies, or discouraging (or even closing) providers providing poor quality at high cost. And second, countries should not rush to adopt every new bright and shiny treatment cooked up by the medical drug or device industry, but focus on treatments that generate good outcomes at affordable costs for patients and society more widely. This would also send an unambiguous signal to drug manufacturers–that society will pay handsomely only if what they build is truly worth it. Contact and Share article and sources: References Chandra, Amitabh, and Jonathan Skinner. “Technology growth and expenditure growth in health care.” Journal of Economic Literature 50.3 (2012): 645-680.


Chandra A, Colla C, Skinner J. (2016), “The Health Benefits of Medicare Expenditures: Evidence from the Healthcare Cost Slowdown,”, unpublished working paper, Dartmouth, December. https://jonskinnerorg.files.wordpress. com/2016/06/ccs-v7-6.pdf

0.8 0.75

Institute of Medicine (2013), Variation in Health Care Spending: Target Decision Making, Not Geography, Washington DC media/Files/Report%20Files/2013/Geographic-Variation2/ geovariation_rb.pdf

0.7 0.65 0.6 0.55 30000











OECD (2014), Geographic Variations in Health Care: What Do We Know and What Can Be Done to Improve Health System Performance?, OECD Publishing,

Price- and risk-adjusted 1-year Medicare expenditures, US$

Source: Chandra, Colla, and Skinner (2016). Each dot represents a hospital with at least 400 heart attack (acute myocardial infarction) patients over the period 2007-11; this reduces the amount of random statistical noise.

OECD Observer No 309 Q1 2017



Designing value-based health systems for patients: The example of pain control and palliative care Felicia M Knaul, Professor, Department of Public Health Sciences at the Miller School of Medicine, and Director, Miami Institute for the Americas, and Afsan Bhadelia, Visiting Scientist, Harvard T.H. Chan School of Public Health

does radically improve the patient’s and family’s experience of suffering, and their quality of life. The trouble is, most outcome metrics would provide no value for these interventions. Addressing health-related suffering can have positive externalities, including in non-health areas. But these are also seldom measured or accrued in considering the full benefits–or positive outcomes–of a health intervention. Alleviating suffering at end-of-life eases the burden on the caretaker and family as well as on the patient and can help prevent complicated grief and ease the bereavement process. Moreover, these interventions are not gender neutral but rather proactively support women, who are often the primary caretakers. A knowledge gap currently exists due to limited data collected from patients with poor outcomes because such patients die

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Alleviating suffering at end-of-life helps the caretaker and family as well as the patient

Health systems strengthening efforts have focused on enhancing performance without significant attention to what value means to the ultimate users of the system–patients. Generating metrics that can better drive health systems in a manner that places patients at the core is an ethical, health and economic imperative. In fact, measures that comprehensively assess patient experiences, preferences and outcomes, can improve accuracy in priority-setting and promote the delivery of valuebased care. Take palliative and end-of-life care, for example. The value of alleviating health-related suffering is not fully captured in outcome measures that consider only if a patient dies, if they become more productive, or the extent to which they are cured of ailments. This skews priority setting in ways that should be obvious to anyone who has been a patient. How much would you value or be willing to pay for having a tooth extraction with instead of without medication to dull the pain? Or if your child’s broken arm has to be set, are you willing to consider an option where she experiences severe pain even if this does not change the ultimate outcome of the break? Imagine waking up after a mastectomy–without pain medication–and trying to breathe. Or, consider a loved one dying of cancer that has metastasised to the bone, is it imaginable that they would live their last days without morphine? Denying pain medication in these circumstances does not change the health outcome for the patient–they die–but it


and there is a shorter window to capture relevant information. Advocacy efforts to inform change are blunted by the truncated sample of patients from whom data is available. A full accounting of benefits–the positive outcomes–to patients and people can dramatically change the cost-effectiveness calculation around a health intervention. This manner of approaching health systems is in line with a diagonal approach–using diseasespecific interventions to drive through systemic changes. This approach is pro-poor, which is valuable because the voice of poor patients is rarely heard and concern for them is not at the forefront of systems policy and planning. Anecdote cannot be effectively projected to policy. Rather, systematic measurement of patient and person value around healthcare is a tool that is much needed to promote evidencebased advocacy and better experiences of care for everyone. Share article and links: References and links Knaul FM, Horton R, et al (2015), “Closing the divide: The Harvard Global Equity Initiative–Lancet Commission on Global Access to Pain Control and Palliative Care”, The Lancet, 8 March; available at: Knaul FM (2013), “Closing the Global Pain Divide”, Huffington Post, 25 September; available at: Visit

Business brief done in the hospital which is itself an extension of the classroom. The goal is to train highly qualified doctors who are fully operational by the end of their university studies. How visible are you internationally?

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We have partnerships with medical faculties in both English and French-speaking countries. They take the form of international conferences such as that on emergency medicine in a situation of crisis organised jointly with Harvard University in Paris in June 2016.

Gérard Friedlander Dean of the Faculty of Medicine at the Université Paris Descartes

An interview with Gérard Friedlander, Dean of the Faculty of Medicine at the Université Paris Descartes How would you describe the Faculty of Medicine at Paris Descartes? The Faculty of Medicine at the Université Paris Descartes is one of the leading medical teaching centres in France in terms of the number of students (about 13,000). It is regularly ranked 1st in France in terms of the percentage of students admitted to the top ranks of the medical internship examination. These excellent results reflect the quality of the training base: our main goal is to train future doctors at the highest level whatever their speciality. The faculty has close ties with the great Parisian hospitals, such as Cochin, Necker and Georges Pompidou, and has signed agreements with eleven other hospitals. The Dean of the Faculty has the power to decide on the hiring of doctors in the above-mentioned hospitals in connection with the review of university hospital staff numbers. What about research? This is a fundamental priority of our faculty. We have seven joint research centers covering the main fields of basic and clinical research. The Imagine Institute, located on the Necker hospital campus and specialised in genetic diseases, has 48 laboratories and 23 dedicated teams. The Cordeliers Research Centre hosts 150 researchers in two departments: “Physiology and Pathophysiology”; and “Cancer, Immunity and Immunopathology.” The Claude Bernard Grand Prix, awarded annually by the City of Paris to a researcher for the whole of their work and commitment to medical research, was awarded in 2016 to Guido Kroemer, Professor at the Faculty of Medicine of the Université de Paris Descartes and head of INSERM’s research team on “Apoptosis, Cancer and Immunity”. This award acknowledges his outstanding ground-breaking work on apoptosis and autophagy in connection with the occurrence of cancer. How many teachers do you have? The faculty has about 800 teachers who have medical training and who conduct research. This triple facet enables both theoretical and practical teaching to be dispensed.

A second aspect concerns organising hospital internships abroad, in the US, the UK, China, and so on. The goal is to enable our students to discover how medical systems work in other countries. In return, we welcome foreign students for training courses and internships. Another notable initiative is the I3DC project (International Intensive Infectious Disease Courses), which brings together the Faculty of Medicine, the Catholic University of the Sacred Heart in Rome and

We train high-level doctors who are fully operational by the end of their university studies the University of Edinburgh. Intensive courses on infectious diseases have been put in place: the project is financed by the European Union. How has the digital revolution affected Paris Descartes? Our faculty took to the digital path several years ago and we intend to continue in this direction, given how the digital revolution can help train future doctors. We have developed the iLumens educational platform which includes simulation rooms fitted out with all the standard equipment found in a hospital. Thanks to high fidelity models, it is possible to work on a patient in a virtual situation. Since 2013, our students have been doing their examinations on tablets and laptops. In 2016, a further step was taken with the internship examination taken on digital tablets in 34 university centres in France over a secure national network. Conducting such an examination on such a scale in real-time was a world’s first. How do you support start-ups? Since 2000 Paris Descartes has been host to Paris Biotech Santé, an incubator to support projects in the development of drugs, medical facilities and care of patients. Over the past sixteen years 118 spinoffs, employing 1,200 employees, have emerged. This experience has enabled an incubator to be launched on the campus of Cochin hospital. Visit

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The three elements all feed each other. Advances in research have a direct impact on the hospital project. Training is linked to what is




Our patients have changed, our healthcare must now follow Dr Samir K. Sinha, Director of Geriatrics, Sinai Health System and the University Health Network Hospitals

heterogeneous, needs of older adults by delivering high-quality, person-centred and cost-effective care to older adults. For policymakers, ensuring that we have a modernised healthcare work force that is trained to identify and address the unique needs of older adults will be key. Strengthening our provision of primary, home and community-based care is not only far less costly than that of institutional care, but ageing in place is more in line with growing societal desires. Adopting more proactive and preventative approaches to the delivery of care that enable healthy ageing will also be essential. Finally, ensuring that our current ways of delivering care are adapted to proactively identify our patients at highest risk of poorer

In 2010-2015 we achieved a 25.8% decrease in the average length of stay, and a 14% decrease in hospital re-admissions


outcomes can allow us to deliver better patient and system outcomes, especially when it is well known that most of our healthcare costs are often concentrated around a small group of complex patients.

In the coming two decades, it is expected that the number of individuals aged 65 and over will nearly double, so that there will be over 1 billion older adults worldwide. With our healthcare systems struggling to cope, this prospect has been characterised by some as a “grey tsunami” that threatens to raise costs, create inefficiencies and ultimately bankrupt us. Describing our changing demographic as a tsunami is problematic. After all, tsunamis are sudden and intense, but we have known that our population was ageing faster than ever for decades. In any case, the fact that our life expectancy has almost doubled over the last century should be considered a triumph, not a tragedy. The greatest concern for our healthcare system isn’t that people are getting older–which has been happening for millennia–but rather that our traditional health and social care systems have not kept pace with the evolving needs of a rapidly ageing population. Part of the reason for this is that we are now coming to understand that older adults are not simply chronologically mature, but like children, have unique medical, functional and social considerations that need to be understood and addressed. For many healthcare policymakers, this prospect challenges us to implement models of care that can meet the unique, and often


In 2010 Mount Sinai Hospital in Toronto, Canada sought to address the changing needs of its rapidly growing and ageing population by implementing its Acute Care for Elders (ACE) Strategy. The aim is to provide more specialised and comprehensive care for older adults using proactive and integrated, inter-professional, team and evidence-based approaches to care. While all older patients benefit, in particular we are better identifying and proactively managing the needs of our frailest patients to prevent functional decline, enable better care transitions, avoid hospitalisations and better support ageing in place. Between 2010 and 2015, under our ACE Strategy and its innovative models of care, we have achieved a 25.8% decrease in the average length of stay, a 14% decrease in re-admissions to hospital and a greater chance of returning and remaining at home through the provision of more proactive, higher quality and more patient-centred care. In preparing to meet the needs of ageing populations worldwide, policymakers in healthcare should remember that older adults want to age in place, but need our systems to adapt to help better enable this. With a better trained work force and care delivery models that emphasise the provision of more proactive services as close to home as possible, we know that this is not just achievable, but may be key to ensuring the overall future sustainability of healthcare systems worldwide. Dr Sinha is the architect of Ontario’s Seniors Strategy. Share article and links: @DrSamirSinha



People-centred healthcare: Don’t forget the nurses! Judith Shamian, President, International Council of Nurses

for doctors and healthcare providers to work together smoothly, nurses are an essential link in the chain. Without the trust and support of nurses, it will not be possible to build the partnership that is the essential ingredient of “people-centred care”. Once that relationship is formed between the nurse, or care professional, and the people, families and communities, the transfer of power and focus towards shared decision-making over one’s healthcare can become a reality.

©Arno Massee/Science Photo Library

To maintain the locus of control in the hands of the “people”, technology can become a very useful tool. This means a technology that enables the dialogue, knowledge and partnership to develop

Nurses are the most trusted professionals from all health and non-health professions Is the concept of “people-centred care” just new jargon for costcutting and to reduce access to routine healthcare? Or does it have the potential to improve both the health and well-being of people, while making the health system more efficient and less costly, and helping people to become healthier at the same time? This is the existential and fundamental question which policymakers and funders, together with the public and wider healthcare community, must answer. From the nursing lens there are several ways to tackle this question. Nursing is based on the premise that each individual patient is a unique entity, even if millions of people in the world might suffer from the same illness, like diabetes, or high blood pressure. But to be able to manage the condition in a truly optimal manner that goes beyond medical therapy, we must recognise the unique social, ethnic, geographical and other factors that are also key determinants of health. Here is where the notion of “peoplecentred” healthcare can play a game-changing role, not as some empty, wasteful jargon, but by nurturing an approach that really does treat each individual and their illness differently. Nurses must be central to this agenda. Nurses interact with the largest number of individuals. The 16 million strong professionals around the world come in touch with the 7 billion people on this earth. Furthermore, based on many public surveys, nurses are the most trusted professionals from all health and non-health professions. Indeed, nurses are the drivers of good healthcare, acting as the interface between often quite worried patients and their families and their doctors, community professionals and pharmacists. Patients and doctors need nurses as partners and as leaders in care if they aim to achieve the desired outcomes. Nurses are not in it for themselves: they work hard and, though knowledgeable, skilled and qualified, are far from the top of the pyramid when it comes to pay and voice. You would ask why this is all relevant. It is relevant because it is essential to have a “trusting” “therapeutic” relationship between healthcare professionals and the public in order for people to take the risk and adopt a culture of “people-centred healthcare”. For patients to be informed and gain confidence as partners, and

and build on existing relationships. But we must understand that technology cannot replace the fundamental relationship between the nurse and the client. If all of this sounds obvious and simple, then why is it not happening in reality? There are many answers to this question, but while nurses may adhere to the notion that each person is the “master of their destiny” as a paradigm, the reality is that for far too long we, as healthcare professionals, have developed a strong dependency model. We use words, terminology and multiple confusing acronyms and abbreviations that become barriers, and leave the public out in the cold, feeling incompetent, unable to enter the “hall of fame” of knowledge, and even afraid to ask intelligent questions about their own health. To change this, we need a cultural transformation, which strongly acknowledges that the only person who has full control of their wellness is the individual patient, and as nurses and healthcare professionals, we are at best a partner in managing often very complex human realities. In addition to this cultural shift, our educational systems have to go through a fundamental transformation from where we are the holders of knowledge and solutions to becoming the enablers. We must work alongside informed, empowered patients to facilitate the attainment of physical, mental and social well-being. If we make that transformation, it could lead to much stronger returns on investment of time, effort and resources, and a healthier, invigorated and more economically active society as well. The concepts and models are well articulated, but to make the final leap, we need to have the right people around the table. That includes nurses if the “next generation of reforms” is truly to be people-centred. Ministers for health, education, finance, decision makers, funders and other medical professionals who shape this crucial policy area: please open your offices and boardrooms and “walk the talk” by letting nurses and the public truly become part of the policy dialogue and turn what could become just more fashionable jargon into a powerful reality that benefits all. Share article and links: the International Council of Nurses website at @JudithShamian

OECD Observer No 309 Q1 2017




Healthcare: Pouring a little cold water on crowdfunding

©Ezra Acayan/NURPHOTO

Claire MacDonald, OECD Observer

Who would have thought that the Ice Bucket Challenge would be credited for bankrolling healthcare breakthroughs? The online campaign, which encouraged participants to be filmed while pouring a bucket of ice water on their heads and then inviting friends to do the same, was started in 2014 by ordinary people as a fun way to raise money for a relative with motor neuron disease, a normally fatal neurodegenerative condition that is also known as Lou Gehrig’s Disease, or Amyotrophic Lateral Sclerosis (ALS). The idea went viral, with millions of people, as well as famous presidents and rock stars, joining in. The challenge became the fifth most popular Google search in 2014 and raised more than US$220 million worldwide. Little wonder the ALS Association credits its recent discovery of a new gene, giving hope for ”real, meaningful therapies” for ALS, to the Ice Bucket Challenge. The success of this campaign is hard to ignore, and while no crowdfunding campaign has come close to matching it, this does not mean the method is without value or impact. The Movember charity is another example. This began in 2003 when two young men in Australia persuaded 30 friends to grow a moustache in November for charity, and is now an annual event. It operates in 21 countries, and has generated some $500 million for research into prostate and testicular cancer, while also encouraging men to talk more openly about their health in general. A key question is whether crowdfunding for medical research is a sustainable solution, or merely the zeitgeist of a generation who live vicariously through social media platforms where “sharing”, ”liking” and ”donating” are a simple click. Are successes like ALS simply arbitrary? After all, the internet is already saturated with Just Giving sites, and littered with causes in dire need of funds. The donating public cannot always be sure about project design, authenticity, standards for data collection, or safety protocols. Nor can they know which cause is more worthy or likely to succeed. In the US, barely 5,600 people are diagnosed with ALS every year, compared with over 300 000 new cases of breast cancer. Both ALS and prostate cancer have traditionally suffered from low profiles


and have had a hard time seeking funding, and the combination of moustaches and ice buckets with social media evidently helped change that. These movements cannot replace long-term funding for medical research or strategic health programmes such as cancer screening, but crowdfunding can work well if managed by the researchers themselves. As scientists have faced growing competition for a shrinking pot of government research funds, an emerging generation of scientists are leveraging the world of crowdfunding, social media and motivational talks to promote and raise money for research. Moreover, official funding processes can be notoriously slow, so when emergencies ignite, scientists want to work quickly. This was the case for the Zika Virus Challenge, which went live on Experiment, a crowdfunding platform for scientists, in March 2016; all modest targets of $2,000-$6,000 were reached. Larger gains are rare, and quirky campaigns that do not report breakthroughs can lose their appeal, even if worthy. This problem applies less to regular funding, since even if survival rates are low for certain cancers, for instance, there is a public sense that a breakthrough can and must be found. While crowdfunding might not always lead to ice-bucket style successes, by raising awareness and making policymakers realise that basic research funding pays off, then its place in today’s fundraising market should be secure. Visit, and programs/prostate-cancer Berkeley Wellness (2016), “Who pays for medical research?”, see www.berkeleywellness. com/healthy-community/health-care-policy/article/who-pays-medical-research Boston, Robert, “Breast cancer vaccine shows promising results in small trial”, IFLScience, see Eunjung Cha, Ariana (2015), “Crowdfunding propels underfunded scientific research”, see Ghose, Anindya (2016), “In with the in-crowd”, in OECD Yearbook, see

Business brief

new pathologies, but also the introduction of new technologies and the increasingly sophisticated demands of patients. Our belief is that appropriate training for highly skilled health professionals is an essential key to address these new challenges. What is essential to improve the quality and range of care available is to place the patient at the heart of the system and help contain rising health system costs.

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So we have developed several master’s degree courses in the health care area that aim to train future graduates to play the role of experts to optimise care quality, patient safety and ensure efficient use of resources. These new health professionals will play a central role in Luciana Vaccaro Rector of HES-SO University of Applied Sciences and Arts Western Switzerland

We have developed a competitive training and research offer which is perfectly in tune with the new demands of the health sector

Interview with Luciana Vaccaro, Rector of HES-SO University of Applied Sciences and Arts Western Switzerland Can you give us an overview of the University of Applied Sciences and Arts Western Switzerland?

healthcare organisations in ushering in new healthcare practices. They will take part in the necessary organisational changes and developments in the health system.

HES-SO the University of Applied Sciences and Arts Western Switzerland is the second biggest Swiss academic institution with 21,000 students. It brings together 28 schools offering a full study and research offer in six areas: design and visual arts, engineering and architecture, music and the performing arts, health and social work.

What is your research strategy? Unlike the federal universities and Swiss Federal Technology Institutes in Lausanne and Zurich, HES-SO does not offer PhD courses. However, we have developed a very important care research offer. Our flagship project concerns caregivers at home. HES-SO is piloting a project that benefits from significant financial support from the Swiss Confederation: the goal is to study all issues of ageing from the perspective of family caregivers. Our approach is multidisciplinary and all-embracing: it encompasses the different aspects that are care, new technologies but also the role of patients and their families.

The academic curriculum is mainly centred around bachelor’s degrees but we also offer master’s. Our masters’ degree courses are designed as advanced modules and are intended for people who are already in a working environment. HES-SO is a genuine higher education cross-canton network (7 cantons). What distinguishes you from other more conventional universities? HES-SO offers university-level courses grounded in professional practice. Graduates come out of HES as generalists with a solid theoretical training and renowned practical skills. They master the tools in their field and know how to conduct cross-disciplinary thinking. They rapidly find positions in the business and service sectors but also in social, health, and cultural institutions.

We also work in such areas as mobility, chronic pain, autonomy for cancer patients, and so on. Another example is the implementation of big data in the health sector: we have two research groups working on this issue. For all these projects, we work in collaboration with local stakeholders: hospitals, home care centres, universities, etc. A word to conclude?

HES-SO is known for its specialisation in the health sector. What is your offer in this area?

I think the Swiss experience can provide food for thought for the OECD countries, especially as regards decentralisation of the health system. Here hospitals are under the responsibility of the cantons whereas insurance schemes are federal. Furthermore, there is a real concern about user involvement and participation. Finally, Switzerland is a genuine laboratory in some areas in which future solutions are tested.

We offer courses in seven disciplines: Midwifery; Nursing; Nutrition and Dietetics; Occupational Therapy; Osteopathy; Physiotherapy; Radiologic Medical Imaging Technology. Our goal is to train high level professionals who will be able to meet the new demands of the health system. Student numbers at HES-SO have grown by 30% over the last five years and are now over 3,600.

Can you tell us more about the courses? In Switzerland, as elsewhere in the industrialised countries, the health sector is undergoing major change due to a combination of several factors: ageing populations, on-going cost increases, treatments for

Sponsored by HES-SO: A network of skills and competences

Faculty of Health Sciences

▪ 6 Faculties Design and Fine Arts; Business, Management and Services; Engineering and Architecture; Music and Performing Arts; Health Sciences and Social Work.

▪ ▪

3,670 students 8 Bachelor’s and 4 Master’s programs

With 28 Schools, over 21,000 students, 68 study programs the HES-SO is the largest UAS (University of Applied Sciences) in Switzerland.




Can healthcare policy and technology heal rural-urban divides?

©Sylvie Serprix

Rory Clarke and Claire MacDonald, OECD Observer

Telehealth is not a substitute for seeing real doctors, but can play a valuable role in patient-centred healthcare and in closing the rural-urban divide as well. But it will require investment and determined policies. A shift of health services and professionals from rural and small town communities towards larger, more centralised services in urban settings may have advantages for cost-effectiveness, but is it patient-centred? Or is it fuelling the already expansive gap between country and city communities, and a sense of abandonment and resentment as people are forced to travel far to get the same care quality as city citizens? This rural-urban divide was evident in recent elections in the US, Brexit and the French regional elections in 2016. Could healthcare policy, bolstered by smart technology, help overcome this “geography of discontent”? One group on the rural disparity radar is teenage girls. The teen birth rate in the


US’s small towns is 63% higher than in its biggest cities, according to a 2016 report from the Centers for Disease Control and Prevention reported in the Los Angeles Times. Rural women experience poorer health outcomes and have less access to healthcare than their urban counterparts, one reason being the limited numbers of healthcare providers, and in particular women’s health providers. They are also less likely to receive contraceptive services, and typically have to travel further than their urban counterparts to access reproductive health services. To overcome this inequitable status, several US states, such as Arkansas, are using telehealth programmes. While the gadgets supporting telehealth and mobile health–mobile phones, tablets, personal digital assistants and the wireless infrastructure–are new, the concept of using telecommunication and multimedia technologies to reach patients virtually is not. As far back as in 1878, The Lancet reported on the use of telephones to reduce unnecessary visits,

and during the mid-20th century NASA used remote monitoring systems to measure astronauts’ physiological functions. So could the new technology and wellness gadgets be the answer to healthcare inequality? While telehealth is not yet a substitute for a doctor who might need to perform a procedure and though it is as yet impossible to download a medicine, the evidence shows that smart communications technology can play a valuable role for patients. Urban-rural digital divides pose a challenge, however. Roughly half of total EU population live in rural, remote and mountainous areas, and only 25% of such areas are covered by fast broadband, compared with some 70% coverage in urban areas. Regions are responding; Bavaria is promoting broadband expansion with €1.5 billion by 2018, for instance. In the US, attention is also focusing on closing the rural-urban digital gap, with advantages for healthcare.

Remote monitoring is one of the most common uses of telehealth, and is becoming increasingly pertinent as the level of chronic disease increases alongside a globally ageing population. In the US, more than 70% of deaths are associated with chronic diseases, which account for up to 75% of annual healthcare expenses, according to the Journal of Medical Internet Research. The journal points out that in the EU, chronic illness is a factor in around 87% of all deaths. Telemedicine can also help doctors in rural areas gain access to specialist knowledge and diagnostic facilities. In India, the G Kuppuswamy Naidu Memorial Hospital has established

Remote monitoring is one of the most common uses of telehealth a live interaction by satellite with the Swami Dayananda Jayavarthanavelu Tribal Rural Hospital in Anaikatti for this purpose, with communication support from the Indian Space Research Organisation (ISRO). Over the past decade in the EU, information technology solutions and telehealth technologies have reached a high degree of integration between hospitals and municipalities. An example is the Renewing Health project, which involved eight countries (Denmark, Finland, Germany, Greece, Italy, Norway, Spain, Sweden) and 7,000 patients suffering from chronic obstructive pulmonary disease (COPD), diabetes or heart diseases. Under the project patients were able to see their own data, and as a result, healthcare professionals reported that patients took greater responsibility for their own health. When they could not see their data, patients were less responsible for their healthcare and the two-way communication was limited. Technology and gadgets continue to develop, from smartphones and portable diagnostic machines to smart pills such as one by US company, Proteus Digital Health that when dissolved in the stomach transmits data and enables

patients and their clinicians to monitor prescriptions and how patients are doing. But there are obstacles to overcome before telehealth can reach more remote communities. One is to ensure the technological capacity needed to accommodate bandwidth-heavy telehealth programmes for smaller towns, villages and farmsteads. Another problem is the lack of acceptance of these technologies by patients and clinicians, and even by healthcare reimbursement systems, and the need for patients, particularly older people, to develop the skills and knowledge needed to use them. Moreover, the interoperability between electronic patient record systems and particular technologies is limited. In the UK, the Whole System Demonstrator telehealth project was carried out with 3,230 patients between 2008 and 2009, according to the Journal of Medical Internet Research. It showed that patients’ primary concerns were personal and about privacy in relation to identity theft, as well as independence. Reticence about self-care and technical competence were also concerns. In any case, people want access to physical doctors and nurses. In France, where city-rural divisions are also influencing the electoral map, the government introduced “A chance for France” in March 2015, which aims to improve healthcare in rural areas where doctors and other public services are scarce. France is one of the OECD countries with the most doctors per head of population and has a highly regarded healthcare system, but “medical deserts” forming in regional towns and surrounding rural communities are a concern, particularly in regions such as Picardy, Normandy and the north, as well as some overseas departments. In fact, while Paris has nearly 800 doctors per 100,000 inhabitants, departments in these regions can have fewer than 200. A new medical “pact” includes such measures as making trainee doctors fulfil part of the training in needy areas, providing incentives and investing in local doctors, hospitals and ambulatory



services. Digital improvements will also be key, and the government has announced plans to get rid of so-called

Providing bandwidth for villages and farmsteads is a challenge white zones: areas in 169 municipalities with no 2G connection, or no telecommunications at all. One innovation that can help bridge the urban-rural divide comes in the form of online health communities. Communities, such as or, can empower and inform patients, and create networks too. People, proximity and physical reality are all important for healthcare, but telehealth matters too. Being online does not remove care professionals, but may in fact demand an extensive care team, and new skills and business services too. Telehealth is not cost free but it could help to stimulate patient-centred healthcare throughout the land. Share article and sources: References Birthe, Dinesen, et al. (2016), “Personalized Telehealth in the Future: A Global Research Agenda”, Journal of Medical Internet Research, https://www.ncbi.nlm.nih. gov/pmc/articles/PMC4795318/ French Government (2015), Fifty concrete measures for rural areas, fifty-concrete-measures-for-rural-areas The Hindu (2008),Telemedicine to bridge rural-urban divide, tp-national/tp-tamilnadu/Telemedicine-to-bridge-ruralurban-divide/article15339446.ece Jadoš, Rozo (2016), Broadband access in rural and mountainous areas in the EU, http://www. Kaplan, Karen (2016), “There’s another type of rural/urban divide in America: Teens having babies”, Los Angeles Times, la-sci-sn-teen-birth-rate-rural-urban-20161116-story.html University of Maryland (2016), “UMD researchers show how online communities bridge the rural-urban healthcare divide”, EurekAlert!, releases/2016-12/uom-urs120916.php See online version of this article for more references.

OECD Observer No 309 Q1 2017


OECD Observer Roundtable

OECD Observer roundtable on pensions

©Dylan Martinez/REUTERS

Healthcare is not the only service feeling the effects of ageing populations. Pension systems are also under financial pressure, with policymakers in many countries struggling to find long-term solutions (see for instance pensions). We ask a range of experts:

What do you see as the biggest policy obstacles for pensions in the future?

poverty line. For about one in two retirees, Social Security provides at least half their monthly income.

Debra Whitman, AARP Chief Public Policy Officer

Yet Social Security benefits are modest by Western standards, replacing only 40% of average income, compared with closer to 60% in other OECD countries. And as things stand, the programme will not be able to pay all promised benefits by 2034, according to its trustees. Unless changes are made, benefits could be cut more than 20% across the board at that time.

The old paradigm of retirees having the support of a three-legged stool consisting of Social Security, employer pensions and personal savings seems from a bygone era for many people in the US. Employer defined benefit pensions have become increasingly rare. Savings are insufficient, with many adults having none at all, not least because largely stagnant wages and a rising cost of living have made it hard for most earners to set even a little aside. Less than half of US employees have access to retirement savings plans in the workplace. Fortunately, almost everyone is covered by Social Security–which in the US refers to a specific social insurance programme for the retired, survivors and the disabled. Its guaranteed benefits, earned through at least 10 years of employment and payroll tax contributions, keep one in three older people in the US above the


Policy experts have long highlighted measures that would address the shortfall–through raising payroll taxes, cutting benefits, or a combination of the two. The political will to address Social Security has been lacking, although there are clear advantages to acting sooner rather than later.

workers throughout their entire career is still needed. The reality is that each leg of the traditional stool needs shoring up, or millions will see their dreams of a golden retirement turning to bronze–at best. We must find ways to avoid that outcome. Visit


The imperative and implications of social security reform Catherine Collinson, Executive Director, Aegon Center for Longevity and Retirement, and President, Transamerica Institute and Transamerica Center for Retirement Studies

Anyway, even if fully funded, Social Security benefits are likely to remain modest, so it is important to strengthen other retirement resources. One encouraging development, seven states–California, Connecticut, Illinois, Maryland, New Jersey, Oregon, and Washington–have passed laws that help workers build nest eggs, typically through payroll deductions. Once implemented, these new programmes will result in the greatest increase in the number of workers with access to retirement savings in several decades. However, federal regulations that made the establishment of state plans easier are under attack by some in Congress, and if they are repealed, the future of these reforms will be jeopardised. For that reason–and the fact that state plans will not include everyone–a national plan that covers all

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Retirement security in the US needs urgent attention

Governments around the world are facing intense financial pressures with their social security retirement programmes. In the US, where I live and work, Social Security serves as the primary source of retirement income for millions of people. However, its trust fund is projected to become depleted in 2034. At that time, unless Congress has enacted reforms, it would only be


Five areas for action in African pensions

able to pay 79% of its promised benefits. Globally, while governments are mustering up the wherewithal to tackle these pension funding-related issues, most people already recognise that change is necessary. According to findings from the Aegon Retirement Readiness Survey 2016 of 16,000 workers and retirees across 15 countries, a scant 7% of respondents said their governments should do nothing because they feel their country’s social security provision will remain perfectly affordable in the future.

Whatever the reforms may be, it is inevitable that individuals and families will ultimately be required to pick up the slack, with some being more affected than others. Workers will place an even greater reliance on their employers for retirement benefits. Those without access to workplace retirement benefits will face an even greater need for meaningful ways to save and avoid being left behind. Without reforms, the social security funding shortfalls will likely stay the same or increase. The longer policymakers wait, the greater the potential abruptness and magnitude of the changes, and the harder it will be for everyone to adjust their plans and expectations accordingly. It is clear that the current retirement system is not tenable. Should we not be engaging in the hard conversations about the sustainability of our view of retirement? Should we not be more committed to finding workable solutions? It is time to stop ignoring the issues–and it is time to start rolling up our collective sleeves and get to work.

Coming off such a low base, there are at least five key areas that require significant policy attention to bolster pensions in Africa. These are: (1) improving the tax systems and revenue collection base of African countries; (2) ensuring political and fiscal stability; (3) developing a savings culture with an eye to retirement; (4) regulatory reform; and (5) enhancing coverage.

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Maintaining the long-term sustainability of national social security programmes is one of the most far-reaching challenges facing policymakers today. It cannot be achieved without the possibility of controversial trade-offs such as raising taxes, reducing benefits, or increasing the retirement age (amid the absence of meaningful employment opportunities for older workers). Even more daunting is how to solve the problem fairly and equitably, across generations and levels of need, and in a way that addresses the risk of poverty among the elderly in the future.

Neuma Grobbelaar, Director of Research, SAIIA

40-70% coverage. Nonetheless, apart from South Africa and Namibia, most African countries have very low levels of pension penetration rates, also reflecting the informality of employment.

Africans have experienced a significant increase in their life expectancy in the 2000s to reach an average life expectancy of 60 years in 2010-2015. Longevity is increasing across the world and the UN projects that by 2050, 80% of over 60s will be living in developing countries. They are also the fastest growing population segment in Africa, increasing by 50% between 2000 and 2015 and projected to increase fivefold by 2050. The last few years have focused the discussion on Africa’s youth bulge as a ticking time bomb in the absence of sufficient employment creation, but its elderly also require more healthcare, housing and social support. Social welfare policy in Africa is underdeveloped and nascent, albeit growing. Pensions are crucial in this sphere: in South Africa pensioners are often the main caregivers and through their grants the sole income earners of many rural but even urban families where unemployment is rife. Nonetheless, only 10% of the adult population in Africa is covered by a pension fund. Within this group, pension funds for civil servants are widespread and African upper MICs have between

For African countries it is especially necessary to explore how pension reform could credibly contribute to a social security system that accommodates a multi-pillar retirement system. This should include non-contributory universal pension schemes; mandatory income related savings; and lastly, voluntary savings. A step in the right direction is the adoption of legislation such as the Taxation Laws Amendment Act in 2015 by the South African parliament, which seeks to harmonise the tax treatment for all types of retirement funds, including pension, provident and retirement annuity funds and to promote a retirement savings culture in South Africa. Visit the South African Institute of International Affairs website at

Let’s speak a language that pension clients understand Romi Savova, Founder and CEO of PensionBee How can policymakers expect ordinary people to save for retirement if pension schemes are so hard for even the experts to understand? The complexity surrounding pensions is the core issue that prevents our generation from engaging with retirement savings. Even Andy Haldane, chief economist at the Bank of England, remarked that he could not make the “remotest sense of pensions”.* I believe it is a similar case for other OECD countries as well. It is vital that we respond to such concerns and focus on eradicating jargon, moving

OECD Observer No 309 Q1 2017



Romi Savova pensions online and ensuring pension mobility. A good place to begin would be standardising customer communications. Savers yearn for transparency and authenticity, but most providers have their savers combing through the actuarial dictionary for words like “pension commencement lump sum”. If providers can’t explain how pensions work in normal language, why should we expect people to save? It is time to build a new language for pensions so that people today understand the benefits (and indeed, the imperative) of retirement saving. The ways providers and savers communicate must also evolve. We need more technology-focused policies to bolster the future of pensions. At PensionBee we believe that managing pensions should be as easy as online banking, and our online service has attracted hoards of savers seeking transparency and access to their balance. At the same time, we have seen some remarkably antiquated practices from the legacy firms, many of which seem removed from the digital world we live in. One provider insists on being addressed only with the full form of its rather obscure name through the post; others refuse to respond if the relevant account number is mentioned only on page two of a given letter. Many consumers find


Finally, we need policies to help consumers switch providers smoothly and simply. Upcoming generations have to be increasingly mobile, travelling from job to job and country to country. While bank account switches and currency transfers can be done in a week, some laws, including UK legislation, allow pensions providers to take six whole months to transfer a pension. In that time you could travel around the world about 87 times. It is time to give savers ownership over their retirement savings, and the freedom and empowerment to choose where they keep their money. Visit *See for instance, “Bank of England chief economist Andy Haldane admits he can’t make sense of UK pensions”, report in, 19 May 2016 PensionBee is an online pension manager, which helps over 22,000 people combine their pensions into one new online plan.

Youth trends will shape the future of pensions Musa Bajwa, Manager, Public Relations, AIESEC* Today’s youth is vastly informed and take considerable interest in the evolution of the world and their environment. According to UN The State of the World Population 2014 report, there are currently around 1.8 billion young people aged 18-25 in the world. According to The Youthspeak Survey held by AIESEC which was globally answered by over 160,000 young people, some 61% of respondents either want to become an entrepreneur or already are one. When asked what the most important in the first five years of developing their career, one in four millennial listed global experiences as a choice. This shows us that generation Y/Z is and will be an

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such requirements baffling, if not impossible to navigate. They also create costs for providers. We need to get rid of unnecessary paper trails and simplify online access to information, where appropriate. The pension dashboard initiatives across the world, such as Australia, the Netherlands, Sweden and the UK, are welcome steps forward.

Musa Bajwa extremely mobile workforce that values experiential learning over the traditional career-building techniques. We are putting forward these results because, according to most OECD member countries’ pension policies, they are not taking into account the inputs of the generation that has to work to make sure that the pension programmes in their countries remain relevant. According to OECD Pensions at a Glance, “The share of individuals aged 65 and above will increase from 8% of the total world population in 2015 to almost 18% by 2050 and from 16% to 27% in the OECD”. This in turn will put added strain on the working-age population, which will significantly have to sustain the pay-as-you-go (PAYG) pension schemes for an increasing number of elderly people in their countries. We also need to remember that a large percentage of young people are more interested in working in different places than in their own country. Lastly, knowing this, the question is, what change would be needed from our respective countries to make sure that young people are actively and consciously being engaged in the process of pension policy formation within their countries? * International Association of Students in Economic and Commercial Sciences, visit


Halving road deaths by 2020: A global health priority HRH Prince Michael of Kent

management becomes a critical overall policy instrument especially as regards vulnerable road users, who account for nearly half of all road fatalities, and where avoiding any impact above 30 km/h is a critical life-saving requirement. To achieve the UN’s ambitious target much needs to be done. According to the World Health Organization, too many countries lack the basic framework of laws that are the sine qua non for

The health sector can act as a powerful catalyst for effective implementation of the “safe system” approach ©Rights reserved

effective road injury prevention. For example, only 44 countries worldwide have best practice helmet laws; only 34 countries have best practice drink driving laws; and only 40 countries apply the most important vehicle safety regulations. Too often also, new road construction in low and middle income countries raises levels of speed but neglects investment in road side architecture that will protect both vehicle and vulnerable road users alike. Every year 1.25 million people are killed and as many as 50 million seriously injured in road crashes worldwide. This epidemic of road injury causes huge economic losses and places severe burdens on public health systems. Fortunately, this predictable and preventable global health emergency has now been given the international recognition it deserves. Road safety is included in the United Nations Sustainable Development Goal for Health, with a target to halve road deaths and injuries by 2020. This provides the strongest possible mandate for urgent action against a scourge that has become the number one killer of young people in all regions of the world. The UN’s very ambitious casualty reduction target poses a significant challenge to governments across the world to reinvigorate their road safety policies and adopt effective strategies for road injury prevention. An unrivalled source of guidance for exactly this is contained in the International Transport Forum’s new publication “Zero Road Deaths and Serious Injuries: Leading a Paradigm Shift to a Safe System”. This report, prepared by an ITF group comprising experts from countries with the most successful performance in road injury reduction, challenges policymakers to envisage a world entirely free from road fatalities and serious injuries. Rather than blame the victim for road crashes, the report advocates a “forgiving” or “safe system” approach which recognises that while people will always make mistakes, there is nothing inevitable about deaths and serious injuries from road crashes. The report promotes an integrated combination of policies for safe vehicles, safe roads and safe road users, which aims to ensure that when crashes occur the impact forces do not exceed the physical limits of the human body and lead to serious injury or death. A key message of the ITF report is the importance of accepting a shared responsibility to design, manage and use our road traffic systems in ways that reduce the risk of injury. In practice, this approach encourages policymakers to apply a combination of road infrastructure, vehicle technologies and behavioural measures. Speed

Health ministers and the public health community as a whole have a vital role to play in road injury prevention. They are responsible, of course, for emergency response and post-crash care which is critical to rates of survival and recovery for victims. But in addition, the health sector can act as a powerful catalyst for effective implementation of the “safe system” approach. Data, such as hospital admission records, for example, are an essential resource to help policymakers determine their priority road safety actions. Another vital issue is funding. With the notable exceptions of the Bloomberg Philanthropies and the FIA Foundation there is a lack of donor support for national, regional, and global road safety initiatives. In 2015 the UN General Assembly adopted a resolution on road safety that called for the establishment of a UN Road Safety Trust Fund. This is a very welcome proposal as it could, if properly resourced, provide much needed support for capacity building in road injury prevention in low and middle income countries that account for almost 90% of the world’s road traffic deaths. With road safety now firmly on the global health agenda and with policy recommendations so expertly framed by the International Transport Forum really there has never been a better time for concerted global action to make roads safe. NB: The International Transport Forum (ITF) at the OECD received the 2016 Special Award of the Prince Michael of Kent International Road Safety Awards for “leadership in improving the delivery of road safety across the world”. References ITF (2016), Zero Road Deaths and Serious Injuries: Leading a Paradigm Shift in Road Safety, available online at WHO (2015), Global Status Report on Road Safety, see UN General Assembly Resolution 70/1 of 25 September 2015, entitled “Transforming our world: The 2030 Agenda for Sustainable Development”, Goal 3: Good Health and Well-being, see UN General Assembly Resolution 70/260 of 15 April 2016, entitled “Improving global road safety”, paragraph 29, see

OECD Observer No 309 Q1 2017



Toyin Ajayi, Chief Medical Officer, Commonwealth Care Alliance (CCA)

OECD wins international publishing award OECD Publishing, which is the publishing brand and agency of the OECD, has won the 2017 Academic and Professional Publisher Award at the London Book Fair, held at the Olympia in London on 14 March. The award, which is organised in partnership with the Publishers Association, was presented under the International Excellence Awards, with the support of Research Information, a print and online magazine from Europa Science Ltd. For Jacks Thomas, director of the London Book Fair, the International Excellence Awards “showcase the true diversity, creativity and dedication to books and reading that define 21st century publishing.” The judges applauded OECD Publishing for its “innovative, robust, content-

People-centred healthcare was the focus of the Policy Forum and Ministerial Meeting on the Future of Health, 16-17 January 2017, at which ministers, professionals and experts from over 40 countries shared ideas and practices on issues such as access, technology, metrics and costs. The ministerial meeting was chaired by the UK’s health secretary, Jeremy Hunt (see introduction). A ministerial statement was issued on 17 January, which set out the achievements in healthcare systems, while focusing on promoting high-value health systems for all; adapting health systems to new technologies and innovation; reorienting health systems to become more people-centred; and encouraging dialogue and international co-operation. Read the Ministerial Statement here: ministerial/ministerial-statement-2017.pdf

specific and mission-appropriate publishing model”, as well as its “commitment to international audiences and linguistic diversity”. Toby Green, who as head of OECD Publishing pioneered OECD iLibrary, a platform that disseminates OECD work to academic and research institutions the world over, received the award on behalf of the organisation. “It’s a great honour, international excellence is what we strive for, and this fantastic award is recognition of the hard work and creativity of a great team at the OECD,” Mr Green said. To find out more about the London Book Fair International Excellence Awards, see Research Information is at For more on OECD Publishing, see and

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Effectopedia, chemical risks and health

The OECD’s Toby Green receives the Academic and Professional Publisher Award at the London Book Fair, 14 March 2017


Exposure to a chemical can lead to adverse effects on the health of people and wildlife. To anticipate and understand the relationships, the OECD, with support from the European Commission, has developed an Adverse Outcome Pathway (AOP) tool in a bid to

Affordable housing database


©Marco Illuminati/OECD

Healthcare for patients

Access to good and affordable housing has become a key challenge for many countries, with all too many people living in lowquality dwellings or facing housing costs they can ill afford, not to mention widespread housing shortages and homelessness. The new Affordable Housing Database can help policymakers address these problems. See affordable-housing-database.htm

describe a logical sequence of causally linked events at different levels of biological organisation. These pathways will help support chemical risk assessment. An AOP Wiki has now been launched at, and the OECD Series on Adverse Outcome Pathways can be accessed at


Recent speeches by Angel Gurría Megatrends to 2050: What better policies for better lives? Speech delivered in Paris, France, 27 January 2017

Ambassadors Mr Paul Dühr, Luxembourg Mr Paulo Vizeu Pinheiro, Portugal

The next generation of health reforms Opening and closing remarks at the 2017 Health Ministerial Meeting, in Paris, France, 17 January 2017 Nuclear Energy Agency workshop on stakeholder involvement in nuclear decision making Remarks delivered in Paris, France, 17 January 2017

Mr Dionisio Pérez-Jácome Friscione, Mexico Ms Marlies Stubits-Weidinger, Austria Mr Klavs A. Holm, Denmark Mr Noé Van Hulst, Netherlands Ms Annika Markovic, Sweden Ms Claudia Serrano, Chile Ms Elin Østebø Johansen, Norway Mr Ulrich Lehner, Switzerland

©OECD/Julien Daniel

Mr Carmel Shama-Hacohen, Israel

For a complete list of the speeches and statements, including those in French and other languages, go to: secretary-general/

Introduction of Mr Fernando Zavala, President of the Council of Ministers of Peru

Mr Zoltán Cséfalvay, Hungary

Speech at the Special Meeting of the OECD Council in Paris, France, 16 January 2017

Mr James Kember, New Zealand

Introduction at OECD Council of Mr Robert

Mr Brian Pontifex, Australia

Fico, Prime Minister of Slovakia

Mr George Krimpas, Greece

Introductory remarks delivered in Paris,

Mr Matei Hoffmann, Germany

France, 16 January 2017

Mr José Ignacio Wert, Spain

People at the centre: The future of health

Mr Jean-Joël Schittecatte, Belgium

Opening remarks at 2017 OECD High-Level

Mr Jong-Won Yoon, Korea

Policy Forum in Paris, France, 16 January 2017

Mr Christopher Sharrock, UK

Remarks at a meeting with the Confederation of Indian Industry, New Delhi, India, 28 February 2017

Mr Erdem Bas¸çi, Turkey Ms Ivita Burmistre, Latvia

Presentation in Mexico City, Mexico,

Mr Aleksander Surdej, Poland

OECD’s review on gender policies in Mexico: Building an Inclusive Mexico: Policies and Good Governance for Gender Equality Remarks delivered in Mexico City, Mexico, 10 January 2017

Making globalisation work for all 5th OECD Parliamentary Days opening remarks in Paris, France, 9 February 2017

Investing to reach the Paris goals and sustainable economic growth Remarks at a seminar held in Stockholm, Sweden, 8 February 2017 OECD’s Economic Survey of Portugal

Mr Pekka Puustinen, Finland Mr Dermot Nolan, Ireland Kristján Andri Stefánsson, Iceland Mr Alessandro Busacca, Italy Mr Petr Gandalovic, Czech Republic Ms Irena Sodin, Slovenia

OECD’s Economic Survey of Mexico

Mr Hiroshi Oe, Japan

Presentation in Mexico City, Mexico, 10 January 2017


OECD’s Economic Survey of Sweden Presentation in Stockholm, Sweden, 8 February 2017

Ms Michelle d’Auray, Canada

OECD’s Tourism Policy Review of Mexico 13 January 2017 India and the OECD in a new economic reality

Mr Pierre Duquesne, France

Laureates & Leaders’ Summit for Children: Towards a child-friendly world Closing press conference remarks delivered in New Delhi, India, 11 December 2016

Mr Juraj Tomáš, Slovak Republic Chargé d’Affaires a.i. Mr Andrus Säälik, Estonia Chargé d’Affaires a.i. Mr Peter Haas, United States Chargé d’Affaires a.i.

Roundtable for Ministers on open government


Opening speech in Paris, France, 8 December 2016

European Union Mr Rupert Schlegelmilch February 2017

Launch in Lisbon, Portugal, 6 February 2017

OECD Observer No 309 Q1 2017



Calendar highlights Please note that many of the OECD meetings mentioned are not open to the public or the media and are listed as a guide only. All meetings are in Paris unless otherwise stated. For a comprehensive list, see the OECD website at FEBRUARY 9-10

Fifth OECD Parliamentary Days, Paris, France


World Government Summit, Dubai, UAE

23-24 OECD Workshop on measuring business impacts on people’s well-being, Paris, France


International Congress on Transport and Infrastructure Systems, Rome, Italy

OECD OECD Forum 6-7 June; OECD Ministerial Week Council Meeting 7-8 June


WB/IMF/G20 Finance Ministers meeting, Washington DC, US


World Summit on the Information Society Forum, Geneva, Switzerland


Launch of PISA 2015 Results Volume III: Students’ Well-Being


High-Level Policy Forum on the OECD Jobs Strategy, Berlin, Germany


Launch of Interim Economic Outlook, Paris, France


International Women’s Day


Finance ministers and central bank governors meeting, Baden-Baden, Germany




Launch of OECD Skills Outlook 2017


G20 Summit 2017, Hamburg, Germany


Second International Conference on National Urban Policy, Paris, France


International Summer School for cooperation and local development in Latin America, Trento, Italy


Launch of African Economic Outlook 2017

18-20 China Development Forum, Beijing, People’s Republic of China


Launch of PISA 2015 Results, Volume IV: Financial Literacy


26-27 G7 Summit 2017, Taormine, Italy


31 May- International Transport Forum Summit 2017, 2 June Leipzig, Germany


OECD Forum on Governance of Infrastructure, Paris, France

30-31 2017 OECD Global Anti-Corruption and Integrity Forum, Paris, France 30-31 Seventh International Summit of the Teaching Profession 2017, Edinburgh, UK


Ninth International Economic Forum on Latin America and the Caribbean, Paris, France


World Investment Forum 2017, Newport Coast, US


G20 Digital Ministers meeting, Dusseldorf, Germany

The illustration originally appeared in OECD Observer No 249 May 2005.


SEPTEMBER Launch of Education at a Glance 2017


G200 Youth Forum 2017, Dubai, UAE


World Anti-corruption Day


Dare to share Germans are considered to have some of the most egalitarian attitudes in the world when it comes to sharing responsibilities between mothers and fathers, second only to Sweden, according to a survey of the International Social Survey Programme. But how does this attitude translate into practice? Not as well as it could, is the overall assessment of Dare to Share: Germany’s Experience Promoting Equal Partnership in Families. True, in the decade to 2012, the share of people opposing the employment of mothers of pre-school-age children halved (interestingly, with more people

against in former West Germany than in the East). But in reality, the main earner model continues to dominate in German families, with fathers working long hours and mothers working part-time. Income inequality is one reason for this: young men often earn more than young women, so when starting a family, the loss of income for the family is deemed smaller when the woman reduces working hours rather than the man. Mothers bear some 62% of unpaid work and take care of the children at home. This locks in traditional gender patterns, whereas a more equal sharing of responsibilities would improve the well-being of families, the report argues. For instance, ensuring women are in paid work reduces a family’s risk of poverty, while fathers’ involvement in parenting is associated with cognitive, emotional and health benefits for the

child. As with many OECD countries, women’s educational attainment outpaces men’s in Germany, with 32.1% of 25-to-34 year-old women having completed tertiary education, compared to 27.9% of their male peers. This suggests potential gains for the economy if fewer women stayed at home. Dare to Share: Germany’s Experience Promoting Equal Partnership in Families proposes several policy recommendations, such as continuing to increase investment in early childhood education and care support, greater investment in care out of school hours, encouraging fathers to take up parental leave and adjusting the tax-benefit system to encourage couples to share paid work evenly. The parental leave reform of 2015 should be properly evaluated and developed, too. Share article at OECD (2017), Dare to Share: Germany’s Experience Promoting Equal Partnership in Families, OECD Publishing, Paris

Making Africa healthy Sub-Saharan Africa suffers from the worst health status in the world, according to the authors of Making Medicines in Africa. As policymakers turn their focus to healthcare, in part spurred on by the UN Sustainable Development Goals, the authors argue that industrial development in pharmaceuticals and the capabilities it generates can play a crucial role in addressing the healthcare needs of the continent. Through a collection of case studies on industrial policies, Making Medicines in Africa shows the successes and pitfalls along the way. Take Kenya’s strong pharmaceutical industry, for instance. Import substitution was instrumental in laying the groundwork for growing the industrial base, the authors

argue, followed by liberalisation and a consequent expansion of the strongest firms. This incubation approach worked, since the Kenyan pharmaceutical industry recorded continuous growth between 2007 and 2013, a period in which total production of tablets, capsules, liquid preparations for oral use and creams alone increased from US$34.1 million to $154 million and the sector is now busily exporting to other sub-Saharan countries. On the other hand, neighbouring Tanzania’s pharmaceutical industry, which was established later and shaped by more explicitly state-driven policies than Kenya’s, has been declining since 2009 due to factors such as the fragmented structure of the industry, and technological and financial issues, which have made it hard to match competition from imports. By 2013, only five locally operating firms remained on the market, compared to eight firms in 2009. Meanwhile, in South Africa, the government’s price controlling policy on medicines led to an average drop

in medicine prices of 24% between June 2003 and June 2006, according to IMS Health, which may hold lessons for policymakers today. A number of countries in Africa have viable pharmaceutical industries, which could be further bolstered by reform, such as the strengthening of regulatory authorities, regional market consolidation and reforming public procurement processes. Trade among sub-Saharan African countries has been gaining in importance and could bring price and technical benefits. In Making Medicines in Africa, the authors are optimistic that a thriving pharmaceutical industry in sub-Saharan Africa could serve as a catalyst for both improving healthcare and fostering economic development, too. Share article at Mackintosh, Maureen, et al. (eds.) (2016), Making Medicines in Africa: The Political Economy of Industrializing for Local Health, Palgrave Macmillan

OECD Observer No 309 Q1 2017



New publications Government at a Glance: Latin America and the Caribbean 2017

All publications are available to read and share at Trafficking in Persons and Corruption: Breaking the Chain

After a decade of sustained economic growth reinforced by high commodity prices, economic conditions are deteriorating in the Latin American and Caribbean region. This report provides the latest available data on public administrations in the region and compares it to OECD countries.

Although many countries have taken considerable steps to combat trafficking in persons, these have not comprehensively focused on the fundamental role that corruption plays in the trafficking process. This publication presents a set of Guiding Principles on Combatting Corruption Related to Trafficking in Persons.

ISBN 978-92-64-26554- 7 January 2017, 200 pages €40 $48 £32 ¥5 200

ISBN 978-92-64-25371-1 January 2017, 104 pages €24 $29 £19 ¥3 100

Revenue Statistics 2016 This annual publication gives a conceptual framework to define which government receipts should be regarded as taxes, presenting a set of detailed, internationally comparable tax data for OECD countries. ISBN 978-92-64-26510-3 December 2016, 380 pages €130 $156 £104 ¥16 900

Private Sector Engagement for Sustainable Development: Lessons from the DAC

OECD Science, Technology and Innovation Outlook 2016 The fully revamped and re-titled OECD Science, Technology and Innovation Outlook is a biennial publication that aims to inform policymakers and analysts on recent and future changes in global science, technology and innovation (STI) patterns and their potential implications on and for national and international STI policies. ISBN 978-92-64-26305-5 January 2017, 192 pages €78 $94 £62 ¥10 100

PISA 2015 Results (Volume I): Excellence and Equity in Education

Members of the OECD Development Assistance Committee (DAC) are increasingly working with the private sector in development co-operation to realise sustainable development outcomes. This report examines the politics, policies and institutions behind private sector engagement, the focus and delivery of private sector engagements, private sector engagement portfolios, effective partnership and thematic issues including risk, leverage and ensuring results.

The OECD Programme for International Student Assessment (PISA) examines not just what students know in science, reading and mathematics, but what they can do with what they know. Volume I summarises student performance in science, reading and mathematics, and defines and measures equity in education.

ISBN 978-92-64-26687-2 January 2017, 104 pages €24 $29 £19 ¥3 100

ISBN 978-92-64-26732-9 January 2017, 492 pages €54 $64 £43 ¥7 000

Youth in the MENA Region: How to Bring Them In Young men and women in the MENA region are facing the highest youth unemployment levels in the world and express lower levels of trust in government than their parents. This report is the first of its kind to apply a “youth lens” to public governance arrangements. It provides recommendations for adjusting legal frameworks, institutions and policies to give young people a greater voice in shaping better policy outcomes. ISBN 978-92-64-26573-8 January 2017, 116 pages €24 $29 £19 ¥3 100

OECD Pensions Outlook 2016 The OECD Pensions Outlook 2016 assesses policy issues regarding strengthening pension systems and, in particular, funded pension plans. It covers defined benefits and defined contribution pension plans; fiscal incentives to save for retirement; policy measures to improve the financial advice for retirement; annuity products and their guarantees; pension design and financial education; and the pension arrangements for public-sector workers, including a comparison with those for private sector workers. ISBN 978-92-64-26519-6 December 2016, 184 pages €40 $48 £32 ¥5 200

State-Owned Enterprises as Global Competitors: A Challenge or an Opportunity? An estimated 22% of the world’s largest firms are now effectively under state control. These firms are likely to remain a prominent feature of the global marketplace in the near future. In this report, the OECD has taken a multidisciplinary approach, looking at the issue from the competition, investment, corporate governance and trade policy perspectives. ISBN 978-92-64-26136-5 January 2017, 176 pages €45 $54 £36 ¥5 800



Focus on healthcare OECD Reviews of Health Systems: Mexico 2016 Ten years after the introduction of publicallyfunded universal health insurance, the Mexican health system finds itself at a critical juncture. This report sets out the OECD’s recommendations on the steps Mexico should take to achieve extensive reform.

All publications available at and Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places

Health workers are the cornerstone of health systems, playing a central role in providing health services to the population and improving health outcomes. This publication reviews key trends and policy priorities on health workforce across OECD countries.

ISBN 978-92-64-23097-2 January 2016, 176 pages €40 $56 £36 ¥5 200

ISBN 978-92-64-23950-0 April 2016, 196 pages €35 $42 £28 ¥4 500

OECD Reviews of Health Care Quality: United Kingdom 2016: Raising Standards Health systems in the UK have, for many years, made the quality of care a highly visible priority, internationally pioneering many tools and policies to assure and improve the quality of care. A key challenge, however, is to understand why, despite being a global leader in quality monitoring and improvement, the UK does not consistently demonstrate strong performance on international benchmarks

Better Ways to Pay for Health Care This report looks at payment reform, one of many policy tools being used to improve health system performance.

ISBN 978-92-64-25820-4 August 2016, 168 pages €30 $36 £24 ¥3 900

Health at a Glance: Asia/ Pacific 2016: Measuring Progress towards Universal Health Coverage

of quality.

ISBN 978-92-64-23941-8 March 2016, 296 pages €35 $42 £28 ¥4 500

Health at a Glance 2015 This new edition of Health at a Glance presents the most recent comparable data on the performance of health systems in OECD countries. Where possible, it also reports data for partner countries.

This fourth edition of Health at a Glance: Asia/Pacific presents a set of key indicators of health status, the determinants of health, health care resources and utilisation, health care expenditure and financing and health care quality across 27 Asia-Pacific countries and economies.

ISBN 978-92-64-26472-4 December 2016, 120 pages €30 $42 £27 ¥3 900

Health at a Glance: Europe 2016: State of Health in the EU Cycle This publication presents key indicators of health and health systems in the 28 EU countries, 5 candidate countries to the EU and 3 EFTA countries.

ISBN 978-92-64-26558-5 December 2016, 200 pages €40 $48 £32 ¥5 200

Tackling Wasteful Spending on Health Countries could potentially spend significantly less on health care with no impact on health system performance, or on health outcomes. This report reviews strategies put in place by countries to limit ineffective spending and waste.

ISBN 978-92-64-26627-8 January 2017, 304 pages €60 $72 £48 ¥7 800

New Health Technologies: Managing Access, Value and Sustainability This report discusses the need for an integrated and cyclical approach to managing health technology in order to mitigate clinical and financial risks, and ensure acceptable value for money.

ISBN 978-92-64-26642-1 January 2017, 228 pages €45 $54 £36 ¥5 800

ISBN 978-92-64-23257-0 December 2015, 220 pages €35 $42 £28 ¥4 500

OECD Observer No 309 Q1 2017



A more violent world? If you have had the impression that there is more violence in the world nowadays, you may not be wrong. According to States of Fragility 2016: Understanding Violence, the world has been becoming more violent for a decade; indeed, according to the Uppsala University Conflict Data Program, 2014 and 2015 marked the second and third worst years in terms of fatalities since the Cold War ended a quarter of a century ago. As 22% of the global population currently live in fragile contexts and their proportion is anticipated to rise to 32% by 2050, the links between fragility and violence are becoming increasingly clear.

Fragility is a combination of the exposure to risks and the inability of the state to manage, absorb and mitigate, or indeed, cope with those risks. Take the case of the Central African Republic (CAR), a country riddled with violence, including armed and sexual attacks, which has led to instability, vulnerability and fear among civilians. The state in the CAR has struggled to exert its control over this violence, particularly outside the capital, where state forces have been present at just over 3% of all violent events in 2015. This situation has been only worsened by competing domestic and regional militia groups. Violence amplifies fragility, and particularly concerns women, girls and young people generally. True, violence is not limited to fragile or conflict states. Nor is conflict the leading cause of violent death; in fact,

OECD Observer Crossword 1







8 9 10

11 14

13 16









23 24


© Myles Mellor/OECD Observer

For crossword solutions do the OECD crossword online. See


9 out of 10 violent deaths are homicides, which affect places as diverse as Latin America and the US. However, homicide rates have decreased globally by approximately 3.5% between 2000 and 2012, but were offset by an increase in conflict-related deaths. If there is reassuring news, it is that fewer countries are registering high violent death rates, even if average violent death rates have been on the rise. States of Fragility 2016 offers the necessary insight to help focus on these intense sources of violence and challenge misleading perceptions so that violence in all its complexity can be properly addressed. Share article at OECD (2016), States of Fragility 2016: Understanding Violence, OECD Publishing, Paris

No 1, 2017 Across 1 Lasting a long time, as diseases 5 National economic stat, for short 7 African capital 8 Exhaust, as resources 9 Antonio Guterres is the head of this international body now 10 There are 12 of this shape on the Euro coins 11 Organ with chambers 14 Parisian friend 16 Addressed, as a problem 18 Internet program, briefly 19 Vital quality in a professional doctor 24 Call from the fields 25 Healthcare should be patient ____

Down 1 Treatment of patients 2 Type of surgery carried out by a machine 3 Free of additives 4 Type of disease still the highest cause of death in most OECD countries 5 Home of the Alhambra 6 Poe’s tool but not John Grisham’s! 11 Shrouded 12 Of current interest 13 “The boot of Europe” 15 Average 17 Collection of useful items 20 Visit 21 Have dinner say 22 Third in a line of kings 23 It includes England, Scotland and Wales


Can more social spending curb emigration? Migration is an ongoing natural phenomenon, with approximately 4.8 million new permanent entries to OECD countries in 2015, representing a 10% increase compared to the previous year. Despite the economic dynamism of certain developing countries, migration is still concentrated in high income destinations, while shocks, uncertainty and vulnerability are often the cause of emigration. Moreover, workers with lower skills are particularly attracted to countries with stronger social safety nets. Could this movement be countered by improving social protection in the home countries? Possibly yes. In fact, an increase in social protection as a share of GDP is linked to reduced rates of planned emigration (see graph, which shows this negative correlation). Costa Rica spends almost 16% of its GDP on social programmes and has only around 4% of planned migration, whereas in the Philippines, where less than

The race for excellence in scientific publishing Seneca, a Roman philosopher, argued that quality mattered more than quantity. It is a dictum that may apply to scientific production, according to recent data for citations. The total amount of scientific publications per year in China, Germany, Japan, the UK and the US doubled from 765,000 in 2003 to almost 1.5 million in 2012, thanks to increased investment in public research. The US leads in quantity terms, with China catching up. But while China published more than four times as many articles in 2012 as they did in 2003, their share among the 10% most cited publications only slightly increased. At the same time, Germany increased its scientific excellence approximately to the same extent as China, despite a significantly smaller volume of scientific output. Meanwhile, the US’s share among the most cited articles fell below that of the United Kingdom, despite a 50% rise in

Public social expenditures reduce the rate of emigration Share of individuals planning to emigrate and public social expenditures 25

Share of people planning to migrate (%)



15 Dominican Republic Cambodia




Burkina Faso



Costa Rica

0 0










Public social protection expenditure as a share of GDP (%)

Source: OECD (2016), Perspectives on Global Development 2017: International Migration in a Shifting World, OECD Publishing

discourage people from emigrating out of necessity.

2% of GDP is spent on social protection, almost 20% of the population plans to leave.

Share article at

Public social spending on programmes such as unemployment insurance, disability pay, medical care and child care all decrease vulnerability and can

OECD (2016), Perspectives on Global Development 2017: International Migration in a Shifting World, OECD Publishing, Paris

Scientific production has increased worldwide but rankings of excellence are slower to change Panel 1. Scientific production Number of scientific publications, selected countries, 2003-12 China

700 000

Panel 2. Scientific excellence Country’s share among 10% most cited, selected countries, 2003-12


All documents

Japan UK % most cited


25 US

600 000






500 000 China

400 000 300 000


200 000


100 000








Source: OECD Science, Technology and Innovation Outlook 2016

the number of scientific publications. The UK and the US are home to the world’s highest ranked universities in terms of scientific excellence, Germany and China are on the rise. A factor that may determine which universities lead in future will be the extent to which these

Japan China

5 0





countries will be able to draw students from diverse countries around the world. Openness, as well as quality, matters. Share article at OECD (2016), OECD Science, Technology and Innovation Outlook 2016, OECD Publishing, Paris

OECD Observer No 308 Q4 2016


DATABANK % change from: previous period



previous year

current period

same period last year


Gross domestic product Industrial production Consumer price index

Q2-2014 0.5 1.8 Q3-2016 -0.5 3.1 Q3-2016 -0.5 Q2-2014 -0.4 -0.1 4.7 Q2-2014 0.5 3.0 Q3-2016 0.7 1.3

Current balance Unemployment rate Interest rate

Q3-2016 -8.6 Q2-2014 -12.8 -14.8 -12.9 Q3-2016 5.7 Q2-2014 5.9 6.2 5.6 Q4-2016 1.8 2.9 Q2-2014 2.7 2.2


Gross domestic product Industrial production Consumer price index

Q3-2016 0.5 Q2-2014 0.2 0.9 1.5 Q2-2014 -0.9 0.2 1.6 Q3-2016 0.6 Q2-2014 1.0 1.8 Q4-2016 0.9 1.4

Current balance Unemployment rate Interest rate

Q2-2016 1.8 Q1-2014 1.5 2.4 3.1 Q3-2016 6.1 Q2-2014 5.0 5.7 4.7 Q4-2016 -0.3 Q2-2014 0.3 -0.1 0.2


Gross domestic product Industrial production Consumer price index

1.3 Q2-2014 0.1 Q3-2016 0.2 1.0 Q2-2014 0.6 Q3-2016 1.8 4.8 3.4 Q2-2014 -0.3 0.4 Q4-2016 0.2 1.9

Current balance Unemployment rate Interest rate

Q2-2016 -0.3 1.1 Q1-2014 -0.2 -5.0 Q3-2016 7.8 8.1 Q2-2014 8.5 8.4 Q4-2016 -0.3 0.2 Q2-2014 0.3 -0.1


Gross domestic product Industrial production Consumer price index

Q3-2016 0.9 Q2-2014 0.8 2.5 1.3 1.1 Q3-2016 3.3 Q2-2014 0.8 4.5 Q2-2014 1.3 2.2 Q4-2016 -0.1 1.4

Current balance Unemployment rate Interest rate

Q3-2016 -14.0 Q2-2014 -10.9 -12.5 -15.0 Q4-2016 6.9 7.1 Q2-2014 7.0 7.0 Q4-2016 0.8 Q2-2014 1.2 0.8 1.2


Gross domestic product Industrial production Consumer price index

Q2-2014 0.2 Q3-2016 0.6 2.1 1.5 Q2-2014 -3.3 Q3-2016 1.3 -0.3 -1.5 Q2-2014 1.6 2.8 Q4-2016 0.3 5.1

Current balance Unemployment rate Interest rate

Q3-2016 -1.6 Q1-2014 -2.0 -1.7 -3.1 Q3-2016 6.5 Q2-2014 6.2 6.2 5.9 Q2-2016 3.5 5.0 Q2-2014 3.9 2.9

Czech Republic

Gross domestic product Industrial production Consumer price index

1.9 Q2-2014 0.3 Q3-2016 0.2 2.5 Q3-2016 -1.7 Q2-2014 0.2 0.9 5.8 Q2-2014 0.1 Q4-2016 0.4 0.2 1.4

Current balance Unemployment rate Interest rate

Q2-2016 1.4 Q2-2014 -1.9 -0.1 -1.0 Q3-2016 4.0 Q2-2014 6.2 4.8 6.9 Q4-2016 0.3 Q2-2014 0.4 0.3 0.5


Gross domestic product Industrial production Consumer price index

Q2-2014 0.2 1.2 Q3-2016 0.4 1.1 Q3-2016 -1.1 Q2-2014 0.6 0.8 1.0 Q4-2016 0.0 Q2-2014 0.4 0.6 0.4

Current balance Unemployment rate Interest rate

Q3-2016 5.7 7.5 Q2-2014 5.3 5.8 6.1 Q3-2016 6.4 Q2-2014 6.4 6.9 Q4-2016 -0.2 Q2-2014 0.3 -0.1 0.3


Gross domestic product Industrial production Consumer price index

Q2-2014 1.1 2.9 Q3-2016 0.2 1.3 Q3-2016 3.4 Q2-2014 3.3 3.0 2.5 Q4-2016 0.0 Q2-2014 0.3 0.0 1.3

Current balance Unemployment rate Interest rate

Q3-2016 0.2 0.0 Q1-2014 -0.1 0.0 Q3-2016 7.3 5.5 Q2-2014 7.5 8.3 Q4-2016 -0.3 0.2 Q2-2014 0.3 -0.1


Gross domestic product Industrial production Consumer price index

Q2-2014 0.2 -0.1 Q3-2016 0.4 1.6 Q3-2016 0.6 Q2-2014 0.5 -1.9 2.7 Q2-2014 0.2 0.9 Q4-2016 0.4 0.7

Current balance Unemployment rate Interest rate

Q3-2016 -1.3 0.6 Q1-2014 -0.4 -0.5 Q3-2016 8.7 Q2-2014 8.6 9.4 8.1 Q4-2016 -0.3 0.2 Q2-2014 0.3 -0.1


Gross domestic product Industrial production Consumer price index

Q2-2014 0.0 1.0 Q3-2016 0.2 0.1 Q3-2016 -0.2 Q2-2014 -0.5 -0.1 -2.1 Q2-2014 0.4 0.6 Q4-2016 0.1 0.5

Current balance Unemployment rate Interest rate

Q2-2016 -4.7 1.1 Q1-2014 -6.7 -13.2 Q3-2016 10.1 Q2-2014 10.2 10.5 10.3 Q4-2016 -0.3 Q2-2014 0.3 -0.1 0.2


Gross domestic product Industrial production Consumer price index

Q2-2014 -0.2 1.3 Q3-2016 0.2 1.7 Q2-2014 -0.9 Q3-2016 0.1 1.0 1.5 Q4-2016 0.6 Q2-2014 0.2 1.1

Current balance Unemployment rate Interest rate

Q3-2016 74.3 Q1-2014 68.6 78.3 65.0 Q3-2016 4.2 Q2-2014 5.0 4.5 5.3 Q4-2016 -0.3 Q2-2014 0.3 -0.1 0.2


Gross domestic product Industrial production Consumer price index

.. .. 1.8 Q3-2016 0.8 Q3-2016 0.0 Q1-2014 2.4 0.5 1.9 Q4-2016 1.0 Q2-2014 1.2 -0.4 -1.5

Current balance Unemployment rate Interest rate

Q2-2016 -0.6 0.2 Q2-2014 0.4 -0.8 Q3-2016 23.2 27.6 Q2-2014 27.1 24.7 Q4-2016 -0.3 0.2 Q2-2014 0.3 -0.1


Gross domestic product Industrial production Consumer price index

Q2-2014 0.8 3.7 Q3-2016 0.3 1.6 Q3-2016 -2.1 Q2-2014 3.5 10.3 -0.1 Q2-2014 0.2 -0.2 Q4-2016 0.7 1.2

Current balance Unemployment rate Interest rate

Q2-2016 1.9 Q4-2013 1.4 0.7 0.3 Q3-2016 4.9 6.6 Q2-2014 8.0 10.4 Q4-2016 0.7 1.3 Q2-2014 2.8 4.6


Gross domestic product Industrial production Consumer price index

Q2-2014 -1.2 2.2 7.6 Q3-2016 4.7 Q2-2014 -5.0 Q2-2016 -1.1 -15.3 -1.7 Q2-2014 0.9 2.3 Q4-2016 0.5 1.9

Current balance Unemployment rate Interest rate

Q3-2016 0.4 Q1-2014 0.0 0.1 Q3-2016 2.9 6.1 Q2-2014 5.1 3.8 Q4-2016 5.9 Q2-2014 6.1 6.5 6.2


Gross domestic product Industrial production Consumer price index

6.5 Q3-2016 4.0 Q2-2014 1.5 6.6 Q3-2016 2.0 Q1-2014 3.8 -0.9 2.8 Q2-2014 0.8 -0.1 Q4-2016 -0.9 0.4

Current balance Unemployment rate Interest rate

Q3-2016 8.2 Q1-2014 3.0 5.7 3.2 Q4-2016 7.3 9.1 Q2-2014 11.7 13.7 Q4-2016 -0.3 Q2-2014 0.3 -0.1 0.2


Gross domestic product Industrial production Consumer price index

Q2-2014 0.4 4.0 Q3-2016 0.9 2.2 Q2-2014 -3.9 Q3-2016 -2.1 -0.6 -0.1 Q2-2014 0.4 -0.3 Q4-2016 -0.2 0.8

Current balance Unemployment rate Interest rate

Q3-2016 2.8 1.7 Q2-2014 2.2 3.6 Q3-2016 4.7 Q2-2014 6.1 5.2 6.7 Q4-2016 0.1 Q2-2014 0.7 0.1 1.5


Gross domestic product Industrial production Consumer price index

Q2-2014 -0.2 -0.2 Q3-2016 0.3 1.0 Q3-2016 1.2 Q2-2014 -0.5 -0.1 1.8 Q4-2016 -0.1 Q2-2014 0.2 0.4 0.1

Current balance Unemployment rate Interest rate

Q2-2016 13.0 5.4 Q1-2014 7.9 -0.1 Q3-2016 11.6 11.6 Q2-2014 12.5 12.2 Q4-2016 -0.3 Q2-2014 0.3 -0.1 0.2


Gross domestic product Industrial production Consumer price index

1.0 Q2-2014 -1.8 0.0 Q3-2016 0.3 Q3-2016 1.2 Q2-2014 -3.6 0.3 2.4 Q2-2014 2.5 Q3-2016 -0.2 -0.5 3.6

Current balance Unemployment rate Interest rate

32.9 Q2-2016 43.4 Q2-2014 6.3 18.7 Q3-2016 3.0 3.4 Q2-2014 3.6 4.0 Q4-2016 0.1 Q2-2014 0.2 0.2


Gross domestic product Industrial production Consumer price index

Q3-2016 0.6 2.6 Q2-2014 0.5 3.5 Q2-2014 -0.9 0.2 Q3-2016 0.6 1.2 Q2-2014 0.3 Q4-2016 0.6 1.6 1.5

Current balance Unemployment rate Interest rate

Q3-2016 20.9 Q2-2014 23.6 27.6 19.4 Q4-2016 3.6 3.1 Q2-2014 3.7 3.5 Q4-2016 1.4 2.7 Q2-2014 2.7 1.6

Luxembourg Latvia

Gross domestic product Industrial production Consumer price index

Q1-2014 0.8 Q3-2016 0.2 0.3 3.8 Q2-2014 -0.1 8.8 Q3-2016 -1.2 2.3 Q2-2014 0.5 0.9 Q4-2016 1.2 1.5

Current balance Unemployment rate Interest rate

Q3-2016 0.1 Q1-2014 0.6 -0.1 0.6 Q3-2016 9.8 10.0 Q2-2014 6.1 5.8 Q4-2016 -0.3 Q2-2014 0.3 -0.1 0.2

Luxembourg Mexico

Gross domestic product Industrial production Consumer price index

Q3-2016 -0.1 Q2-2014 1.0 4.8 2.7 Q2-2014 0.9 -1.8.. Q3-2016 -2.0 Q2-2014 -0.1 Q4-2016 0.5 3.6 0.7

Current balance Unemployment rate Interest rate

Q3-2016 1.8 0.2 Q2-2014 -7.1 -5.7 Q3-2016 6.3 Q2-2014 5.0 6.6 5.1 Q4-2016 -0.3 Q2-2014 3.7 -0.1 4.3


Gross domestic product Industrial production Consumer price index

Q3-2016 1.0 2.0 Q3-2016 0.1 .. Q4-2016 1.8 3.2

Current balance Unemployment rate Interest rate

Q3-2016 -9.3 -10.4 Q3-2016 3.8 4.3 Q4-2016 5.6 3.4


% change from: previous period

current period

previous year

same period last year


Gross domestic product Industrial production Consumer price index

Q2-2014 0.7 Q3-2016 0.8 Q2-2014 3.7 Q3-2016 0.2 Q2-2014 0.8 Q4-2016 -0.1

1.1 2.5 -2.0 2.8 1.0 0.7

Current balance Unemployment rate Interest rate

Q4-2013 24.7 Q2-2016 18.1 25.6 19.1 Q2-2014 7.0 6.6 Q3-2016 5.8 6.8 Q2-2014 0.3 Q4-2016 -0.3 0.2 -0.1

New Zealand

Gross domestic product Industrial production Consumer price index

Q2-2014 0.5 Q3-2016 1.4 Q2-2014 -1.1 Q3-2016 1.0 Q2-2014 0.3 Q3-2016 0.3

3.3 4.5 2.7 1.0 1.6 0.4

Current balance Unemployment rate Interest rate

Q4-2013 -0.7 -1.8 Q2-2016 -1.3 -1.7 Q2-2014 5.6 Q3-2016 4.9 6.4 5.5 Q2-2014 3.4 2.6 Q4-2016 2.1 2.8


Gross domestic product Industrial production Consumer price index

Q2-2014 0.9 1.8 Q3-2016 -0.5 -1.0 0.2 Q2-2014 -1.1 -6.6 Q3-2016 -3.4 Q2-2014 0.7 3.6 1.8 Q4-2016 0.5

Current balance Unemployment rate Interest rate

Q2-2014 12.4 Q3-2016 4.2 14.3 8.8 Q2-2014 3.3 Q3-2016 4.9 3.5 4.5 Q2-2014 1.8 Q4-2016 1.1 1.81.1


Gross domestic product Industrial production Consumer price index

Q2-2014 0.6 3.3 Q3-2016 0.2 2.2 Q2-2014 -0.2 3.4 3.2 Q3-2016 -0.4 Q2-2014 0.0 0.3 Q4-2016 0.7 0.2

Current balance Unemployment rate Interest rate

Q1-2014 -0.8 -3.0 Q2-2016 -0.2 -0.8 Q2-2014 9.2 10.5 Q3-2016 6.2 7.4 Q2-2014 2.7 2.9 Q4-2016 1.7 1.7


Gross domestic product Industrial production Consumer price index

Q2-2014 0.3 0.9 Q3-2016 0.8 1.6 1.5 Q2-2014 1.6 0.5 Q3-2016 -1.0 Q2-2014 1.0 -0.3 0.8 Q4-2016 0.4

Current balance Unemployment rate Interest rate

Q2-2014 -0.1 -0.3 Q2-2016 -0.5 1.0 Q2-2014 14.4 Q3-2016 10.9 16.9 12.3 Q2-2014 0.3 0.2 -0.1 Q4-2016 -0.3

Slovak Republic

Gross domestic product Industrial production Consumer price index

Q2-2014 0.6 2.4 Q3-2016 0.7 3.2 Q2-2014 -0.8 4.9 Q3-2016 -1.5 1.9 Q2-2014 0.2 -0.1 Q4-2016 0.3

Current balance Unemployment rate Interest rate

Q1-2014 0.5 0.5 Q2-2016 0.3 -0.2 Q2-2014 13.4 14.3 Q3-2016 9.6 11.3 Q2-2014 0.3 0.2 Q4-2016 -0.3 -0.1


Gross domestic product Industrial production Consumer price index

Q2014 1.0 2.8 Q3-2016 1.0 3.0 Q2-2014 1.8 3.8 Q3-2016 1.8 6.8 Q2-2014 1.5 0.6 Q4-2016 0.4

Current balance Unemployment rate Interest rate

Q2-2014 0.7 0.7 Q2-2016 0.8 0.6 Q2-2014 9.5 10.5 Q3-2016 7.8 9.0 Q2-2014 0.3 0.2 Q4-2016 -0.3 -0.1


Gross domestic product Industrial production Consumer price index

Q2-2014 0.6 3.2 1.2 Q3-2016 0.7 Q2-2014 0.6 2.3 Q3-2016 0.8 1.9 Q2-2014 1.0 0.2 Q4-2016 1.6 1.0

Current balance Unemployment rate Interest rate

Q2-2014 -5.6 1.3 Q2-2016 7.9 3.3 Q2-2014 24.7 Q3-2016 19.4 26.2 21.6 Q2-2014 0.3 Q4-2016 -0.3 0.2 -0.1


Gross domestic product Industrial production Consumer price index

Q2-2014 0.7 2.8 2.6 Q3-2016 0.5 Q2-2014 -1.4 Q3-2016 -0.4 -0.6 -0.7 Q2-2014 0.6 0.0 Q4-2016 0.6 1.4

Current balance Unemployment rate Interest rate

Q2-2014 7.5 9.2 Q2-2016 6.0 6.3 Q2-2014 8.0 8.0 Q3-2016 7.0 7.2 Q2-2014 0.6 0.9 Q4-2016 -0.8 -0.4


Gross domestic product Industrial production Consumer price index

Q2-2014 0.0 1.4 1.1 Q3-2016 0.0 Q4-2013 -1.0 -1.2 Q3-2016 0.0 0.5 Q2-2014 0.5 -0.2 0.1 Q4-2016 -0.1

Current balance Unemployment rate Interest rate

Q4-2013 14.3 15.1 Q2-2016 18.2 20.8 Q2-2014 4.4 Q3-2016 4.8 4.2 4.9 Q2-2014 0.0 Q4-2016 -0.7 0.0 -0.8


Gross domestic product Industrial production Consumer price index

Q2-2014 -0.5 -1.5 2.5 Q3-2016 -3.4 Q2-2014 -0.9 2.6 Q3-2016 -6.0 -2.8 Q2-2014 2.6 Q4-2016 2.4 9.4 7.6

Current balance Unemployment rate Interest rate

Q2-2014 -9.3 -17.5 Q2-2016 -8.2 -8.7 Q1-2014 9.1 8.5 Q3-2016 11.3 10.2 .. .. .. ..

United Kingdom

Gross domestic product Industrial production Consumer price index

Q2-2014 0.9 Q3-2016 0.6 Q2-2014 0.3 Q3-2016 -0.4 Q2-2014 0.7 Q4-2016 0.6

3.2 2.2 2.1 1.1 1.7 1.2

Current balance Unemployment rate Interest rate

Q1-2014 -30.6 -27.3 Q3-2016 -33.5 -24.9 Q2-2014 6.3 7.7 Q3-2016 4.8 5.3 Q2-2014 0.5 0.5 Q4-2016 0.4 0.6

United States

Gross domestic product Industrial production Consumer price index

Q2-2014 1.1 Q3-2016 0.9 2.6 1.7 Q2-2014 1.3 -0.3 4.2 Q4-2016 -0.2 Q2-2014 1.2 1.8 2.1 Q4-2016 0.2

Current balance Unemployment rate Interest rate

Q2-2014 -98.5 -106.1 Q3-2016 -113.0 -123.1 Q2-2014 6.2 7.5 Q4-2016 4.7 5.0 Q4-2013 0.0 0.2 Q4-2016 0.8 0.4

European Union

Gross domestic product Industrial production Consumer price index

Q2-2014 0.2 1.9 1.2 Q3-2016 0.5 Q2-2014 0.0 1.3 Q3-2016 0.2 1.2 Q2-2014 .. 0.7 Q4-2016 .. 0.8

Current balance Unemployment rate Interest rate

.. .. Q2-2016 58.2 51.8 Q2-2014 10.3 10.9 Q3-2016 8.5 9.3 .. .. .. ..

Euro area

Gross domestic product Industrial production Consumer price index

Q2-2014 0.0 0.7 Q3-2016 0.4 1.8 Q2-2014 -0.1 0.8 Q3-2016 0.5 1.2 Q2-2014 .. 0.6 Q4-2016 .. 0.7

Current balance Unemployment rate Interest rate

Q4-2012 51.7 17.2 Q2-2016 111.8 94.4 Q2-2014 11.6 12.0 Q3-2016 10.0 10.7 Q2-2014 0.3 0.2 Q4-2016 -0.3 -0.1

1 Brazil

Gross domestic product Industrial production Consumer price index

Q3-2016 -0.8 -0.8 Q2-2014 -0.6 -2.9 Q2-2014 -1.9 -4.2 Q3-2016 -1.2 -5.4 Q2-2014 2.0 6.4 Q4-2016 0.7 7.0

Current balance Unemployment rate Interest rate

Q2-2014 -19.6 -19.9 2016-Q3 -5.3 -11.4 .. .. .. .. .. .. .. ..

1 China

Gross domestic product Industrial production Consumer price index

.. .. .. .. Q2-2014 -0.4 2.2 Q4-2016 0.1

Interest rate

2016-Q2 61.5 Q2-2013 54.2 58.1 85.0 .. .. .. .. Q2-2014 4.6 .. .. 4.7

1 India

Gross domestic product Industrial production Consumer price index

Q3-2016 1.8 5.9 Q2-2014 1.2 7.2 Q2-2014 2.0 Q3-2016 -1.2 -0.9 4.3 Q2-2014 2.5 6.9 Q3-2016 1.5 5.3

Current balance Unemployment rate Interest rate

2016-Q2 -1.2 .. .. -7.4 .. .. .. .. .. .. .. ..


Gross domestic product Industrial production Consumer price index

Q2-2014 1.2 Q3-2016 1.2 5.1 .. .. Q2-2014 0.4 3.3 Q4-2016 0.7 7.1

Interest rate

Russian Federation

Gross domestic product Industrial production Consumer price index

Q1-2014 -0.3 .. .. 0.7 Q2-2014 0.9 0.1 Q3-2016 -0.4 1.6 Q2-2014 2.6 Q3-2016 1.0 6.8 7.6

2016-Q3 -3.5 Q4-2013 -3.5 -7.3 -3.0 .. .. 2016-Q3 6.9 .. .. 8.0 Q2-2014 8.5 5.7 2016-Q2 3.2 18.4

1 South Africa

Gross domestic product Industrial production Consumer price index

Q3-2016 0.1 Q2-2014 0.2 0.7 1.1 .. .. Q2-2014 2.0 6.9 Q4-2016 0.9 6.6


balance Current Unemployment rate

balance Current Unemployment rate Current balance Unemployment rate Interest rate

balance Current Unemployment rate Interest rate

Gross domestic product: Volume series; seasonally adjusted. Leading indicators: A composite indicator based on other indicators of economic activity, which signals cyclical movements in industrial production from six to nine months in advance. Consumer price index: Measures changes in average retail prices of a fixed basket of goods and services. Current balance: Billion US$; seasonally adjusted. Unemployment rate: % of civilian labour force, standardised unemployment rate; national definitions for Iceland, Mexico and Turkey; seasonally adjusted apart from Turkey. Interest rate: Three months.

Current balance data are reported according to the BPM6 classification except Mexico and non-members.

Q2-2012 22.7 .. .. 23.4 2016-Q3 11.0 .. .. 13.3 Q2-2014 8.8 7.4 2016-Q2 -2.3 -2.6

.. .. .. .. 2016-Q4 7.5 .. .. 6.4 ..=not available, 1 Key Partners. Source: Main Economic Indicators, January 2017.

OECD Observer No 309 Q1 2017



Addressing high costs of specialty drugs Cancer represents an increasing budgetary pressure on healthcare systems. In OECD countries, total pharmaceutical spending accounts for one-fifth of healthcare spending on average, but while overall spending for medicines did not increase (and even decreased) since 2008-09, the share of high cost “specialty medicines”, to treat cancer patients, for instance, has increased sharply, as it represented 37.7% of total prescription drug spending in the US in 2015. The trouble is, while oncology drug costs are expected to grow strongly, it is not necessarily accompanied by a commensurate increase in cure rates or other health benefits for patients. Spending on cancer treatment is predicted to reach US$150 billion worldwide by 2020; already, 12 out of 13 cancer drugs approved by the US Food and Drug Administration (FDA) in 2012 cost more than $100,000 per year. These trends partly reflect an increase in efforts to treat and cure cancer in OECD countries, but they also result from commercial strategies of pharmaceutical companies. Furthermore, the duration

Cancer drug costs

Median monthly costs of cancer drugs at FDA approval in the US, 1965-2015 70 000

Individual drugs

Monthly price of payment (2014 USD)

Median monthly price (per 5 year period)

60 000 50 000 40 000 30 000 20 000 10 000 0 1965






Source: OECD (2017), New Health Technologies: Managing Access, Value and Sustainability, OECD Publishing

of treatment with new cancer drugs has increased, partly due to their ability to prolong life, which also increases the average cost of treatment. This adds to pressures on public budgets and is a source of (sometimes heated) discussion among policymakers and pharmaceutical firms. Some experts argue that drug companies should be paid generously for discovering and rolling out new




€ 94 US$ 124

treatments, for instance, but allow their prices to fall after that: in other words, pay for the innovation, not for the supply. Share article at OECD (2017), New Health Technologies: Managing Access, Value and Sustainability, OECD Publishing, Paris

£ 75 ¥ 12 400

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