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From Challenges to New Opportunities

23 April 2015 marks the launch of DNV GL and Sustainia’s forthcoming publication, The State of Healthcare: From Challenges to Opportunities. This publication is the culmination of a year long journey that took us around the globe in order to uncover the challenges currently facing the world’s healthcare systems, as well as the inspiring solutions and opportunities that exist to create change.

With the launch of this publication, we also mark the end of our journey to co-create safer, smarter and more sustainable healthcare systems. This journey began in April of 2014, with the launch of Person-Centred Care: Co-Creating a Healthcare Sector for the Future. We then set off to 10 healthcare conferences in 10 different regions across four continents to share our findings from Person-Centred Care and gather expert knowledge and insights for The State of Healthcare. We brought together patients, professionals, policy makers and researchers at three roundtables in Shanghai, Brussels, and Washington DC, which helped shape the publication’s focus on those three particular healthcare systems.

Not only a physical journey, throughout this past year we also cultivated an active and engaged online network of 190 global healthcare experts from over 45 countries. These experts have contributed with blog posts, social media engagement, insights at our roundtables and much more. While the formal digital network will come to a close on 23 April, we invite all network members to keep sharing their ideas and experiences. Our yearly Sustainia100 publication includes solutions for health and the healthcare sector, so we are always on the lookout for exciting, innovative ideas. Please feel free to reach out to us if you know of any!

Finally, we want to thank everyone who took part in this journey toward the co-creation of healthcare. Your insights, interviews, roundtable attendance, online engagement and overall support were a vital part of this project and this publication. The online version of The State of Healthcare will also be available on the 23rd of April and we hope you will all check it out and see the final product of this year-long journey.

#cocreatinghealthcare #health #Healthcare

The Illusion of Certainty

TRAVEL-LOG FROM WASHINGTON D.C., USA

With the roundtable in Washington D.C., wereached our final destination on our Co-Creating Healthcare journey. The guiding question for this roundtable was the same as for those in China and Europe: How do we improve the quality of care? To take a stab at answering this question the roundtable brought together different stakeholders from the American healthcare system.

The keynote speaker, Ms. Susan Sheridan, pictured above giving her inspiring talk, became a passionate patient engagement advocate after her family suffered from no less than two major healthcare system failures. She was forced to ask herself the question: “Who is in charge of our safety?” Her illusion of certainty with the healthcare system was broken when she found that this question had no clear answer.

On her personal quest for answering this question, she has become one of the most influential people in healthcare in the U.S. and she is now Director of Patient Engagement at the Patient-Centered Outcomes Research Institute – fighting for the creation of a safer healthcare system.

At the roundtable, she made the case that we need a “patient-centered policy making movement” and introduced the group to the different steps necessary before reaching patient centered care.

After Susan’s inspiring and moving talk, the activities began.

From challenges…

In smaller groups, the participants were asked to brainstorm about the biggest challenges that healthcare is facing in the U.S. and the result was a multifaceted range of challenges, from an overload of information and not enough translation into useful communication, to the lack of a cost-efficient payment model.

A reoccurring theme in the discussion of challenges for improving the quality of care in the U.S. was the involvement of patients – or lack thereof. The discussion revolved around which patients should be engaged, how much involvement they should have and whether or not information in the healthcare sector is too complex for patients to use in a meaningful way.

To this ePatient Dave deBronkart, seen here addressing the roundtable, noted that “Healthcare is the only industry where usability is considered the victim’s problem.”

...to opportunities

While identifying challenges was the “easy” part, the participants were also asked to identify opportunities for moving forward.

Some of the ideas were very straight forward and could be easily implemented, such as including nurses in patient rounds. Another suggestion, which would require more coordination, was to create more open health records that allow patients to participate in their care and have full access to their own information.

But when we voted on the opportunity with the biggest potential to create change, the idea which got the most votes was the replacement of the fee for service model with a new structure that provides the right incentives.

Other opportunities mentioned were:

A patient safety liaison outside the care team – a person who can interact with patients and address concerns

More open health records

Strong, courageous leadership and common goals to change the healthcare culture

Empower private care givers, such as mothers

Break the “10 minute rule” so physicians can have more meaningful conversations with patients

Include patient centeredness in the training of healthcare professionals

One of the key-takeaways from this roundtable was that we should break the illusion of certainty within healthcare communication and create pathways for inviting patients into the conversation. Professionals should learn to let go of control and patients should be guided towards taking that control into their own hands.

Such a transformation may sound straight-forward, but it involves quite a lot of minor and major changes before the system is geared towards placing the patient in the center of care. Nonetheless, there was broad agreement that this was the future within healthcare.

All though the U.S. roundtable was the last physical stop, the co-creating healthcare journey continues. We will be incorporating everything we’ve learned along the way into our forthcoming publication, State of Healthcare, set to be released in April.

#travel log #roundtable #cocreatinghealthcare cocreatinghealth #patient involvement #innovation

Healthcare Solutions in the U.S.: Community Health Workers

Our third and final roundtable on the future of healthcare is taking place today, February 9th in Washington DC! To prepare for the event, we have been posting some interesting articles about solutions to healthcare challenges in the United States - including how to combat burnout in the healthcare field. Today we decided to focus on community health workers and the ways in which they can improve health care delivery and lessen the burden on other care providers.

Be sure to follow the #CoCreatingHealthcare hashtag on Twitter today to follow along with the roundtable's activities. And of course, check back here in the coming days for a full recap of the roundtable's highlights and solutions.

How Community Health Workers Can Reinvent Health Care Delivery In The US

BY JUDY PHALEN AND REBECCA PARADIS

As health policy, research and practice are becoming increasingly focused on improving the health of populations and addressing social determinants of health, Community Health Workers (CHWs) may be just what the doctor ordered. As part of the public health workforce with ties to the local community, CHWs can now be reimbursed by Medicaid for providing preventive services if recommended by a physician or other licensed practitioner.

This groundbreaking CMS regulatory change, along with policy support from the Affordable Care Act, holds the promise of bridging the gap between mainstream health care and community health through expanding the CHW profession and its impact on clinical care. Much like other disruptive changes in health care, however, fulfilling this potential will require a new way of thinking among state policymakers and the health care system at large.

Who are Community Health Workers?

While CHWs hold many different titles and roles, the American Public Health Association’s classification best defines them as “a frontline public health worker who is a trusted member and/or has a close understanding of the community served.”

They also can be defined by what they are not: CHWs are not physician extenders, nor are they unskilled labor. Community Health Workers have a long and proud history of accomplished service in the U.S. and abroad in reaching traditionally underserved populations within communities that typically have both complex medical and social needs.

CHWs work daily to combat the ethnic and racial disparities in health care documented more than a decade ago by the Institute of Medicine. In addition, CHWs are on the front lines of alleviating the negative effects of social determinants of health implicated as primary factors in overall health by the Robert Wood Johnson Foundation.

Overcoming Obstacles to CHW Integration

The Network for Excellence in Health Innovation (NEHI) convened a day-long meeting, with support from the Jewish Healthcare Foundation, the Rose Community Foundation and the Association of American Medical Colleges, to explore CHWs’ capacity to transform health care delivery in the U.S.

Experts discussed opportunities and challenges as states and health systems pursue training and certification policies that optimize CHWs’ potential. This event highlighted the need for further dialogue on the issue as well as policies that support the inclusion of CHWs in the collaborative health environment.

Other takeaways from the meeting included:

A Thoughtful Approach to Workflow Redesign

As research mounts to support the return on investment of CHWs and their potential role in reducing costs and improving health outcomes, innovative health systems like Hennepin County Medical Center,Camden Coalition of Healthcare Providers, University of Pennsylvania Health System, and Molina Healthcare are integrating CHWs as full and, often, lead members of their care teams. This required redesigning care processes and infrastructure to fit new needs.

Community health workers have not traditionally been included as providers in most delivery systems, so physician response to CHW integration varies depending on their level of familiarity with the workforce and the value they see CHWs bringing to patient care. Additionally, social workers, nurses, case managers and other medical professionals could perceive some overlap with CHW duties and their own, which may lead to anxiety over job security.

Health systems have addressed these hurdles by focusing early efforts on relationship-building, organizing regularly scheduled meetings and “huddles” between participants, educating managers to know when and how to delegate work to CHWs, and working with nurse and social services management to define the role of CHWs within their particular system’s culture, including leadership positions.

From the CHW perspective, additional issues have emerged. Population health needs traditionally have not been within the purview of the delivery system, nor are electronic health records structured to document social determinants of health and interventions to overcome them. These leading health systems have spent significant investments in health information technology and analytic support to better capture data collected by CHWs, as well as identifying high-risk patients who need to be connected to a CHW, and tracking patients’ progress and care plans.

The more deeply integrated CHWs become within care teams, the more doctors and other providers are interested in recognizing the important role that CHWs play in supporting the health of individuals and communities.

CHW Voice in Certification and Training Processes

As states and health systems struggle to develop and adopt training and certification standards for the CHW workforce, CHWs must be fully involved so that their perspectives and experience inform the process. Qualities of a successful CHW are hard to teach, such as an empathetic nature and ability to understand human behavior and the communities served.

Seeking out CHWs with these characteristics is just as important as the curriculum they receive. Certification and training programs should be built to reinforce CHWs’ diverse strengths in providing informal counseling, sharing appropriate health information, and building community capacity to address underlying causes of health inequities rather than focusing on health professionalization norms.

Alan Weil, Editor-in-Chief of Health Affairs and a speaker at the event, eloquently describes in his blog post this tension between professionalizing the community health work force and protecting its values.

“We should honor the wisdom and experience of CHWs as they define their future rather than assuming that they will be absorbed into a health care system that is only beginning to learn how to support people in their communities,” Weil writes. No matter which path policymakers take, for it to be successful, CHWs will need to lead the process.

Community Health Workers Benefit All

Tapping the CHW workforce has the potential to bring improvements across multiple sectors invested in collaborative community health:

traditionally underserved individuals will receive increased access to services, including those that can improve factors related to social determinants of health;

whole communities will have better resources to improve health cohesively and comprehensively;

health care delivery systems can benefit from the skills, community knowledge and cultural competency that CHWs possess in order to connect with those at risk for poor health outcomes;

public and private payers may see reductions in total health care spending; and

community health workers will receive increased compensation and more professional training

Achieving true collaborative community health will require bringing all stakeholders to the table. It’s time to set a place for CHWs.

This article originally appeared in Health Affairs Blog and has been republished here with permission.

#cocreatinghealthcare cocreatinghealth #patient involvement #health #health equity

Overcoming Burnout in the U.S. Healthcare Sector

In the lead up to our third and final roundtable on the state of healthcare - taking place on February 9th in Washington DC - we want to provide some insight on healthcare issues in the United States. As with other regions of the world, burnout and pessimism among healthcare professionals is a tough challenge to overcome in the U.S. system. While some problems will require long term structural changes, the article below reminds us that immediate action can be taken to address many of the causes of workforce dissatisfaction. Focusing on solutions, rather than just problems, can help practitioners at every level become happier and more productive care providers.

Keep in mind, our journey to co-create more sustainable healthcare systems doesn't end next month. Rather, we'll be incorporating everything we've learned along the way into our forthcoming publication, State of Healthcare, set to be released in April. Stay tuned for more blog posts on the U.S. healthcare system as we approach our February 9th roundtable!

Can pessimism among healthcare professionals be overcome?

BY TAMARA ROSIN

Is the American dream dead? Many Americans believe so. According to a New York Times poll, only 64 percent of respondents said they still believed in the American dream, the lowest rate in nearly two decades.

Pessimism is widespread and is even more potent now than it was during the depths of the financial crisis — in 2009, 72 percent of Americans still believed hard work would lead to big payoffs, according to the NYT.

The timing of the poll's results is interesting because economists say the economy is at its highest point since the recession. Furthermore, the nation added 321,000 jobs last month and average hourly earnings have increased much more than expected. That, combined with lower oil prices, puts more money in the wallets of average Americans, according to the NYT.

So, why the sad face? Is the Gatsbian notion of the American dream — the promise that through hard work, anyone can transcend the boundaries of inequality and get rich — merely a romantic vestige of the past, a fallacy? Is the American dream hopeless? Is the green light simply out of reach?

Perhaps. Or, maybe Americans have shifted their idea of who's to blame for their inability to attain the dream. According to the NYT's poll, the majority of respondents, 54 percent, said they were more concerned that over-regulation in Washington would limit economic growth than they were about inequality.

Sounds familiar. One of the biggest complaints in healthcare is the burdensome, often excessive regulatory demands of the Patient Protection and Affordable Care Act, including the regulations of meaningful use and the two-midnight rule, as well as preparing for the implementation of ICD-10, among others.

The law is further exacerbated by Congress' inability to cooperate across the partisan divide, most recently demonstrated by the lawsuit House Republicans, led by House Speaker John Boehner (R-Ohio), filed against the Obama administration over unilateral actions he took on the healthcare law regarding the employer mandate and subsidy payments to insurance companies.

The belief that politics and regulations play too heavy a hand in healthcare — and more importantly, the seeming inability to effectively adhere to the many demands of these regulations — has led to increased frustration across the industry. According to the biennial "Survey of American Physicians" by Physicians Foundation and Merritt Hawkins, 46 percent of physicians would give the PPACA a failing grade, while only 25 percent would give it an A or a B. One half of respondents believe implementing ICD-10 will cause "severe administrative problems" in their practices, and three-fourths believe it will "unnecessarily complicate coding."

Industry-wide dissatisfaction is endemic. Nearly a quarter of physicians (23 percent) said they would not choose to become a physician again if they could turn back time in a survey by The Medicus Firm, and 21 percent of respondents said they would not choose a career in healthcare at all.

Also, 61 percent of physicians who experienced a pay cut last year would not encourage a young person to pursue a career in the medical field, according to a survey by Jackson Healthcare. Notably, only 35 percent of physicians whose income increased in the past year reported they would be very likely to recommend such a career path.

Such negative outlooks are troubling, to say the least, and cast doubt on the industry's ability to achieve its goals of providing high-quality healthcare services at low costs to as many people as possible with this level of demoralization.

But it's not all bad, Old Sport!

Yes, the stakes of a dissatisfied, disengaged workforce in healthcare are higher than some other fields because essentially everyone depends on medical professionals for care. But keep in mind, dissatisfaction occurs in all industries. And, more importantly, it is not irreversible.

Surveys such as the ones cited above shed light on the degree of dissatisfaction experienced by the healthcare workforce and help healthcare leaders understand what factors they should aim to remedy. There are ways to combat dissatisfaction and turn it around. It may not be fast or easy, but it's possible.

While changing the way politics and regulations challenge the everyday operations of the healthcare workforce may be an unrealistic undertaking, there are other ways to combat discontent.

A prime example is the recognition that certain foundational principles in healthcare are in a need of a makeover. Healthcare's triple aim — enhancing patient experience, improving population health and reducing costs — is the commonly accepted set of top priorities in healthcare systems across the nation. Although they're all important goals, the triple aim fails to address a critical component of the healthcare model: the providers. By including a "fourth leg" to the triple aim, one focused on improving the work life of healthcare workers, overall system performance will improve and rates of satisfaction will rise.

Addressing the day-to-day concerns and setbacks contributing to burnout is a solid first step. Most physicians cited the amount of time spent performing "secretarial" or administrative tasks encroaching on time with patients, the lack of autonomy over their schedules, isolation and unrealistic timeframes for implementing change as the major factors contributing to dissatisfaction. Implementing strategies to help alleviate these everyday concerns can go a long way.

Sometimes, in the face of seemingly unsurpassable challenges and discontent, pessimism is easier than change, but it's a choice. The road to achieving the goals of the U.S. healthcare system may seem riddled with hurdles, but it's not impassable.

Here is what some CEOs had to say about their outlooks on the future of healthcare at Becker's Hospital Review's CEO Roundtable this past November.

Julie Manas. President and CEO of Sacred Heart Hospital (Eau Claire, Wis.). I am optimistic because I see all of you here willing to learn and share best practices. If I’m not optimistic as a leader, I can’t expect those taking care of patients will be optimistic. We have to mold ourselves to the changing environment rather than being rigid.

Ora Pescovitz, MD. Former CEO of University of Michigan Health System (Ann Arbor). I’m extremely optimistic, too. Darwin said those that best manage change survive. There are dramatic changes, new discoveries and advancements all across the industry. I think the future is very bright.

Jim Rohan. Vice President and Managing Director of SullivanCotter and Associates (Chicago). This is a great opportunity to reinvent yourself. You’re not the first CEO to go through this stuff. There are a lot of lessons to be learned from auto, banking and other industries.

Alan Channing. Former CEO of Sinai Health System (Chicago). I’m bullish on healthcare reform and bullish on today’s environment. This is a tremendously exciting time, and I think each of us has said we’re excited because we’re leaders.

Chuck Lauer. Former Publisher of Modern Healthcare (Chicago). I’ve been in healthcare for about 50 years. Look at the quality of the people on this panel. They’re all adapting to change. This is a great industry and will continue to be, and the quality of people in this industry is better than any other industry. I think the future of healthcare is great, and this is an exciting time to be here, and I applaud the professionals in this industry.

This post originally appeared on Becker's Hospital Review and has been republished here with permission.

#Healthcare #cocreatinghealthcare #roundtable #solution #health

Expert Insights: An Interview with Professor Francesco De Lorenzo, President of the European Cancer Patient Coalition

Our recent roundtable on the state of healthcare in Europe, which took place in Brussels on 18 November 2014, yielded some fascinating insight into how practitioners, researchers, patient organizations and many others view the various healthcare systems in Europe. They offered their expert opinions on the challenges and, most importantly, the solutions that exist to create safer, more sustainable systems in the future.

One expert participant in the day's activities, pictured above, was Prof. Francesco De Lorenzo, President of the European Cancer Patient Coalition and a cancer survivor. We talked further with Prof. De Lorenzo after the roundtable to discuss his views on patient engagement and the future of healthcare in the EU. His thoughts and insights will also be featured in our forthcoming "State of Healthcare" publication, set to be released in April. For a sneak peak, check out our full interview with him below.

How do you see the role of patient organizations in the EU now and in the future?

Nowadays, patients are crucial partners not only in the implementation and evaluation of healthcare policies, but also in their design. Within a Europe Union with 28 Member States and growing harmonised institutions, patients need strong, specialised and professional advocates to push on the crucial common problems faced by all patients and raise awareness on the unbearable national and local situations existing. That is why organisation like ECPC provide European stakeholders with an invaluable “access point” to true patients needs. Through ECPC, European cancer patients can make their voice heard in key discussion tables at the European level, where many decision on health take place.

What is the biggest challenge facing patients in the EU today? Do you think the region is equipped to handle this challenge in the future – how so?

The European Union is a beacon of rights and freedoms for the whole continent. However, there are still unbearable inequalities in the way EU’s 500.000 million citizens access healthcare, particularly cancer treatment. Inequalities in access to healthcare have different and varied faces: drugs are not evenly priced in all Member States, and in several countries essential drugs are not available at all. Patients’ freedom to seek healthcare outside their country is declared by EU law, but cross-border healthcare remains complex, bureaucratic to obtain and in several cases too expensive for the patient. Innovative, lifesaving treatments like immuno-oncology therapies are not quickly and safely made available to patients. In brief, there is a plethora of causes leading to unequal treatment of patients in Europe. Considering the overall high standards and effectiveness in curing cancer in Europe, it is unacceptable not to grant access to the best care available to all European citizens. The Cross Border Healthcare Directive can provide a partial solution to the problems, but I believe patients shall be formally involved in the very process of implementing the Directive, hence ensuring a more concrete application of the European norm.

Can we make any general conclusions about healthcare in the EU, or is the region too varied to be discussed as one entity?

Europe’s healthcare future is approaching a crossroad, pushed by two opposing trends. On one hand, patients and physicians recognise the need for more cooperation and harmonisation in the field of health in order to make our healthcare systems more efficient and equitable. On the other hand, Member States resist this harmonisation on the basis of national prerogatives and budget constraints. Hence the problems of European healthcare are both regional and global and we need to find a compromise solution that would increase accessibility and sustainability. We do not have to start this process anew: initiatives like the European Reference Networks can lay down models for further harmonisation of our healthcare systems.

What are some tangible ways that patients can become more actively involved in their healthcare?

I strongly believe in the power of patient’s advocacy. ECPC’s advocacy efforts are based on real needs and true experience: from this standpoint it is very difficult for policymakers not to take our voice into consideration. The European Parliament demonstrated to be a formidable partner in advocating patients’ rights. The European Cancer Patient’s Bill of Rights, ECPC Call to Action and several other advocacy efforts are finally bringing practical fruits. The European Commission has demonstrated a high level of sensitivity towards patients’ perspective, establishing the Expert Group on Cancer Control and including patients’ representatives in the CanCon Joint Action. My suggestion to patients associations would be to get in touch with their local Member of the European Parliament. That is what ECPC will help our Members to do during our next Annual General Meeting in Brussels, the largest cancer patients’ gathering in Europe in 2015.

Furthermore, patients can have a crucial role in the design of better clinical research programmes, particularly on quality of life.

However, such an important role requires solid and competent patients’ organisations. It is my strong belief that large umbrella patients’ organisations like ECPC can provide both the professionalism necessary to interact with European-level stakeholders and strong links with real life patients experience.

What role does preventative care play in an effective healthcare system?

The European Union has been very vocal on the role of prevention, particularly through the promotion of healthy lifestyles. This is laudable and ECPC strongly encourages equilibrate nutrition, physical activity and screenings. However, prevention has many faces. In many cases, early diagnosis represents the most reliable weapon a cancer patient has to successfully beat his/her disease. For a cancer patient, either in remission or facing the treatment, prevention means avoiding the recurrence of cancer or preventing other chronic diseases. Effective screening is also the only reliable instrument we have to effectively reduce the incidence of cancer and therefore helping our health systems saving billions of euros. There is still much to do to bring effective early diagnosis and tertiary prevention and to all European patients.

What aspect of of healthcare in the EU holds the greatest opportunity for improvement in the future?

Many of the problems European cancer patients face are related to the sharp decrease of resources allocated to healthcare. A sustainable solution would be to better integrate the promising eHealth and mHealth technologies into European citizens’ lives. ECPC believes that the development of eHealth and mHealth infrastructures and applications can effectively increase patients’ quality of life and treatment effectiveness, lowering the costs of traditional care. We are actively working to demonstrate this through eSMART, an EU funded project investigating the use of mobiles to monitor cancer treatment.

At the institutional level, as I mentioned also before, the thorough implementation of the Cross Border Healthcare Directive can create a true European space for healthcare services and ensure European patients’ freedom of mobility to seek state-of-the-art healthcare abroad.

#cocreatinghealthcare #Healthcare #expert #patient involvement #patient

The First Thing That Dies in a Hospital

BY ERIK RASMUSSEN, CEO OF MONDAY MORNING, FOUNDER OF SUSTAINIA, PATIENT

Life is full of tests, where we as human beings must overcome a challenge. We all know the feeling before an important exam, a job interview or an important sports event, where we have to gather all our strength and resources to perform at our best. Where every detail counts.

Ironically, when I faced the biggest challenge of my life, namely being diagnosed with cancer in the mortal stage, I was met by a healthcare that could only see the disease that needed a cure, not the person that had a lot of strengths also.

Realizing that in the age of iPhones, big data, and apps that help us monitor our sleeping and eating patterns, the world of healthcare has not embraced the thought of involving the user provoked me to initiate a search for the inspiring healthcare cases that view the patient as an equal partner in the health process. The project has demonstrated the benefits of involving patients in handling their biggest challenges. It has also shown that person-centered care takes many forms.

In Tanzania, for example, it comes in the form of offering tuberculosis patients the opportunity to treat themselves at home with better treatment rates and less strain on both healthcare professionals and patients to follow. The model is designed to deal with the chronic shortage of health workers and improve the access to TB treatment for patients who otherwise had to walk long distances or find the money to pay for public transport causing many to drop out of treatment. The patients are given the choice between receiving daily treatment at a health facility, supervised by a medical professional, or at home supported by a trained family or community member.

The model has since been adopted as national policy and applied across the country and a recent survey of patient experience revealed that 88 per cent of TB-patients chose home-based treatment, indicating a huge demand for the new treatment option.

But the Tanzania case is just one out of many person-centered care examples out there - the challenge is to advance the scattered experiments to normal healthcare practice. The fact that we are not there yet, is not the fault of the individual doctor or nurse but the result of a system that is built around treating diseases rather that treating persons. This is mirrored in the way the professionals are rewarded, how the healthcare staff is organized, in the way they communicate with the patients and the lack of research in patient centered care.

We need a complete reconfiguration of the healthcare system with the patient in the center of care. Such a system makes patients, practitioners, providers and policy makers equal partners in the health process and draws on the resources available in the patients network.

Examples inspire change

But even though the healthcare system is one of the most complex to change, there are numerous inspiring examples of people and organizations who are doing things differently with great results to follow.

In El Salvador, the involvement of local communities caused maternal deaths to drop to zero in 90 per cent of the municipalities involved in the initiative. All relevant stakeholders including the mothers-to-be, the mother-in-laws, the grandmothers and health workers as well as community and religious leaders were invited to a series of community consultations to get ideas and input to saving more young women’s lives during maternity and these were then converted to a concrete action plan.

In Thailand, involving families and communities in healthcare has been a cornerstone of Thailand’s successful healthcare reform. The reform relies on a triple foundation focused on 1) creating new attitudes towards patients, 2) integrating family data in the patient’s journal and 3) involving the community.

Within one year after the reform, the number of local health centers had risen from 60, covering 600,000 people to 1,164 covering 12 million people.

I have mentioned a few examples of using the person-centered care approach to create better health outcomes – but there are numerous more around the world. They are still the exception to the rule and therefore there is a need to identify the good examples and communicate about them. We need to demonstrate that this approach is not just a “fashion-bug” that will pass with time – but the path we need to take in creating the sustainable healthcare system of tomorrow.

The examples mentioned in this article can be read in full in the “Guide to Person-Centred Care – co-creating the healthcare sector for the future” – it can be downloaded for free on www.sustainia.me/cocreatinghealthcare.

#cocreatinghealthcare #Healthcare #patient #patient involvement #solution

Gaining ground by finding common ground: Innovation and cooperation in Brazil's healthcare system

While inter-sectoral cooperation and well-structured public private partnerships (PPPs) have amazing potential to transform healthcare systems around the world, these projects often face serious barriers due to organizational failures and disconnecting priorities. Brazil's state of Bahia, however, is proving that this need not always be the case. Their government has collaborated with a stream of new PPPs, leading to numerous successful projects and showcasing that when operated effectively and efficiently, these relationships can truly benefit everyone.

The article below, originally featured on GE Look ahead, explores this story in detail and highlights the need for innovative and collaborative projects in healthcare systems. The article is republished here with permission from GE Look ahead.

Bridging the gap: Linking actors across the healthcare value chain will increase the efficiency of Brazil’s healthcare system and the opportunities it provides for investors

BY BEN TAVENER

“We need to encourage people to work together, starting from the youngest members of the sector. Innovation is key, but so is the need for a change of culture,” Giovanni Guido Cerri, dean of the University of São Paulo Medical School, told the audience of government and corporate executives at “Driving Innovation in Healthcare”, a high-level event programmed by The Economist and sponsored by GE on October 30 in São Paulo.

Speakers at the event repeatedly drew attention to a burning issue at the heart of both the public healthcare system and the private healthcare sector, namely a highly fragmented healthcare value chain along which all actors need to connect and cooperate more effectively.

In the public sector, lack of integration hinders effective cooperation between different levels of government, notably between the municipal, state and federal levels of government—each of which shoulders varying levels of responsibility for healthcare. Part of the problem lies in a bewildering array of systems for contracts, payments and purchases used by different departments and regions, as well as blurred lines of responsibility between government strata.

Brazil’s push towards local primary care, which has expanded healthcare coverage to 56.4% of the population , for example, has been burdensome for smaller municipalities that lack the infrastructure, personnel and resources to manage services in an efficient, integrated manner. The solution lies in innovative management technologies, says Daurio Speranzini, chief executive of GE Health Care in Latin America, including contract and payment models, as well as integrated referral and data-sharing systems, with parallel training to provide users the skills to interpret data and anticipate trends.

Actors will also need better coordination and communication in the area of public-private partnerships. This is all the more important as the national healthcare system is increasingly relying on private actors to deliver more healthcare services and marry the ever-growing demands of the public system with the financial power of the private sector. With contracts of up to 35 years, supporters argue that PPPs are a long-term solution to the system’s “connectivity” problems and would also reduce inefficiencies and costs.

“It’s vital to maintain a close relationship with the private partner,” says Washington Couto, secretary of health for the state of Bahia, noting that the initial reluctance about PPPs among local governments and investors has been trumped by Bahia’s successes and the open, connected way in which the projects were and are conducted. “We have implemented innovative systems to ensure that PPP payments and dialogue between all parties continue to flow. You can’t do business without these two things.”

A small but steady stream of new PPPs is now lending the process more credibility: The Bahia government has signed off on two further PPP projects—including a new hospital and a network of 12 imaging centres; in addition, nine other major healthcare facility contracts have been signed across Brazil. Three of these facilities are already in operation, according to Radar PPP.

Along with the establishment of guarantee funds for PPPs, bundling contracts together can help deliver tailor-made projects while providing both universal management systems and savings to the government—which can retain oversight and monitor performance closely to ensure that contractually binding targets are met. With that in mind, São Paulo recently finalised a $2bn PPP contract to build, equip and run three hospitals in the state .

Nonprofit PPPs have also taken off in recent years, connecting the SUS with so-called social organisations (OSs), which include NGOs and leading private hospitals. “One of the critical success points of the OSs in São Paulo was the innovative IT system and the innovation in contractual management between the government and private sector,” said Ana Maria Malik, professor of health at the Fundação Getúlio Vargas.

Some delegates, including Ms Malik, noted that PPPs were still in their infancy, making it too early to hail the partnerships as an outright success; others already see PPPs as a bridge to a more efficient, higher-quality health service—and a vital link to investment, both domestic and foreign, that the system sorely needs.

Keen to forge wider connections and with the most experience in health PPPs in Brazil, Mr Couto said that Bahia was now pioneering an innovative intergovernmental network to exchange information and “perfect PPPs models to guarantee success” for future projects.

Panellists also noted the importance of bringing together different members of the wider healthcare community—from the medical industry and investors to students and researchers—and fostering a new culture of being part of a holistic health system from the outset of their careers. This will be particularly important when it comes to doctors and nurses—many of whom leave rural areas at the expense of the population there.

“A change in culture is necessary to get researchers, industry and investors working together. [Research foundation] FAPESP and a number of companies are interested in making this bridge … but stronger financial incentives are required,” said Mr Cerri. Formal partnerships are also needed between universities and private companies to develop and create innovative products and solutions tailor-made to the local market, he argued.

Linking actors across the healthcare value chain will help improve the efficiency of Brazil’s healthcare system, with technology is destined to play a major role in these improvements—opening up opportunities for investors. As Mr Speranzini puts it: “Brazil’s health system is highly fragmented and needs to be connected, but before we leap ‘outside the box’ with innovation, there are plenty of innovative things still inside it that can cut costs and waste through improved management.”

For related stories from GE Look ahead, check out the following slideshows:

Just what the doctor ordered

How do we fix this?: reducing infant mortality

#expert #Healthcare #Heath #cocreatinghealthcare #brazil #public-private partnerships

Do large hospital corporations alienate physicians from their patients?

Patients in large healthcare systems often say they feel like numbers, not people. But is the same true of doctors in these systems? Do large hospitals and healthcare systems inherently produce a disconnect between doctors, the work they do, and the patients they care for? If so, how can we remedy this situation to create better healthcare systems for everyone - providers and receivers? Check out the post below by Richard Gunderman, MD to find out.

Have doctors joined the working class?

BY RICHARD GUNDERMAN, MD

On September 28, 1864, exactly 150 years ago this weekend, the first meeting of the International Workingmen’s Association (IWA) was convened at St. Martin’s Hall, London. Among the attendees was a relatively obscure German journalist by the name of Karl Marx. Though Marx did not speak during the meeting, he soon began playing a crucial role in the life of the organization, in part because he was assigned the task of drafting its founding documents.

The work of the IWA and Marx is increasingly relevant to the practice of medicine today, largely because of the rapidly shrinking percentage of US physicians who own their own practices. This moves physicians into the category of what Marx and his associates called, “working people.” According to data from the American Medical Association, in 1983 76% of physicians were self-employed, a number that had fallen in 2012 to 53%. And the trend is accelerating. It is estimated that in 2014, 3 in 4 newly hired physicians will go to work for hospitals and health systems.

To put this change in Marx’s terms, the rapid fall in physician self-employment means that a shrinking percentage of physicians own what he called the means of production. In his view, this alienates workers – in this case physicians – from other physicians, themselves, the work they do, and from patients. Whether we agree with Marx on every point, his writings on this topic provides a provocative perspective from which to survey the changing landscape of contemporary medicine.

As applied to medicine, the first form of alienation Marx highlights takes place between members of the medical profession itself. When physicians are paid by someone else, working in someone else’s facility and using someone else’s equipment, they begin functioning more and more as instruments of production, like workers on an assembly line. Before long, many tend to see each other largely as commercial competitors, overlooking any mutual professional interests they might otherwise share in common.

When fewer and fewer physicians are self-employed, those who employ them often begin to treat them like any other commodities that can be traded in a competitive market. When employers talk about hiring, they may do so in terms of FTEs (full-time equivalents), as though physicians were just undifferentiated units of labor. On more than one occasion, I have heard executives talk about the number of physician “bodies” they will need to adequately staff a facility.

The second form of alienation Marx predicted occurs within physicians themselves. Physicians are not just units of work – they are also human beings. When physicians are self-employed, they enjoy many opportunities to find personal fulfillment by helping their patients and communities from their own volition. Once they become employed, however, they often become objectified, merely carrying out tasks prescribed to them by someone else.

As a result, employed physicians find themselves spending less and less time thinking about the choices they can make to serve their patients and community, instead simply carrying out – and often resenting – the demands of those they work for. For example, when quality initiatives are imposed on physicians by employers and payers, the pursuit of quality may take on the character of an external demand, as opposed to something physicians freely choose because they believe in it.

A third form of alienation takes place between the worker and the act of working. As physicians lose control of the means of production, both physicians and the work they do often becomes commoditized. Decisions about what patients to care for, how to care for them, whose aid to seek in doing so, where such care should be provided, and how to determine the quality of the care delivered all tend to shift from the physician to the physician’s employer.

As the evaluation of physicians’ work becomes increasingly tied to compliance with externally imposed policies and procedures, physicians themselves derive less and less intrinsic psychological fulfillment from caring well for patients. This trend can be exacerbated by the widespread tendency of employers to use physician compensation as a way to influence and control the practice of medicine. Before long, some physicians may think more about their wages than about the patients they care for.

The final and perhaps most pernicious form of alienation occurs between workers and the product of their labors – in this case, between physicians and their patients. The commoditization of medicine promotes an attitude of mutual suspicion, often encapsulated as “Buyer beware.” Relationships between physicians and patients become superficial, transient, and largely commercial, which tends to erode trust, compassion, and the commitment to excellence in patient care for its own sake.

With time, physicians learn to think of themselves as healthcare providers, their work as healthcare delivery, and their patients as consumers or customers. The physician, in other words, becomes a mere vendor and the patient a mere purchaser. Seeing physicians and patients in this light leaves little room for the virtues of character and trust. It is difficult for physicians to take themselves seriously as professionals if patients treat them with the same suspicion as snake oil salesmen.

The signs of the alienation Marx describes might take many forms. One would be decreasing job satisfaction and increasing job turnover, which have been shown to have substantial effects on quality of care. Another would be increasing rates of burnout, depression, substance abuse, and even suicide attempts, which again affect the care patients receive. One simple indicator is the frequency with which physicians smile and express fulfillment and pride in their work.

Even if we do not agree with Marx on every point, it is difficult not to see in his 150-year-old writings provocative and in many cases prescient warnings regarding the present plight of the profession of medicine. If he is right, as the gap between physicians and what he calls the means of production widens, physicians will tend to become increasingly alienated from colleagues, themselves, their work, and above all their patients.

What remedy would Marx offer? Extrapolating from his 1864 IWA “Inaugural Address,” he would call on physicians to unite. He would encourage physicians to secure medicine’s means of production, through the ownership of their own practices. His objective would not be to secure higher wages or enhanced job security. Instead it would be to decrease alienation and promote conditions under which both patients and physicians are most likely to thrive.

This post originally appeared on The Health Care Blog. Richard Gunderman, MD is a professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy, and vice-chair of the Radiology Department, at Indiana University.

#expert #unions #hospital #cocreatinghealthcare #Healthcare #health

Professionals: Hosts or guests in patients' lives? Reflections from the European roundtable

Last week’s roundtable discussion in Brussels marked the second stop on our journey with DNV GL to co-create better healthcare systems worldwide. Having recently hosted an eye-opening and insightful discussion in Shanghai in October, we were ready to hear what our European participants had to offer. And they did not disappoint.

The day started out with Danish representative in European Parliament, Christel Schaldemose, advocating for health issues to be higher on the European Commission’s agenda, particularly given the inherent link between economic productivity and healthcare spending. Our participants then formed groups and determined what they believed to be the greatest challenges facing the European healthcare system today. Many noted that inequality of service and access was a major problem, as well as a lack of both strong leadership and systematic approaches to care provision. Our discussion also revealed that inefficient use of funds and an inability to properly manage long term and chronic illnesses also pose serious threats to health systems throughout Europe. Another challenge, which came up throughout the day, was how to properly manage the “mobile patient” – a distinctly European phenomenon given our open borders. How can we ensure a standard of quality, access, and ease of use throughout the entire region given today’s increasingly mobile populations?

As is typically the case, identifying failures and shortcomings was the simple part. Lamprini Gyftokosta, Policy Advisor at Insurance Europe, and the participant voice of the roundtable agreed: “The easiest task of the day was to identify the current and future challenges for the healthcare systems. But,” she continues, “I was very pleased to see that the discussion did not stop there.”

We, too, were thrilled that the group was not interested in harping on unfixable problems. Rather, we turned our attention to developing potential solutions to combat these challenges. Participants decided that change must occur in four key areas: mindsets, organization, the patient’s role, and access and resources. Change can be effected in these arenas by, for example, streamlining measuring and reporting, including patient representation on hospital boards, publicizing organizational data, and remembering that health professionals are the guests in patients’ lives, not the hosts.

Lamprini also found this session to be inspiring and illuminating: “What I found challenging and extremely interesting was the common efforts from the people in the room, with the excellent guidance from Sustainia, to identify ways in which we can change the mind set of patients, people, doctors, nurses, hospitals and policymakers towards a sustainable healthcare solution. But also what we can achieve and what we cannot achieve by providing a proper healthcare education to people, by giving patients more power - without forgetting that they are patients and they also need guidance.”

Our third discussion of the day focused on accreditation – a huge issue in healthcare today – which was co-hosted by Dr. Francesco De Lorenzo, President of the European Cancer Patient Coalition, a critical voice in advocating for patients’ rights. While accreditation is typically thought of as an administrative burden, the main take away from this session was that we must develop more innovative, collaborative, and multidisciplinary approaches to accreditation. Patients should be consulted before guidelines are established. Treatment programs ought to include other professionals, such as psychologists and physiotherapists. These cooperative and collaborative teams will help achieve more efficient accreditation that adheres to a common standard of quality while still recognizing the needs of individual patients.

As with any workshop in which participants come together from numerous different sectors, fostering a participatory environment was key to a successful exchange of ideas. Fortunately, our roundtable had no trouble with communication. As Lamprini remarks, “I was thrilled to see that every single person in the room engaged actively into the discussions. Networking and exchanging of views with the other participants from different sectors was easy and smooth, a very pleasant atmosphere. The best thing was that everyone in the room shared the same goal: to bring ideas on the table that will facilitate the co-creation of sustainable healthcare systems in the EU and globally, where the focus should be on people, as well as on the patient.”

Maria Iglesia, Head of the Strategy and Analysis Unit at DG SANCO concluded our roundtable with some final reflections. While the nature of healthcare provision in Europe is intricate and complex, one thing is clear and universal: public budgets are tight and they are not likely to expand anytime soon. This means we need to do more with less. This means we need to innovate. This means we need to simplify. Solutions exist in a wide array of forms – from better digitization of records to better communication between patients and professionals. We must utilize all forms to create truly sustainable and successful solutions. We will carry this sentiment of innovation and simplification with us to Washington DC for our final roundtable discussion on February 9th 2015.

It is our goal that these roundtable discussions will open the lines of communication between our groups of participants and the industries from which they come. The more dialogue that exists around these issues, the faster we can reach the ultimate goal of more sustainable co-created healthcare. The insights of those who participated will also contribute to our forthcoming State of Healthcare publication, which will outline the current situations faced by various regions of the world as well as the most exciting and innovative opportunities for meaningful change in the coming years.

This journey gets more exciting with each stop we make, and with Shanghai and Brussels under our belt, we are looking to an eye-opening and fruitful discussion in Washington DC has next year. If you haven’t yet done so, be sure to join our ever-growing network of health experts to learn more about the roundtables, stay up to date on the latest news, and connect with other dedicated health professionals.

#roundtable #brussels #travel log

Diagnosing Europe: Expert views on the region's state of healthcare - Part 6

Today marks the second roundtable discussion on our journey with DNV GL to co-create safer, smarter, more sustainable healthcare systems. We are meeting with European healthcare experts in Brussels to learn about the challenges we currently face, and discover possible solutions and opportunities for improvement.

The roundtable also coincides with today’s sixth and final blog post in this series of expert views on healthcare. Below, Dr. Ilaria Mosca illuminates some of these challenges and opportunities by discussing them in terms of healthcare reform in the Netherlands, namely how improving access to care can bring with it increased public spending. How can Europe provide better, more person-centered care to patients without breaking the bank? Remember to join our Global Network of Health Experts to stay up to date on debates such as this one and to get involved on our journey.

Health reforms in the Netherlands have increased access to health care, but have also led to an unexpected growth in health spending.

BY DR. ILARIA MOSCA

The Dutch health care reform implemented in 2006 showed that introducing regulated competition in a typically government-run sector was feasible. The rationale of the change was that the government would stimulate competition rather than strongly regulate the supply of health care. The widespread interest raised by the Dutch experiment is visible in other countries such as the United States. Many American policymakers looked closely at the universal health insurance mandate of the Netherlands. Indeed some parts of the Affordable Care Act – the so-called ‘Obamacare’ bill – do resemble the Dutch experiment.

Prior to the reform, the Dutch system had strong government regulation and an inefficient dual system of public and private insurance. This led to several issues. First, long waiting lists were the rule of the day because of the strict rationing implemented by the government. Second, there was no information available on the quality of health care delivery. Third, patients falling under the sickness fund scheme – roughly two thirds of the population – could not switch across health care providers, and high-risk privately insured patients had limited access to health insurance. The 2006 reform had several goals: cost containment, efficiency, better quality of care, and accessibility to the health care system. The health policy agenda is far from being completed and is a work in progress subject to continuous changes and influences from the underlying political mainstream.

A quick scan of the 2006 reform, seven years after its implementation, shows significant improvements in the accessibility of health care services and the availability of health (quality) information. It has been, however, less successful on other fronts such as cost containment and efficiency. The individual health insurance mandate guarantees full coverage to the whole population. Every person living or working in the Netherlands has to take out insurance – the only exception is people younger than 18 who are automatically covered and entitled to receive health services. Financial accessibility – measured in out-of-pocket expenditure – is among the lowest across OECD countries, at less than 7 percentage points of total health care spending. Waiting lists were consistently reduced from the year 2000 and most of them are now below the so-called ‘agreed acceptable standards’.

The lack of clear and available information was tackled with the 2006 reform. The launch of several websites (such as kiesbeter.nl) partly helped to achieve the goal of information transparency, which is a prerequisite for consumer choice. The use of patient-reported indicators and the set-up of a national quality programme by the Ministry of Health to develop quality information for health care purchasers, i.e. health insurers, were further steps towards making information more transparent. There is, however, still room for improvement. Negotiations between insurers and providers do not always focus on the quality of care because of missing quality information on performance indicators and low data reliability.

Perhaps one of the most unexpected – and unwanted – trends following the reform is the steady growth of health care spending. The latest OECD figures show that 11.9 per cent of GDP is spent on health, which is second only to the United States (17 per cent). Long-term care and hospital care caused health care expenditures to increase dramatically. In 2011 a total of € 90 billion were spent on health care. Most of the spending was on hospital care and long-term care: € 23.6 billion and € 16.1 billion respectively. Between 2000 and 2011 four sectors significantly increased their share in the national health spending budget: hospital care (from 24 per cent to 26.2 per cent), dental care (from 4.8 per cent to 5.1 per cent), mental health care (from 5.5 per cent to 6.1 per cent) and care for the handicapped and disabled (from 8.5 per cent to 9.3 per cent). The profits of self-employed doctors, such as medical specialists with their own practice as well as GPs, rose by 8 per cent and 5.7 per cent respectively between 2001 and 2009. The government’s answer to these cost overruns has been – in some cases – to set a legal ‘macrobudget instrument’ to guarantee that the total hospital expenditure does not exceed a certain amount in a year. Needless to say, the constant growth of health care costs received significant attention in the elections in the Netherlands last September. The financial sustainability of the Dutch health care system is at risk and no day passes by without news on the health care agenda.

For example, a recent report of the Netherlands Bureau of Economic Policy Analysis (CPB) raised issues on the long-term sustainability of health care in the Netherlands. Solidarity might be at stake in the future because highly-educated individuals fund health care much more, but consume fewer health care services than poorly-educated individuals. According to the CPB’s calculations highly-educated people spend €4,000 a year to receive €2,000 back in care services. The poorly-educated spend €2,000 a year but receive health care worth €3,000. Further attempts by the new coalition government to introduce an income-dependent health insurance premium – which is currently community rated – raised fierce objections and fell off the political radar fairly quickly.

It is clear that the health agenda in the Netherlands is still unfinished. Several topics will surely keep playing an important role in the political discussions ahead: how to guarantee financial sustainability in the long-term, how to maintain accessibility while facing rises in the level of private payments, how to implement deregulation and the need to control costs.

This post originally appeared on the London School of Economics blog, European Politics and Policy.

About the author

Dr. Ilaria Mosca has a Ph.D. in Economics from the University of Lugano, Switzerland and is currently a Senior consultant in health for Ecorys Netherlands.

Be sure to check out the earlier posts in this series here.

#expert #health care spending #public spending #Healthcare #cocreatinghealthcare #access

Diagnosing Europe: Expert views on the region's state of healthcare - Part 5

Staying on the theme of equality of healthcare access in Europe – as we read about on Friday – today’s article discusses the difficulties of maintaining high quality care in a unified European region. Dr. Mihai Călin, a Romanian health and medical journalist, illustrates this issue by highlighting the exodus of healthcare workers from Romania to elsewhere in Europe in search of better working conditions. How can all Europeans have access to a high level of care when such large disparities still exist between countries? This will be one of many questions we seek to address at our roundtable discussion in Brussels tomorrow.

Romanian healthcare workers keep packing

BY DR. MIHAI CALIN

An oncologist from Tulcea, a city 280 kilometres east of Romanian capital Bucharest, returned to work one week into his retirement because there was no other specialist to care for his 4000 patients. In Maramureș, a Romanian county on the northern border with Ukraine, an anaesthesiologist has to commute between two towns so that emergency surgeries can be performed–other operations are being postponed for less crowded days. Călărași, a poor county in the south, only has one diabetologist.

All of these reports are partly owing to the massive migration of medical personnel, which began after Romania’s accession to the European Union in 2007. Between 14 000 and 20 000 doctors—and probably at least as many nurses—have left the country over the past seven years, leaving behind patients with even poorer access to care and overwhelmed colleagues. Many Romanians are pinning their hopes for solutions on the EU—the destination for most migrant health workers.

Two years ago at the European Health Forum in Gastein, John Dalli, the European commissioner for health at the time, told me that he sees this phenomenon as a “reversal of solidarity,” and blamed rich EU member states for “poaching” doctors and nurses from poorer countries, which have invested billions of euros from their small budgets in healthcare workers’ training.

This year, the migration of healthcare workers was again high on the forum’s agenda. But despite strong statements by the former commissioner, there is actually not much that Europe can do to solve Romania’s problem. The EU promotes free movement of people and harmonisation of health training, thus enabling mobility, Professor James Buchan from Queen Margaret University in Edinburgh told me. Even the European Joint Action on Health Workforce Planning and Forecasting— which, as its Belgian coordinator acknowledged, was born out of political speeches on the mobility issue—is aimed not at policy coordination between the 28 member states in order to cover all their needs, but at strengthening the capacity of individual countries to manage their own problems.

Indeed, each country holds the key to recruiting foreign workers and retaining the ones it has trained. Miklos Szocska, a former Hungarian minister of state for health, described to me one of the innovations that his government came up with in reaction to 10% of its medical population leaving. The government introduced a tax on products with a high salt and sugar content, increased excise duty on alcohol and tobacco, and used the tens of millions of euros it raised to increase wages in the medical sector for the first time in eight years.

Although salaries by no means reached the levels of wealthier EU countries, the pay rises were enough—along with an increased budget for primary care and scholarships for residents—to slow down migration. The measure has also encouraged food producers to reformulate their products and has improved consumers’ habits, which in turn led to a reduction in cardiovascular mortality. A powerful majority in the parliament and strong political will were essential to dealing with the huge industry lobby, Szocska told me.

While our neighbours were making efforts to keep their health workforce at home, Romanian leaders had no effective response to the deepening crisis. One of the strategies suggested by Buchan—a return of service from health workers whose training was paid for by the state—has been introduced for some medical residents, but can be either ignored or eluded. If you get an offer from abroad, you can just leave and easily pay off your debt to Romania from there, as a group of young graduates studying for their residency exam explained to me.

Plans to build European funded regional hospitals that would offer modern conditions to health workers have been heralded for years and are not likely to come true anytime soon. Moreover, there was never enough money in Romania’s health budget (one of the smallest in Europe) for substantial wage increases.

And you can forget about finding innovative sources to finance the health budget: the current left wing government— like all before it—never stood up to the junk food and tobacco industry. It is not support in parliament that it’s lacking—it actually has one of the strongest majorities in recent years—but political will. Income growth is only a promise for election campaigns, like the current presidential race, where the incumbent prime minister is the front runner. This promise is probably aimed at patients who wonder why their caregivers are leaving, rather than at doctors and nurses themselves: they’ve heard such promises before and they are still packing.

Note: this article originally appeared on the BMJ blog. If you haven’t already, remember to join our Network of Global Health Experts, and stay up to date on the rest of our journey.

Be sure to read the previous posts in this six-part series, leading up to our roundtable discussion in Brussels tomorrow! You can start from the beginning with the series' first post here.

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Diagnosing Europe: Expert views on the region's state of healthcare - Part 4

Today, in Part 4 of our 6 part series of expert views on European healthcare matters, we hear from someone who is not only an expert, but also a patient. Dimitris Kontopidis is a Cystic Fibrosis (CF) patient and the vice-president of the Hellenic Cystic Fibrosis Association. He was also a candidate for the EU Parliament in 2014. In the post below, he discusses a very important element of healthcare in Europe: equality of access. As we become a more interconnected and global society, how can we ensure that all Europeans have equal access to quality health care? Kontopidis believes that increasing patient participation, and focusing on patient-centered care when developing healthcare policies, can help alleviate some of the inequalities that currently afflict our systems.

My goal is to strive for equal access to healthcare for all Europeans

BY DIMITRIS KONTOPIDIS

What are your thoughts on healthcare inequalities amongst EU nations?

My disease is a prime example of healthcare inequalities in the EU. The average life expectancy of CF patients in Europe is over 40 years; however, this median age drops to less than 30 in Greece. Greece lacks a specialised centre for the disease, CF-trained health professionals and general public knowledge surrounding the disease. Lung transplantation is not an option for those who cannot afford the down payment needed by a specific transplantation center in Austria. Unfortunately, Greece is not the sole example of EU countries ridden with social inequalities.

The European institutions must include patients in shaping the European Agenda for healthcare to reduce the inequalities and inadequate healthcare Europeans live with. Cross-border healthcare centres and networks of reference, eHealth and access to new and innovative therapies are not simply ideas that “may” benefit society; they are solutions that many European countries have implemented successfully.

Why did you decide to run for election for the European Parliament?

I consider my candidacy an opportunity to bring to light the inequalities that exist in healthcare across the EU. As one who lives daily with chronic disease, I firmly believe that I can be of substantial assistance in shaping healthcare policy that reflects the EPF manifesto “Patients + Participation = Our Vote for a Healthier Europe”.

What are you goals for patients in Europe and what are the resources necessary to achieve these goals?

My goal is to strive for equal access to healthcare for all Europeans, particularly now amidst the economic crisis. I am actively promoting patient-centred care throughout Europe. Patients must become the focal point for healthcare services, which will require training and education for patients and their organisations.

We must build patients’ capacity to improve their own leadership, organisational skills and strategic planning that will result in on-the-point interventions and successful patient campaigns. Human resources, knowledge of rights, cooperation and networking are the founding pillars of a powerful and effective voice for the patients’ population.

In your opinion, what do patients want from their healthcare systems and how can they work towards these goals?

Patients can—and should—be part of the equation that will lead to increased efficacy and quality of health systems in Europe. This idea has been the focus of the “Patients in Power” conference in Greece for the past two years, which combines the active participation of institutions, healthcare professionals and patients to provide a strong voice for patients in our country!

To me, this conference is a crucial example of innovative concepts shaping healthcare policy. It provides the possibility to create an equal Europe—a social Europe—which will emerge from our joint efforts. As a patient of chronic disease, I will continue to champion this idea as a candidate for the European Parliament.

Note: This post originally appeared on the site, European Patients Forum

Click here for Parts 1, 2, and 3 of our series of expert opinions.

Remember to join our Network of Global Health Experts, and stay up to date on the rest of our journey.

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Diagnosing Europe: Expert views on the region's state of healthcare - Part 3

While Part 1 and Part 2 of this blog series centered on non-communicable diseases, we’d like to change gears now and take a look at another key issue in European healthcare today: spending. The recent financial crisis has had a substantial impact on healthcare policies, particularly in terms dwindling financial resources and the effect they have on healthcare access and coverage. In the following article, Dr. Philipa Mlodovsky and Dr. Sarah Thomson explore these issues and offer some valuable insights into the varied state of healthcare spending in Europe. A full summary of their study has also since been published, and is available here.

European health systems are changing in response to the financial crisis but face barriers to implementing necessary reforms.

BY DR. PHILIPA MLADOVSKY AND DR. SARAH THOMSON

European health ministers meet in Dublin next week to consider the impact of the financial crisis on health and health systems. In their discussions they will draw on a survey showing how almost every health system in the European Union has been affected by fiscal constraints associated with the crisis. Health sector responses to fiscal constraints between 2008 and 2011 fell into three categories: i) changes to public spending; ii) changes to health coverage; and iii) attempting to do more with available resources.

Changes to public spending

A third of EU countries made explicit cuts to the health budget, mainly those countries hit hardest by the crisis; Hungary and England froze health budgets, representing a cut in real terms; and Belgium, Denmark and France chose to stick to planned increases in public spending on health. Countries that rely on the labour market to finance health care were forced to compensate for revenue lost due to rising unemployment. Most did this by increasing payroll contribution rates and transfers from central government to the health sector, but a handful benefited from countercyclical policies put in place during the ‘boom’ years – the accumulation of financial reserves and other automatic stabilisers.

Changes to health coverage: Many countries tried to lower public spending on health by shifting costs to individuals. Around half of all EU countries increased user charges for essential services, particularly outpatient prescription drugs. Over a third reduced entitlement to specific services. This suggests a trend toward cuts in coverage, although some countries also reduced or removed charges to protect low-income groups. Policies that remove entitlement to health benefits for specific groups of people give cause for concern, but only Ireland and the Czech Republic went down this route.

Attempting to do more with available resources

Latvia and Lithuania sped up plans to restructure the hospital sector through closures, mergers and centralisation. Ireland, Greece, and Lithuania introduced policies to shift care from inpatient to outpatient settings or improve coordination with primary care. Around a third reported restructuring key organisations (the Ministry of Health, statutory health insurance funds, other purchasing agencies) to reduce overhead costs. Two-thirds of countries introduced or ramped up policies to control spending on prescription drugs, with some success in driving down drug prices and switching to generics. A third reduced or froze health worker salaries and a few succeeded in lowering health service prices.

Three observations emerge from the survey. First, health system responses to fiscal constraints have varied across countries. While there is a clear pattern of cuts to public spending on health among the worst-affected countries, the mix of countries introducing reforms is eclectic. Some countries seem to have been very active, although the fiscal constraints they face are relatively mild. Those with the severest constraints have not always been as active or made changes in areas one would have expected, even when there is significant external pressure for change.

Second, some countries have tried to use the crisis to address weaknesses in their health system, but have not always found it easy to make necessary changes. One barrier to implementation has been resistance from powerful actors such as physicians and pharmaceutical companies. For example, in Ireland (where physician salaries are among the highest in the OECD) the government was able to negotiate lower pay for general practitioners and new hospital physicians only, leaving the salaries of existing hospital physicians untouched. In Greece pharmaceutical companies threatened to withdraw their products in response to proposed price cuts. In contrast, policies likely to affect more vulnerable groups – for example, higher user charges and cuts to spending on mental health and public health – seem to have been implemented without (or in spite of) challenge. Other barriers were the time needed to develop and introduce complex reforms; and the difficulty, in the context of budget cuts, of making upfront investments to produce long-term savings.

Third, some countries have been better able than others to cope with a fiscal shock, partly because they had anticipated and prepared for such an eventuality, for example by putting in place countercyclical measures such as accumulating reserves (Czech Republic, Estonia, Lithuania). This emphasises the importance of political vision and leadership in the health system.

Cross-country variations in response to the crisis are intriguing. Understanding them may shed light on important questions about how health systems can and should respond to fiscal shocks, about why some reforms are introduced and others are not, and about what it is possible to achieve, in terms of efficiency gains, when health systems face prolonged financial pressure. This is why we are now carrying out a larger study, with a new survey and detailed analysis of a smaller group of countries. Preliminary findings will be presented to European health ministers at a high-level meeting in Oslo in April.

This article is based on a survey carried out by Philipa Mladovsky, Sarah Thomson, Jonathan Cylus and Divya Srivastava at the LSE, and Marina Karanikolos and Martin McKee at the London School of Hygiene & Tropical Medicine, working for the European Observatory on Health Systems and Policies in collaboration with Tamás Evetovits at the World Health Organization Regional Office for Europe.

About the authors

Philipa Mladovsky – European Observatory on Health Systems and Policies/LSE Health Philipa Mladovsky is a Research Fellow in Health Policy, LSE Health and the European Observatory on Health Systems and Policies and Deputy Editor of Globalization and Health. Her research interests include health care financing, equity in access to health care, migrant health, human resources for health and the impact of the financial crisis on health systems.

Sarah Thomson – European Observatory on Health Systems and Policies/LSE Health Sarah Thomson is Senior Lecturer in Health Policy at the LSE, Head of the LSE Hub of the European Observatory on Health Systems and Policies and Deputy Director of LSE Health. Her research interests include health system financial sustainability, health financing policy and comparative policy analysis in high- and middle-income countries.

Note: this article originally appeared on the London School of Economics blog, European Politics and Policy.

Part 4 of the series is now up!

If you haven’t already, remember to join our Network of Global Health Experts, and stay up to date on the rest of our journey.

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Diagnosing Europe: Expert views on the region's state of healthcare - Part 2

Yesterday’s article by Dr. Joan Costa-i-Font highlighted potential policy initiatives for combating obesity. Today, we bring you a piece by Dr. Wilm Quentin that also focuses on NCDs, but from a different viewpoint - looking instead at how the private sector could become part of the solution in alleviating NCDs. These two perspectives illustrate the nuanced and complex nature of this debate, and help remind us that everyone – public sector, private sector, individuals, NGOs, etc. – is responsible for alleviating the burden of NCDs on society.

NCDS and the private sector - part of the problem or part of the solution?

BY DR. WILM QUENTIN

One of the last sessions of the European Health Forum Gastein aimed to find answers to the question of how to engage the private sector in the prevention and control of non-communicable diseases (NCDs).

Gauden Galea, director of the Division of NCDs and Life-Course at the World Health Organization’s Regional Office for Europe, and organiser and moderator of the session, asked: “What are the first steps that we can take to activate the private sector in collaboration for NCD prevention and control?”

The question shows that—three years after the 2011 UN General Assembly “Political Declaration on the Prevention and Control of NCDs,” which called for private sector action against NCDs—we are still talking only about the “first steps” that can be taken to activate the private sector in contributing to NCD prevention and control.

It would be great if companies could use their commercial power to promote health—by creating healthy foods and products, which would in turn promote healthy lifestyles and help us to make healthy choices. However, currently, it seems that companies continue to mostly “promote consumption at the expense of health and wellbeing,” as Ilona Kickbusch, director of the Global Health Programme at the Graduate Institute of International and Development Studies, Geneva, puts it. Why is it that companies mostly continue to be part of the problem—producing and marketing unhealthy products that contribute to NCDs—but only rarely part of the solution?

There are a limited number of success stories. One of these is the Danish Forum of Responsible Food Marketing Communication, a self regulatory body, including producers, retailers, advertisers, and media in Denmark. The forum has helped bring about the almost complete elimination of TV commercials that promote unhealthy foods for children, as shown by Mette Peetz-Schou, head of secretariat at the self regulatory body. However, Mette also admits that the threat of government action in regulating food marketing to children played an important part in motivating industry to engage with the forum.

Medical technology companies are, of course, part of the solution, as they help to improve the treatment of NCDs and they can be important partners in advocating for more resources to be spent on NCDs. Trevor Gunn, managing director for international relations at Medtronic, showed in his presentation that official development aid (ODA) is disproportionately focused on communicable disease. While NCDs account for about two thirds of mortality, they receive less than 5% of ODA. More resources are needed to adequately address the challenge of NCDs. However, medical technology companies also have important commercial interests in treating NCDs—and less interest in preventing them.

While over the years much interest has rightly focused on the social determinants of health, participants of the session seemed to agree that it would be important to spend more efforts on understanding and illuminating the commercial determinants of health. Ilona Kickbusch suggested that a Commission on Commercial Determinants of Health should be set up, similar to the Commission on Social Determinants of Health.

My personal conclusion after the session was that “yes, the private sector could be part of the solution.” However, in order for private companies to contribute to the prevention and treatment of NCDs, it will first be necessary for governments to take action: providing appropriate incentives (e.g. through the taxation of unhealthy foods or subsidies for healthy foods); regulating workplace conditions; (at least) threatening to regulate food marketing; mandating food labelling to make it easier for consumers to distinguish healthy from unhealthy food; and providing sufficient funding for the treatment of NCDs in low income countries, which make up 80% of the NCD disease burden.

Wilm Quentin is a senior research fellow at Berlin University of Technology and the European Observatory on Health Systems and Policies. He specialises in comparative health systems and services research in Europe, with a particular focus on payment systems for hospitals and physicians. He is currently working on Health systems in Transition (HiT) health system reviews for the European Observatory on Health Systems and Policies.

Note: this article originally appeared on the BMJ Blog.

Part 3 of this blog series is now available.

If you haven’t already, remember to join our Network of Global Health Experts, and stay up to date on the rest of our journey.

#expert #health #Healthcare #cocreatinghealthcare #ncd #europe #private sector

Diagnosing Europe: Expert views on the region's state of healthcare - Part 1

In the lead up to our roundtable in Brussels next week, we want to inspire our participants – as well as everyone else – to start conceptualizing concrete solutions to healthcare issues by sharing some fascinating and relevant blog posts from experts in healthcare. In the days leading up to the roundtable, we will cover a wide range of topics impacting health care in Europe.

Today, we are featuring an article by Dr. Joan Costa-i-Font, an economist and Senior Lecturer in Political Economy in the Department of Social Policy at the London School of Economics, who touches on how policy can help curb the rising obesity epidemic and its associate health risks and costs.

Given that obesity produces significant social costs, public health authorities need to be far more pro-active in designing interventions

BY DR. JOAN COSTA-I-FONT

Obesity in Europe has reached epidemic proportions. The prevalence of overweight and obese people in the adult in Europe varies between 36.9 % and 56.7 % for women and between 51 % and 69.3 % for men. Britain ranks at the very top. This is not new, as far back as 2001, a National Audit Office reportsuggested that obesity was rising faster in England than in other parts of Europe.

Recent data indicates that 65 per cent of men and 58 per cent of women in the UK were overweight in 2011, a more than 30% increase since 1993. It is highly uncertain how the so-called ‘obesity epidemic’ will evolve, but as I explain below, obesity is in itself is a problem of ‘mis-adaptation’ of individual behavior to lifestyles with lower demands for energy consumption. Given that obesity produces significant social costs, public health authorities need to be far more pro-active in designing interventions that influence the social rewards of being in a healthy weight.

Diagnosing the problem

The proliferation of white-collar jobs is making life significantly more sedentary. Even in manufacturing and agriculture, technological developments have made them less energy demanding. Leisure-time physical activity has also decreased. The internet reduces the need to travel by allowing people to work, socialize and shop from the comfort of their homes. Public transport has brought important benefits in terms of allowing people to commute at low cost and low calorie expense. As a result, sedentary time has expanded dramatically; in England most people are sedentary for six or more hours both on weekdays and weekends. According to The Health and Social Care Information Centre, the average Briton watches 3 hours of TV per day.

Our food preferences have not adjusted to such low calorie demands. On the contrary, food is still a source of ‘immediate gratification’ to counteract the demands of a faster world, which creates cognitive overloads and engender stress. Given that food is far more accessible and affordable than it was in the past, the latter is likely to give rise to an ‘obesogenic environment’ which particularly affects those with a genetic predisposition for weight gain. So what does this tells us about how to tackle the obesity epidemic?

Market failures highlighted by obesity

The choice of fat and sugary foods is often driven by limited information of the long-term consequences of consumption and limited self-control resulting. The widespread availability of these products easily escalates to a form of fat and sugar addiction. Similarly, obesity cannot be regarded as only an individual’s problem as it has multiple knock-on effects; for example, in the design of the physical environment (airplane seats, elevator capacity etc.).

Furthermore, given that it increases the propensity of a long list of chronic conditions (which in turn increase the probability of disability later in life), it is likely to exert short and long term cost sequences to the sustainability of our of health and social care systems. This suggests that obesity is the consequence of a number of market failures, namely information imperfection, limited self-control and most importantly, the existence of marked negative externalities to society. Policy intervention could play a role in counteracting the impact of these failures on individual behavior but how can we devise effective policy?

The role of food prices and fat taxes

Economic factors, such as the low prices and higher availability of food relative to other goods, could be modified to a certain extent by some form of ‘fat tax’. Advocates of the tax pick on the existence of an externality that can either be curbed by higher prices or compensated with the revenues raised from the tax. Examples of such taxes include taxes on foods whose content of saturated fat exceeds 2.3g/100g in Denmark or the proposal to tax fizzy drinks ( so-called ‘soda tax’) in New York, which some British scholars have also been entertaining.

However, fat or soda taxes exhibit several problems. First, we know from taxing other ‘sin goods’ that people addicted to fat and sugar are unlikely to modify their behavior with a change in relative prices. Second, fat taxes do not generally differentiate between the overweight population and the rest; hence, it might well be creating a ‘government failure’ by taxing the wrong people.

Similarly, changing the relative prices of unhealthy foods might not modify the ‘obesogenic environment’, and result in further inequalities in unhealthy lifestyles. Instead, other factors need to be considered, such as interventions that make a difference to the calories burned at work or doing home chores, or promoting active leisure pursuits. Finally, given that not every one metabolizes food in a similar way, blind taxation on fats or sugars could be an unhealthy penalty for some or create serious unintended consequences for others.

Interventions in the environment

If changing the relative prices seems to problematic, interventions should instead be combating sedentary behaviors and the current productive model. Arguably, sedentary lifestyles do not necessarily equate to high calorie consumption. There are different policies to be encouraged; including what can be labeled as ‘fitness subsidies’ to encourage healthy activities and promote the consumption of healthy foods.

Other potential ways of correcting market failures is using the media to change social norms to counteract information problems and help reinforce individual commitment to a healthier lifestyle. Other policies include regulating sedentary behaviors at the workplace and within cities. These policies would be expected to incentivize unconscious physical activity (for example, reserving lifts for disabled use, reducing the number of stops in public transport so that people are likely to walk more, etc.).

As most people will have limited awareness of such activities food intake unlikely to expand, producing a positive ‘fitness effect’ overall. However, the latter examples illustrate that tackling the obesity epidemic is not just the responsibility of health policy makers. It is something that should be taken into consideration in the drafting of other policies which determine, for example, how we plan workplace routines to how we design public transportation.

About the Author

Dr Joan Costa-Font is an academic economist and Senior Lecturer in Political Economy in the Department of Social Policy at LSE . His research is on the economic analysis of welfare institutions, health, health care and aging, with a particular focus on Europe. He is co-editor of the Applied Economics, Perspectives and Policy (AEPP) journal.

Note: this article originally appeared on the London School of Economics blog, British Politics and Policy.

You can read Part 2 of this 6 part series here.

Sustainia and DNV GL have teamed up in an effort to co-create more sustainable healthcare systems all over the world. We are in the midst of an exciting global journey to present the insights of our Person-Centred Care publication, and gather new ideas and solutions from experts in and users of healthcare systems. In total our journey has 10 stops, including three highlighted roundtables, the first of which took place in Shanghai last month. Up next is our session in Brussels on 18 November, followed by our third and final roundtable in Washington DC in February. If you haven’t already, remember to join our Network of Global Health Experts, and stay up to date on the rest of our journey.

#expert #health #Healthcare #cocreatinghealthcare #europe #obesity #ncd #policy

Another word for challenges

TRAVEL-LOG FROM SHANGHAI, CHINA

When we set out to discover opportunities and challenges within global healthcare, we knew that China was an important country to look at. We were therefore very excited to host a roundtable in October with researchers, patient organizations, and professionals from the Chinese healthcare system.

Mr. Tao Duan, President of Shanghai First Maternity & Infant Hospital, kicked-off the day with a quote from Abraham Lincoln: “The best way to predict your future is to create it,” which was a great opening for a day filled with discussions on how to create a safer, smarter, and more sustainable healthcare system in China.

However, as it currently stands, the future for healthcare in this region is not too bright. In China, chronic diseases are estimated to account for 87 % of all deaths. One example of such a chronic disease is diabetes. The number of people living with diabetes in China is over 100 million, which is greater than in any other country in the world. This means that as of 2013, 1 in 4 people with diabetes worldwide lived in China. Eleven per cent of adults in China have diabetes, while 50% have pre-diabetes, putting them at risk for major health problems such as cardiovascular disease, chronic kidney disease, and cancer.[1]

This development has come quickly, since only just over a decade ago, type 2 diabetes was considered very rare in China[2]. And this unfortunate rising trend is evident in many other preventable diseases, as well. Cardiovascular disease, chronic obstructive pulmonary disease, diabetes mellitus, and lung cancer are expected to double or even triple over the next two decades in people over 40 years old. And even with the knowledge of these ominous future scenarios, the rate of smoking among Chinese men is estimated to be 54 % and the average intake of salt is twice the current World Health Organization recommendation[3].

A major problem contributing to these figures is that the current healthcare system is not organised to address the treatment and management of the main causes of chronic disease in China. Low pay and an often volatile relationships between overworked doctors and frustrated patients have seen the number of medical professionals fall in the last decade, leaving many of China's almost 25,000 hospitals short-staffed.[4]

Read also Ian Lewis’ analysis of Chinese Healthcare: http://cocreatinghealthcare.tumblr.com/post/100661212450/when-im-64

This issue was reinforced by the participants at the workshop, who mentioned overworked professionals as a big challenge in securing high-quality care. Another challenge mentioned was healthcare reform, which while great in theory isn’t supported with financing and long-term planning.

Answering the question: “How do we further improve the quality of care in China?” the participants came up with these guidelines:

1) Establish incentives to improve quality of care

2) Make it easy to measure quality

3) Involve the patient in their treatment plan and establish feedback

opportunities

4) Focus less on check-lists and more on changing mind sets

5) Establish trust throughout the system

6) Create a Master’s program in Patient Health and Safety

Mr. Alex Lam, Vice Chairman of the Hong Kong Alliance of Patients’ Organizations, delivered his closing reflections on the day, stressing that China is behind the starting line, but that there is great potential within the healthcare sector. “What is another word for challenges?” he asked to the room, and the participants replied: “Opportunities.”

At the end we took a group photo with the pledge cards on which we wrote how we intend to co-create health.

Inspired by the workshop in Shanghai, we are continuing forward on our journey around the globe, with highlighted roundtables in Brussels on November 18th and Washington DC on the 9th of February, 2015. We look forward to keeping you posted on our progress along the way.

[1] http://www.medscape.com/viewarticle/831911

[2] http://www.diabetes.co.uk/global-diabetes/diabetes-in-china.html

[3] http://bjgp.org/content/64/623/270

[4] http://www.reuters.com/article/2014/10/14/china-healthcare-digital-idUSL3N0S51Y520141014

#Healthcare #health #cocreatinghealthcare #shanghai #diabetes

When I'm 64

October the 28th 2014, DNV GL and Sustainia will be conducting the first Roundtable on the Future of Healthcare in Shanghai, China. Stakeholders from the realm of healthcare will meet to co-produce solutions that can inspire a safer, smarter and more sustainable healthcare approach. Ahead the event, we asked Ian K. Lewis, Partner of Mayor Brown JSM, to set the scene with insights to challenges and opportunities in the Chinese healthcare system.

BY IAN K. LEWIS, PARTNER OF MAYER BROWN JSM

The words “When I get older, losing my hair, many years from now” from the old Beatles song about life as a 64-year-old are familiar to many. Sir Paul McCartney is, however, now in his seventies and the song has a rather different relevance to a generation that is now much more focused on health care than would have been the case in the Swinging Sixties. However, it is not only the “baby boomer” generation that is considering health care and “senior living” options; it is entire populations. This is affecting government policy and opening up new opportunities for industry investors in branded residences of a different kind and healthcare and medical tourism.

Aging Population – Senior Living

The aging population problem in Japan is well known but much less has been said about the same issue that will shortly start to have a major impact on China. The issue is now receiving more attention as the country faces up to the fact that while the percentage of people who were of retirement age in 2010 was under 10 percent, by 2030 this will have climbed significantly – and by 2050, almost 25 percent of the population in China will be over 60 years of age. Put another way, in 2010 China had eight workers to support every person of retirement age; by 2050 there will be only two. In fact by 2050, there will be more people over the age of 60 in China than there are people in the US!

Reform – foreign investment welcome

The aging population in China has become a concern at a time when health care generally is the focus of government reform and the subject of public discussion. There are a number of reasons why the problems in China are of special importance:

The PRC's one child policy has made China's aging population problems more severe - a smaller number of children will be expected to care for growing numbers of the elderly in the traditional Chinese way (i.e., at home) and for many, this will be impossible.

China’s urbanisation policy encourages younger people of working age to move to the cities – often leaving older members of society in smaller towns and villages with little or no family support.

Rapid economic development and changes in lifestyles have resulted in numerous health issues that have put additional strains on the PRC health care system.

At the same time, China is embarking on an ambitious Healthy China 2020 programme which seeks to establish a modern universal health care system. The costs of this, however, are very significant and, given competing priorities, it is unlikely that sufficient money will be available to provide adequate care for the elderly. As a result of many factors including these issues, the government has already taken steps to open the door to private investors (including foreign investors) to fill this need. A number of operators have entered the market including Cascade Healthcare, Belmont Village and Right-at Home.

Barriers

Notwithstanding the opportunities that China offers, there are still a number of significant barriers to a foreign investor wishing to enter either the China health care system or to provide housing for "seniors". These problems are cultural and financial:

Cultural issues – it is difficult for many Chinese to accept housing for the elderly and the traditional expectation is that family support should provide all care required for older members of society. The problem is made worse by the fact that many existing state-run homes for the elderly are overcrowded, badly run and essentially an option of last resort for most people.

Objectives – most development projects in China are driven by real estate developers. This is a problem as developers look for a short-term return and are not primarily driven by a need to provide health care.

Cost – The cost of providing international standard health care is beyond what most people are willing to pay and therefore although there is an opportunity, there is at the moment an issue with the level of demand. Many existing facilities charge RMB 10,000 to RMB 15,000 per month for basic residential nursing home care. The challenge is that most industry experts believe that they need to charge between RMB 15,000 and RMB 20,000 per month just to cover operation costs and RMB 25,000 to RMB 30,000 to make money. Many feel that the market is not yet ready for long-term private health care senior living support at this sort of price level.

Many investors that have entered the China market recognise that the opportunities are not going to bring short-term rewards. However, changes in society, an ever increasing middle class and the projected number of elderly people add up to a strong medium-term business case for investment in this sector.

Hospitals

Private hospitals

The opportunities for foreign investment in private hospitals are perhaps less long-term than those relating to nursing homes/senior living. For example, Chindex International is a major player that has attracted investment from Shanghai Foshan Pharmaceuticals and TPG of the US. Raffles Medical Group (Singapore) and Malaysian IHH Healthcare have also invested. Foshan Pharma has indicated that it has ambitions to invest in hundreds (perhaps as many as 500) hospitals throughout China.

Reform

Private hospitals offer attractive profit margins and the whole sector is benefiting from changes in the law that allow higher levels of private investment – cities such as Beijing now allow 100 percent foreign ownership of hospitals.

Reform was introduced in July 2014 by the Circular of the National Health and Family Planning Commission and the Ministry of Commerce on Carrying out the Pilot Program of the Establishment of Wholly Foreign-Owned Hospitals, although earlier relaxations applicable elsewhere date back to 2012. These relaxations result, in part, from the government’s need to expand health care generally as well as the need for funding.

China’s health care spend is very low by global standards at 5.2 percent of GDP (by comparison, health care spend is 17.9 percent in the US). A strategic objective of the Healthy China 2020 programme is to increase health care spending to 7 percent of Chinese GDP by 2020 and private participation will help make these objectives easier to achieve.

Expansion

Public hospitals account for over 90 percent of hospital revenue which exceeds RMB 1.25 trillion. Private hospitals are however growing rapidly and the Chinese government has set a goal to increase the private hospital services contribution to 20 percent by 2015.

Sensitivity

Nevertheless the China market has been a frustrating one for many investors. Rules and regulations vary from city to city and while some local governments are eager to attract investment others are less enthusiastic. Foreign ownership is relatively new. There is also increased sensitivity following the GSK scandal which illustrated the high level of corruption that exists throughout the hospital system. However, overall government objectives and the pressure of public opinion (which has become much more of a factor in recent years due to social media and other means of communication) has made it desirable to accelerate the expansion of private health care.

Medical Tourism

Medical tourism in the PRC is in its infancy. Within Asia, 90 percent of the medical tourism market is accounted for by India, Thailand and Singapore. China by comparison has made only limited progress, but the potential for it to become a major regional medical tourism destination is enormous.

There are however already medical tourism offerings in Sanya, Hainan Island where the Sanya Traditional Chinese Medicine Hospital is marketing services to Russians, Europeans and the Middle East with the average patient spending around US$20,000 per head. China even has established a China International Medical Tourism Association which promotes China as a medical tourism destination based on high levels of technology, low prices and Chinese traditional medicines.

There are also some facilities in Beijing including the Cining Oasis Health Management Hospital with 60% of its patients coming from outside the capital (although interestingly Cining has partnerships in Japan, Switzerland, Singapore, United States and South Korea to cater to its Chinese clients’ desire to seek medical assistance overseas). The biggest demand from Chinese travellers seeking medical assistance is for health care overseas. It is thought that in 2012 some 32,000 Chinese travelled to South Korea for cosmetic surgery. Thus the potential for China to provide a broader range of medical services at home is obvious.

The issue is that at present, medical tourists from China are looking forquality medical services and perhaps treatment that cannot be found in the PRC. In contrast, patients from Europe and the United States generally choose overseas medical services on grounds of cost (Thailand, for example, may well offer medical services that are very much cheaper than those available in the United States). If China gets it right, it can realistically hope to capitalise on both domestic and foreign demand.

Opportunities Worth Considering

Anyone undertaking business in China needs to be willing to adapt to an ever changing business environment. As some sectors mature or become more highly regulated, the scope for foreign investment may in some cases be reduced. There is little doubt that in the decades to come there will be opportunities for foreign investment in a number of areas including those discussed above. Companies with specialised expertise in the management of homes for the elderly in Europe and the US may find China a rewarding market. Hotel operators that have had experience of medical tourism in Thailand may find considerable scope for expansion in the PRC. Likewise the importance of brand and quality management are likely to apply to private sector health care facilities as they do in more traditional leisure-based properties.

To return to Sir Paul McCartney in the context of foreign investors being able to offer the experience and expertise that China needs, the answer to the question “Will you still need me, will you still feed me, when I’m 64?” is certainly still yes.

ABOUT THE AUTHOR:

Ian Lewis is a partner of Mayer Brown JSM. He has over 20 years' experience gained in several Asian jurisdictions. He has substantial experience with risk analysis, drafting and negotiation of commercial documentation around the region, and mergers and acquisitions and infrastructure-related arrangements in China. He has significant China commercial law, PRC real estate and hospitality experience.

CONTACT:

IAN K. LEWIS

[email protected]

Beijing, T+86 10 6599 9266

#Cocreatinghealthcare #Health #Healthcare #china

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