Health Systems Strengthening - what others thought

Jocalyn Clark blogged about my workshop on PLoS Medicine:
http://blogs.plos.org/speakingofmedicine/2011/11/25/what-is-health-systems-strengthening/

I also received a summary of the feedback forms and people really enjoyed the day, particularly the two part format with an overview of the theory in the morning and experiences from the field in the afternoon. And almost everyone said what they learned will affect their practice :) Really chuffed and happy that people found the workshop useful. Thanks again to my speakers and Anne Radl for her support - I wouldn't have been able to do this without you :)

Doctors and Critical Care - or: Quality, not Quantity

Interesting piece on the procedures (and more important lack thereof) doctors chose for themselves shall they become critically ill - and the (complex web of) drivers that lead to very different decisions for their patients:
http://zocalopublicsquare.org/thepublicsquare/2011/11/30/how-doctors-die/read/nexus/

Health Systems Strengthening

As some of you might know, I organised and led a workshop on Health Systems Strengthening this weekend. I got interested in how the systemic view, which I took on the UK health system in my PhD, applies to the developing world following a Gates Distinguished Lecture last year. The more I read about it, including Nigel Crisps book (a review here), the more intrigued I got. By chance I met Anne Radl from the Cambridge Humanitarian Centre and she encouraged me to share my knowledge.

I opted for a 2 part design - in the morning I led a 2h session, supported by Jocalyn Clark, a PloS Medicine editor from Toronto who had been in charge of a recent series of HSS articles. In the 2h I tried to cover the basics - what is health systems strengthening, why do we need it and how can we do it. We had a great group of participants, who shared their experiences of working in places like Ethiopia, Bangladesh or the Gulf region - this really enriched the session. Over lunch there was some time for more informal exchange and networking and I was really impressed by the diverse and interesting backgrounds.

In the afternoon we had three speakers who shared their field experience and brought the concepts which we had we covered in the morning to life. First, Egbert Sondorp joined us via videolink from Amsterdam and shared his experiences of trying to rebuild the Afghan health system after the end of the rule of the Taliban. He stressed the importance of small steps and a long-term strategy. In Afghanistan the strategy was trying to ensure the delivery of a basic set of services as a starting point, but it is clear that other building blocks, such as stewardship and sustainable financing, will have to follow. Next was Geoff Walsham of the Cambridge Judge Business School, an expert in information and communication systems and technologies. He shared insight obtained while carrying out work in India and stressed that information technology can only be one part of the story. Our final speaker was Bruce Mackay from HLSP, a health sector consultancy. His field experiences were Bangladesh and Mozambique. He also stressed the importance of the private sector, particularly for the poor in developing countries. The WHO reports that in Bangladesh about 75% of health service contacts are with non-public providers, yet most health system plans hardly mention these providers at all.

Each of the presentations had been followed by a short Q&A session, so that after a short coffee break there was a chance to have a more general discussion between the two speakers who were present in person and the audience. All in all, I think it was a very successful day - and from what I have seen of the feedback forms the participants shared this view. Thanks to Anne and my speakers for making this possible.

If you're interested in my handout, you can find it here.

I also got an email from the World Bank, suggesting some further references:
Roberts et al, "Getting Health Reform Right" published by OUP (a text book the World Bank uses for teaching about health systems strengthening and sustainable financing)
and even more at this link.

Figure of the day (2)

In 2008 the 5% of the population with the highest health care expenses accounted for 47.5% of total health care spending.

On the other hand, the 50% of the population with the lowest expenses only accounted for 3.1% of total health care spending.

Source: Kaiser Family Foundation
http://facts.kff.org/chart.aspx?ch=1344

Preventing NCD for US $1.20 per person per year

The WHO just published a report investigating low-cost interventions to prevent non communicable diseases and/or lessen the economic impact of NCDs. I find it interesting and encouraging that the recommendation span both individual intervention such as screening but also large-scale population-based interventions (e.g. action against tobacco use or campaigns for better nutrition).

Expert Comment - Part 2

On September 16 I blogged about an expert comment by Dr Sudeep Chand of Chatham House about the UN meeting on non-communicable diseases. In a follow-up he assesses the outcomes of the meeting.

Unfortunately, it seems a chance was missed to address the global challenge of health in a global, coordinated way: "There is little in the declaration that is specific on international cooperation or coordination. [...] Health system development, the regulation of industry, and key interventions across sectors such as education, environment, agriculture, and transport remain areas for intervention at the national level."

Competition in health care

Interesting article in the Guardian about what competition means in health care:

"Competition is the supreme example of waste in health services. Private health and health insurance systems generate enormous transaction costs."

http://www.guardian.co.uk/commentisfree/2011/oct/09/nhs-nightmare-choice-competition

The human side

I just found this blog entry about how google's automatic archiving of chats unintentionally created a history of the relationship between a women and her terminally ill boyfriend - a powerful reminder what health services are ultimately about: people.

Submitted

I am done - last Friday I handed in my PhD thesis. As you can see from the wordle, it focused on design, services, processes and knowledge :)

I will stay in Cambridge for a bit longer to write publications (to tell the world what I found out about design, services, processes and knowledge) and hopefully implement some of my findings in the Cambridge and Peterborough Foundation Trust.

Figure of the day (1)

public spending on health in the UK and the US as a percentage of GDP in 2006: 7%
additional private spending in the UK: 1.5%
additional private spending in the US: 9%

(source: Nigel Crisp - Turning the World Upside Down)

Expert Comment - Outlook UN meeting on Non-Communicable Diseases (NCD)

Just found this very interesting comment from a Chatham House expert in my inbox. Dr Sudeep Chand is rather pessimistic on the upcoming high-level meeting of the United Nations General Assembly on the prevention and control of non-communicable diseases (NCD). He argues that a more systemic view is needed, which looks beyond intermediary factors of habit and choice (which will probably dominate the agenda). Let's hope the right people read his comment.

Korean News

I mentioned in one of my last posts that I was interviewed by Korean journalists. Just got an email that the story is online. Unfortunately the story is in Korean and google translator makes a right mess out of it. They included a picture of me - not the most flattering one, so not worth checking it out for that. However, I'll still post the link,  just in case you can read Korean. And if you can read what they wrote about me, I'd be interested to hear what I am reported to have said :)

I know it's politics ...

... and I also know that you can't know everything. But I find such ignorant scaremongering absolutely irresponsible - especially if it comes from people who are dismiss solid scientific evidence which does not play to their agenda (climate change, evolution ...) as "believes".

TIME: Vaccination Causes 'Mental Retardation'? Fact-Checking Michele Bachmann's Claim

Read more: http://healthland.time.com/2011/09/13/vaccination-causes-mental-retardation-fact-checking-michele-bachmanns-claim/#ixzz1XwDr2RKC

Comparing Health Care Systems

A friend of mine worked for a news agency in Korea. And a team of this agency is right now in Europe to research health care systems. So I agreed to talk to them. Now my research in the past 3 years gave me an in-depth insight into the UK system. However, my main focus was on how to improve the process by which services are designed. We talked a bit about the UK system but inevitably the Korean journalists were interested where I see the differences between the UK and the German health care system and which one performs better.

Very interesting question - and a rather tough one. While I lived in Germany I was in full-time education and insured with my parents, so my knowledge is restricted to what I picked up over the years from the news, conversations etc. I was quite sure that someone must have done that type of research and indeed I just stumbled upon a report from the independent Commonwealth Fund which compares the systems of Australia, Canada, Germany, the Netherlands, New Zealand, the UK and the US.

Summary of the summary: The Netherlands come first overall, followed by the UK in 2nd place. Germany comes 4th and the US last. Furthermore, the US are also last in 5 out of 6 dimensions. The one dimension where the US only are 2nd to last is Quality Care, here the Canadians are trailing the pack. Not all is bad though, the US are leading in preventive medicine and are strong when it comes to waiting times for more specialized care.

page v of "Mirror Mirror on the Wall" by the Commonwealth Fund

Also interesting that the two nations with the highest per capita health spending (US $7,290 and Canada $3,895) are last and second to last, respectively. The other countries spend between $2,454 (NZ) and $3,837 (Netherlands), whereby the UK, which overall ranked 2nd, had the 2nd lowest expenditure at $2,992.

The full report can be found here. Happy reading :)

Building Change on Local Knowledge - Catalyst for Change: Investment in Girls’ Education

Together with fellow Gates Scholar Julia Fan Li, I interviewed the very charismatic Ann Cotton, founder of CAMFED. CAMFED is a Cambridge-based charity that champions women's education. We produced a five-minute-long video clip and wrote an article. The latter was published in the Winter 2010 edition of Gates Scholars magazine - you can find the magazine here, our article is on page 10 and 11.

Unintended consequences

Promoting abstinence as the main content of sexual education programs in the US - another example of bad design on pretty much every count. Yes it fits some people's world view but completely misses the actual aims. Widespread promotion of abstinence has had no effect on the rate of young people's sexual activity but the US have the highest teen pregnancy and STI ratios in the developed world. Definitely unintended consequences. Time for a redesign?

http://www.thenation.com/blog/162525/dont-have-sex-you-will-get-pregnant-and-die

Expectations

interesting blog article about "raised expectations", sense of entitlement and NHS bashing in a well-known British paper:
http://www.briankellett.net/brian-kellett-dot-net/2011/8/1/raised-expectations.html

Nigel Crisp - Turning the World Upside Down

(This review will be published in "The Eagle 2011", the annual year book of St John's College Cambridge)

What happens if you turn the world upside down? Well, things are starting to look very different. And a different perspective is needed as the world is changing, and so are the demands placed on health services all over the world. Firstly, the world has become more interdependent. Disease travels faster - SARS for example, which had started in rural Asia, reached over 30 countries within just a few months and caused severe disruptions in the economy, travel and trade. Borders between rich and poor countries are blurring; health has gone global.

Secondly, patterns of disease are changing, partly due to demographics, and costs are rising. This is particularly a problem in the developed world. The 19^th and 20^th century, when our health systems were developed, were characterized by a fight against acute disease. But, the challenge of the 21^st century is an epidemic of non-communicable chronic disease. Thus, a shift is needed – from focusing on treating disease to allowing people to lead lives which are as healthy as possible. While the developing world is still largely plagued by acute and communicable diseases, it has a pragmatic and more holistic view on health which could hold the key for the problems of the developed world.

Lord Crisp uses his wide-ranging experiences to provide an insight into these challenges for health care and ways to solve them. Having read philosophy at St John’s, he went on to become the only person so far to simultaneously hold the posts of Chief Executive of the NHS, the largest health organization in the world, and Permanent Secretary of the UK Department of Health. Lord Crisp left these posts in 2006 and is now an independent cross-bench member of the House of Lords. His particular area of interest is international development and global health. He authored the report “Scaling Up, Saving Lives” which set out practical ways to increase the training of health workers in developing countries. Among other projects, in 2007 Lord Crisp co-chaired an international task force on increasing education and training of health workers globally; and in 2009 he co-founded the Zambia UK Health Workforce Alliance to increase number of health workers trained in the country.

“Turning the World Upside Down” sets the stage by discussing the links between health, wealth and social change. Lord Crisp does so by first looking at the developing world and then contrasting and comparing its challenges with the developed world. He shows how health cannot be seen in isolation, but is rather a deeply contextual issue – a key insight that leaders should keep in mind when designing interventions and programmes. Lord Crisp goes on to examining the status quo of links between rich and poor countries, and concludes that there is an unfair trade occurring in both directions. Poor countries are exporting the scarce resource of health workers to rich countries and in exchange importing ideas and ideologies which might not fit their societal context. Health workers are critical to any health system and understaffing is a global problem. Better remuneration, living conditions and facilities as well as safer environments draw health workers from poorer countries to richer ones. Several countries have enacted policies of ethical recruitment, but Lord Crisp argues that the extent of the problem also warrants more fundamental questions. Understaffing means a smaller supply than demand. Yet what is meant by demand? Does it mean workers needed to achieve a medically desirable level of care, or the level of care which a society can afford? If the latter definition is employed, the landscape of over- and undersupply changes dramatically.

 Lord Crisp continues to turn the world upside down in the following chapter and looks at what rich countries can learn from low and middle-income countries. These lessons fall into three broad categories: different ideas, attitudes and approaches to health; specific innovations in policy or treatment; and working together. He argues that pragmatism, creativity and vision, often born out of the lack of resources, can complement Western thinking. For example, many developing countries address their shortages of health professionals by basing their health system on workers who are not as extensively trained. Instead, these community health and mid-level workers receive specific training which is determined by local need instead of oriented along professional lines. Lord Crisp goes on to look at the practical implications of the health challenges of the 21^st century – what role do science and systems play? And who is really in charge: the professionals or the patients? In the final two chapters he summarizes the need for a paradigm shift to global health and what action is needed to confront the challenges of health in the 21^st century. Lord Crisp argues that transition will inevitably occur due to the burden of cost, which will become unbearable. Amongst others, it will be necessary to move clinical and public health closer together in order to shift from a focus on curing disease to one on keeping people healthy. This will have to be linked to new business models and financial incentives, as well as a need to rethink training and deployment of staff according to tasks instead of professions.

Lord Crisp provides a fascinating insight into the links between health in the developed and the developing world. He challenges a one-size fits all approach and argues for the need of a systemic view. He also challenges ideological preconceptions to developmental work. Lord Crisp argues that it is about economic growth, not aid, and that as aid builds dependency, the true goal should be empowerment. His experiences of working both in the developed and developing world allow a first-hand insight and lead to a pragmatic look at issues. Lord Crisp argues convincingly that both sides can learn from each other – let us hope that they are listening.

Making Health Care Safer - Summary

I only summarized the main plenary sessions so far but the conference had so much more to offer - lots of interesting posters and several very interesting talks in the parallel sessions. A big well done to the organizers for assembling such an interesting program.

I think what I take away from the conference are a couple of main themes:

• context-dependency - this was raised over and over again, one size fits all just don't work but more importantly what works in one place might not necessarily work in another. Is decentralization key to addressing this? But how can we then ensure quality and uniform standards?
• emotion - Justin Waring mentioned this and I also came across it in my reseach. Health care services are dealing with people and people are not (always) rational. Surprise, optimism, fear or anger are all strong emotions which will influence how people react in certain situations. So far this has not been addressed at all.
• complexity
• knowledge
• organisational hurdles

The amazing thing is that these are themes which also surfaced in my own work - thus I seem to be on the right track. Makes me a bit more optimistic (speaking of emotions) about my viva :)

Making Health Care Safer – More Plenary Talks

I really liked Denis Fischbacher-Smith’s talk. He talked about the report Organisation with a Memory which he worked on. This was based on the premise that organisations should learn from adverse effects in order to prevent future systems failures. 

He identified three main obstacles to learning 

1. organisations driven by short term imperatives
2. high management turnover and
3. involvement of politicians.

He stressed the difference between passive (lessons are identified but not put in practice) and active learning (lessons become embedded in organisational culture and practices) but also pointed out the communication problems across disciplines and between medical and management functions. Other points he touched upon where the importance of culture and the problem that organisations tend to manage what they can measure. All in all his talk was fairly pessimistic (some might say realistic) about organisational learning. But perhaps this is just another example that we really need new ideas and approaches in health care which are compatible with the existing culture and hopefully can shift it towards being more receptive to learning in the long run.

The first talk on day two brought the focus back on patient safety. Teun Zuiderent-Jerak who looked argued that while safety is a system property, there are several ways a problem can be framed and approaches. He used medication safety as an example, where the classical approach is to control medication behaviour and report errors, while an alternative approach is to see errors and safety as synonyms. The first approach would seek to standardize dispensation while the second one focuses on fostering resilience. Such a shift from control to delegation would have impacts on multiple levels – and would raise very different questions when it comes to spreading and sustaining change than the first approach of standardization.

The last plenary talk was by Justin Waring who first summarized where he sees the field of patient safety. He felt that the scale of the problem, its sources and potential solutions have been well researched in the past years. But there are still gaps that future research will have to address. To do so, he identified three critical perspectives: knowledge (which seems to be sticky when it would need to be slippery and vice versa), cultures (how ideas are lives and breathed) and power and organization (resistance to change and unintended consequences). 

He went on to identify four concrete gaps: 

1. Sources of safety
2. Roles of professional practice networks
3. Role of emotion and
4. Spaces between care processes.

Slides for many of the plenary (and parallel sessions) can be found here:

http://www.sdhi.ac.uk/pastconferences.htm

Thesis Writing

You might have seen my new posts - and perhaps wondered about my long silence. I started this blog to spread some of the ideas developed during my PhD (and hopefully obtain some feedback) until I get the chance to write them up as "proper" journal papers. The reason why I have been silent for so long was that I actually worked on writing up my PhD thesis. And indeed I now have a first draft (hurrah) and am right now waiting for the verdict from my supervisors .... To pass the time I went to the very interesting "Making health care safer" conference in Scotland. I already started to post about it - and will try to write more over the next couple of days :)

Also now all my thoughts about my PhD work are nicely ordered, I will have some more stuff to blog about in the coming weeks and I also have become really interested in the past year in the relationship between healthcare services and developmental work - so watch this space :)

Making health care safer: learning from social and organisational research (Day 1) - Part 3 Knowledge Flows

I also went to Curtis Olson’s session about team learning. He stressed that in practice change involved practical knowledge, experiential learning and practice-based evidence and that practioners are more than just users or customers of knowledge but should rather be seen as experimenters. He also mentioned the importance of not only having know-what but also know-how available and accessible.

I found that this resonated very well with my work around knowledge flows in healthcare design (see one of the older entries in this blog) which stresses both the importance of seeing knowledge not just as something that goes into the design process but also as something that is produced by the design process – amongst others by the practioners. My service design knowledge typology also draws attention to the fact that different types of knowledge differ in their tacit and explicit components. Something that conventional literature often neglects by assuming all knowledge to be explicit and readily sharable. However, as Curtis points out, some knowledge cannot be shared this way and rather has to be acquired through observation and experience.

Making health care safer: learning from social and organisational research (Day 1) - Part 2 Context

Another topic raised by Naomi Fulop was how media and political agenda play different roles for Healthcare Associated Infections (HCAI) and medication errors. This may explain why professional tend to accept much higher rates of error for the latter than for the former (Naomi did a study and found that on average 40% of patients in the ward studied had at least one drug omission in the past 24h) – the stronger external pressures lead to a much lower accepted level for errors.

This demonstrates the importance of context, something I also came across several times in my PhD. Naomi also touched on a particular type of context: contra-productive incentives, which lead to errors being hushed up instead of reported (which is the prerequisite for learning). For example, if a “never event” occurs during surgery and is reported the hospital will not be reimbursement for the procedure and faces potential fines. However, she also argued that more research is needed to investigate which contextual factors are related to safety and quality, which of these are modifiable, to which level and what their respective relevance is. 

I fully agree.

Making health care safer: learning from social and organisational research (Day 1) - Part 1 Complexity

The Social Dimension is Health Institute has put on a great event here in St Andrews and I am able to present some of my ideas around complexity in health care as a poster (pdf handout). The idea of the poster session was less to present traditional posters but rather find ways to trigger conversations – and I had some very interesting conversations indeed once my poster finally arrived (my luggage only got here 29h after myself, Easyjet had forgotten it in Luton).

The plenary sessions were also very interesting – I find it particularly interesting (and reassuring) that researchers from different backgrounds, such as the medical sociologists Mary Dixon-Wood and Naomi Fulop, come to similar conclusions to the ones I drew from my PhD work.

Mary talked about theories of change and how they are often not explicit or not articulated which leads to enthusiasm at the executive level while the frontline staff is not aware of the underlying rational and subsequently much less enthusiastic. Mary referred to the intervention which she and her team studied as a complex intervention. I think in particular the healthcare improvement community often uses the term for problems or interventions which are merely complicated (I will try to write a future post on this) but Mary did point out that the intervention does not just consist of the multiple components but also how it functions socially.

This is similar to the message of my poster: the real complexity of an organization lies in its social functioning. This social functioning emerges around the structure set through the formal organizational structure. The latter ticks all the boxes of a complicated system (and not the ones of a complex one) and thus it should be able to apply design principles to it.

Naomi raised a related point in her talk by pointing out the need to conceptualize and manage the coexistence of formal governance processes and informal professional processes.

I think one comparison could be a wisteria where the formal structure provides the scaffolding. Through the scaffolding I can exert some influence on how my wisteria will grow. A good scaffolding will increase the chances of having it grow the way I want it to (which can be further aided by pruning), with a bad scaffolding it will definitely be a mess.