The Nuffield Trust recently joined forces with Salzburg Global Seminar and the British Medical Journal to host a global meeting on health system reform. Housed in the magnificent surroundings of Schloss Leopoldskron, Salzburg Global Seminar has been a refuge for thinking and reflection since the Second World War. On this occasion, emerging leaders from 29 countries spanning every stage of economic development, met to discuss the challenges of achieving universal access to high quality health care that is both affordable for individuals and for nations.
Inspiration and provocation were provided by international health care leaders focusing on system reform, the role of professionals and patients in changing health systems and the implementation of system change.
Surprisingly for such a diverse group, there were several common themes that emerged throughout the week.
There was a strong focus on chronic disease management as low and middle income countries are rapidly catching up with advanced economies in the percentage of their population with a chronic condition. There was a central concern with developing primary care and preventative services as the foundation of any health care system, with a strong consensus that care should be provided as much as possible outside hospitals. In low income countries, this goal runs up against public perceptions of primary care as being inferior to hospital-based care as well as the priorities of international aid donors that tend to focus on disease specific programmes for HIV or malaria rather than building the foundations of the health care system. Mature health systems that do not have a primary care gate keeping system, for example the US, face a similar challenge as individuals are free to consult specialists directly.
Countries face a common challenge of keeping health care affordable for all citizens and for the nation as a whole, with a range of approaches being taken from heavy price controls in Japan to subsidising health insurance for those on lower incomes in Colombia. Human resources were identified as critical to the evolution of health care, with the number and skill mix of health care workers presenting as much of a challenge as the need to retrain them to work in teams and in partnership with patients.
Finally, there was a strong emphasis on the importance of communities in shaping health care systems, with low income countries having richer experience of community driven change than more regulated, mature systems.
Among the many examples of reform discussed at the conference, three illustrate the breadth of innovation currently underway.
The Singapore health system is noteworthy for its sophisticated understanding of the interplay between government and the market, and its tendency to reform through tinkering with, not tearing up, the system. As an example of the Singaporean approach, take the changes that were made in the relationship between the public and private insurance systems in 2005. The public system in Singapore offers catastrophic insurance coverage through a system called MediShield. Private insurers used to compete with MediShield, with the result that low risk individuals were cherry picked into private insurance, leaving the public system with the sickest and most expensive patients. The government responded by making it obligatory for everyone to be first insured by MediShield, while leaving open the possibility of buying supplementary private insurance. This left the principle of patient choice in place, while also ensuring the sustainability of the public system.
An example from India demonstrates how tiered pricing and specialisation can create inclusive, market-based models of care. The Narayana Hrudayalaya hospital in Bangalore includes a 1000 bed cardiac specialty centre. The hospital manages to perform cardiac surgery for around $3000 per patient compared to $50,000 in the US, while achieving a similar level of quality. Customers can opt for a private suite or other hotel type facilities and pay more accordingly. Those who pay account for 60 per cent of all patients and they finance free care for the remaining 40 per cent of patients. All patients receive the same quality of cardiac care but those who receive free care are treated on a multi-bed ward.
The hospital has achieved these impressive results by attracting high volumes of the same cardiac procedures; by finely engineering the care process to eliminate waste and to only involve the most highly skilled cardiac surgeons when strictly necessary; and by running a cash business that eliminates much of the administration required for third party payment and tracking cash flow in real time.
Finally, we turned to Sweden for a powerful example of community engagement. In a deprived part of Gothenburg, community members were intimately involved in the design of the Angereds Närsjukhus hospital. The impetus for the work came from a study that demonstrated higher rates of cardiovascular disease, chronic obstructive pulmonary disease, lung cancer and alcohol-related deaths than in other parts of Sweden. Extensive dialogue with the community facilitated by going out to where people congregated such as the shopping mall, religious meetings and other community events led to the creation of a unique mission statement for the hospital.
The goal of the hospital is ‘to improve the health of the population in the north eastern part of Gothenburg by creating an innovative hospital that helps mobilise the local community and thereby increases the sense of safety and security among the people living in the area’. This intense engagement has led to the development of new services in response to community needs such as a large pain management centre.
These are just three examples to illustrate the wealth of innovation to be found globally. Future podcasts which will be available on the Nuffield Trust website will feature these and other examples in more detail.
One suggestion that emerged at the meeting was to create an international repository of health reform ideas that policy-makers could tap into to find inspiration and expertise from across the world. Bearing in mind the need to ‘adapt not adopt’ ideas from elsewhere, this could be a powerful way to disseminate the best international ideas and cement a genuinely global dialogue on health system reform.
Further information about this event is available, including a series of podcasts and a briefing paper which served as a discussion document at the summit.