“Healthcare administrator
contemporary challenges and how to build a better health system
“
Introduction :
Our
healthy future cannot be achieved without putting the health and
wellbeing of populations at the centre of public policy. Our ill
health worsens an individual’s economic prospects throughout the
lifecycle. For young infants and children, ill health affects their
capacity to accumulate human capital; for adults, ill health lowers
quality of life and labour market outcomes, and disadvantage
compounds over the course of a lifetime.And, yet, with all the
robust evidence available that good health is beneficial to
economies and societies, it is striking to see how health systems
across the globe struggled to maximize the health of populations
even before the COVID-19 pandemic – a crisis that has further
exposed the stresses and weaknesses of our health systems. These
must be addressed to make populations healthier and more resilient
to future shocks.
1.Five changes for sustainable health
systems that put people first
- · The COVID-19 crisis has affected more than 188
countries and regions worldwide, causing large-scale loss of life
and severe human suffering. The crisis poses a major threat to the
global economy, with drops in activity, employment, and consumption
worse than those seen during the 2008
financial crisis. COVID-19 has also exposed weaknesses in
our health systems that must be addressed. How?
- · For a start, greater investment in population
health would make people, particularly vulnerable population
groups, more resilient to health risks. The health and
socio-economic consequences of the virus are felt more acutely
among disadvantaged populations, stretching a social fabric already
challenged by high levels of inequalities. The crisis demonstrates
the consequences of poor investment in addressing wider social
determinants of health, including poverty, low education and
unhealthy lifestyles. Despite much talk of the importance of health
promotion, even across the richer OECD countries barely 3% of total health spending is devoted to
prevention. Building resilience for populations also
requires a greater focus on solidarity and redistribution in social
protection systems to address underlying structural inequalities
and poverty.
- · Beyond creating greater resilience in populations,
health systems must be strengthened.
- · High-quality universal health coverage (UHC) is
paramount. High levels of household out-of-pocket payments for
health goods and services deter people from seeking early diagnosis
and treatment at the very moment they need it most. Facing the
COVID-19 crisis, many countries have strengthened access to health
care, including coverage for diagnostic testing. Yet others do not
have strong UHC arrangements. The pandemic reinforced the
importance of commitments made in international fora, such as the
2019 High-Level Meeting on Universal
Health Coverage, that well-functioning health systems
require a deliberate focus on high-quality UHC. Such systems
protect people from health threats, impoverishing health spending,
and unexpected surges in demand for care.
- · Second, primary and elder care must be reinforced.
COVID-19 presents a double threat for people with chronic
conditions. Not only are they at greater risk of severe
complications and death due to COVID-19; but also the crisis
creates unintended health harm if they forgo usual care, whether
because of disruption in services, fear of infections, or worries
about burdening the health system. Strong primary health care
maintains care continuity for these groups. With some 94% of deaths caused by COVID-19 among people aged
over 60 in high-income countries, the elder care sector is
also particularly vulnerable, calling for efforts to enhance
control of infections, support and protect care workers and better
coordinate medical and social care for frail elderly.
- · Third, the crisis demonstrates the importance of
equipping health systems with both reserve capacity and agility.
There is an historic underinvestment in the health workforce, with
estimated global shortages of 18
million health professionals worldwide, mostly in low- and
middle-income countries. Beyond sheer numbers, rigid health labour
markets make it difficult to respond rapidly to demand and supply
shocks. One way to address this is by creating a “reserve army” of
health professionals that can be quickly mobilized. Some countries
have allowed medical students in their last year of training to
start working immediately, fast-tracked licenses and provided
exceptional training. Others have mobilized pharmacists and care
assistants. Storing a reserve capacity of supplies such as personal
protection equipment, and maintaining care beds that can be quickly
transformed into critical care beds, is similarly
important.
- · Fourth, stronger health data systems are needed.
The crisis has accelerated innovative digital solutions and uses of
digital data, smartphone applications to monitor quarantine,
robotic devices, and artificial intelligence to track the virus and
predict where it may appear next. Access to telemedicine has been
made easier. Yet more can be
done to leverage standardized national electronic health
records to extract routine data for real-time disease surveillance,
clinical trials, and health system management. Barriers to full
deployment of telemedicine, the lack of real-time data, of
interoperable clinical record data, of data linkage capability and
sharing within health and with other sectors remain to be
addressed.
- · Fifth, an effective vaccine and successful
vaccination of populations around the globe will provide the only
real exit strategy. Success is not guaranteed and there are many
policy issues yet to be resolved. International cooperation is
vital. Multilateral commitments to pay for successful candidates
would give manufacturers certainty so that they can scale
production and have vaccine doses ready as quickly as possible
following marketing authorisation, but could also help ensure that
vaccines go first to where they are most effective in ending the
pandemic. Whilst leaders face political pressure to put the health
of their citizens first, it is more effective to allocate vaccines
based on need. More support is needed for multilateral access
mechanisms that contain licensing commitments and ensure that
intellectual property is no barrier to access, commitments to
technology transfer for local production, and allocation of scarce
doses based on need.
- · The pandemic offers huge opportunities to learn
lessons for health system preparedness and resilience. Greater
focus on anticipating responses, solidarity within and across
countries, agility in managing responses, and renewed efforts for
collaborative actions will be a better normal for the
future.
2. Improving population health and
building healthy societies in times of
COVID-19
- The COVID-19 pandemic has been a
stark reminder of the fragility of population health worldwide; at
time of writing, more than 1 million
people have died from the disease. The pandemic has already
made evident that those suffering most from COVID-19 belong to
disadvantaged populations and marginalized communities. Deep-rooted
inequalities have contributed adversely to the health status of
different populations within and between countries. Besides the
direct and indirect health impacts of COVID-19 and the decimation
of health systems, restrictions on population movement and
lockdowns introduced to combat the pandemic are expected to have
economic and social consequences on an
unprecedented scale.
- Population health – and addressing
the consequences of COVID-19 – is about improving the physical and
mental health outcomes and wellbeing of populations locally,
regionally and nationally, while reducing health inequalities.¹
Moreover, there is an increasing recognition that societal and
environmental factors, such as climate change and food insecurity,
can also influence population health outcomes.
- The COVID-19 pandemic has made it
evident that to improve the health of the population and build
healthy societies, there is a need to shift the focus from illness
to health and wellness in order to address the social, political
and commercial determinants of health; to promote healthy behaviors
and lifestyles; and to foster universal health coverage.² Citizens
all over the world are demanding that health systems be
strengthened and for governments to protect the most vulnerable. A
better future could be possible with leadership that is able to
carefully consider the long-term health, economic and social
policies that are needed.
- In order to design and implement
population health-friendly policies, there are three prerequisites.
First, there is a need to improve understanding of the factors that
influence health inequalities and the interconnections between the
economic, social and health impacts. Second, broader policies
should be considered not only within the health sector, but also in
other sectors such as education, employment, transport and
infrastructure, agriculture, water and sanitation. Third, the
proposed policies need to be designed through involving the
community, addressing the health of vulnerable groups, and
fostering inter-sectoral action and partnerships.
- Finally, within the UN's
Agenda 2030, Sustainable Development Goal (SDG) 3 sets
out a forward-looking strategy for health whose main goal is to
attain healthier lives and wellbeing. The 17 interdependent SDGs
offer an opportunity to contribute to healthier, fairer and more
equitable societies from which both communities and the environment
can benefit.
3. Imagine a 'well-care' system
that invests in keeping people healthy
- The burden of chronic disease is
increasing at alarming rates. Across the OECD nearly 33% of those
over 15 years live with one or more chronic condition, rising to
60% for over-65s. Approximately 50% of chronic disease deaths are
attributed to cardiovascular disease (CVD). In the coming decades,
obesity, will claim 92 million lives in the OECD while
obesity-related diseases will cut life expectancy by three years by
2050.
- These diseases can be largely
prevented by primary prevention, an approach that emphasizes
vaccinations, lifestyle behaviour modification and the regulation
of unhealthy substances. Preventative interventions have been
efficacious. For obesity, countries have effectively employed
public awareness campaigns, health professionals training, and
encouragement of dietary change (for example, limits on unhealthy
foods, taxes and nutrition labelling). Other interventions, such as
workplace health-promotion programmes, while showing some promise,
still need to demonstrate their efficacy.
- The COVID-19 crisis provides the
ultimate incentive to double down on the prevention of chronic
disease. Most people dying from COVID-19 have one or more chronic
disease, including obesity, CVD, diabetes or respiratory problems –
diseases that are preventable with a healthy lifestyle. COVID-19
has highlighted structural weaknesses in our health systems such as
the neglect of prevention and primary care.
- While the utility of primary
prevention is understood and supported by a growing evidence base,
its implementation has been thwarted by chronic underinvestment,
indicating a lack of societal and governmental prioritization. On
average, OECD countries only invest 2.8% of health spending on
public health and prevention. The underlying drivers include
decreased allocation to prevention research, lack of awareness in
populations, the belief that long-run prevention may be more costly
than treatment, and a lack of commitment by and incentives for
healthcare professionals. Furthermore, public health is often
viewed in a silo separate from the overall health system rather
than a foundational component.
- Health benefits aside, increasing
investment in primary prevention presents a strong economic
imperative. For example, obesity contributes to the treatment costs
of many other diseases: 70% of diabetes costs, 23% for CVD and 9%
for cancers. Economic losses further extend to absenteeism and
decreased productivity.
- Fee-for-service models that
remunerate physicians based on the number of sick patients they
see, regardless the quality and outcome, dominate healthcare
systems worldwide. Primary prevention mandates a payment system
that reimburses healthcare professionals and patients for
preventive actions. Ministries of health and governmental leaders
need to challenge skepticism around preventive interventions,
realign incentives towards preventive actions and those that
promote healthy choices by people. Primary prevention will
eventually reduce the burden of chronic diseases on the healthcare
system.
4 .Lessons in integrated care from the COVID-19
pandemic
Since the start of the COVID-19
pandemic, people suffering non-communicable diseases (NCDs) have
been at higher risk of becoming severely ill or dying. In Italy,
96.2% of people who died of
COVID-19 lived with two or more chronic
conditions.
Beyond the pandemic, cardiovascular
disease, cancer, respiratory disease and diabetes are the leading
burden of disease, with 41 million annual deaths. People with
multimorbidity - a number of different conditions - often
experience difficulties in accessing timely and coordinated
healthcare, made worse when health systems are busy fighting
against the pandemic.
Here is what happened in China with
Lee, aged 62, who has been living with Chronic Obstructive
Pulmonary Disease (COPD) for the past five years.
Before the pandemic, Lee’s care
manager coordinated a multi-disciplinary team of physicians,
nurses, pulmonary rehabilitation therapists, psychologists and
social workers to put together a personalized care plan for her.
Following the care plan, Lee stopped smoking and paid special
attention to her diet, sleep and physical exercises, as well as
sticking to her medication and follow-up visits. She participated
in a weekly community-based physical activity program to meet other
COPD patients, including short walks and exchange experiences. A
mobile care team supported her with weekly cleaning and grocery
shopping.
Together with her family, Lee had
follow-up visits to ensure her care plan reflected her recovery and
to modify the plan if needed. These integrated care services
brought pieces of care together, centered around Lee’s needs, and
provided a continuum of care that helped keep Lee in the community
with a good quality of life for as long as possible.
Since the COVID-19 outbreak, such
NCD services have been disrupted by lockdowns, the cancellation of
elective care and the fear of visiting
care service. These factors particularly affected people
living with NCDs like Lee. As such, Lee was not able to follow her
care plan anymore. The mobile care team was unable to visit her
weekly as they were deployed to provide COVID-19 relief. Lee
couldn’t participate in her community-based program, follow up on
her daily activities, or see her family or psychologists. This
negatively affected Lee’s COPD management and led to poor
management of her physical activity and healthy diet.
The pandemic highlights the need
for a flexible and reliable integrated care system to enable
healthcare delivery to all people no matter where they live,
uzilizing approaches such as telemedicine and effective triaging to
overcome care disruptions.
Lee’s care manager created short
videos to assist her family through each step of her care and
called daily to check in on the implementation of the plan and
answer questions. Lee received tele-consultations, and was invited
to the weekly webcast series that supported COPD patient
communities. When her uncle passed away because of pneumonia
complications from COVID-19 in early April, Lee’s care manager
arranged a palliative care provider to support the family through
the difficult time of bereavement and provided food and supplies
during quarantine. Lee could even continue with her physical
activity program with an online training coach. There were a total
of 38 exercise videos for strengthening and stretching arms, legs
and trunk, which she could complete at different levels of
difficulty and with different numbers of repetitions.
Lee’s case demonstrates that early
detection, prevention, and management of NCDs play a crucial role
in a global pandemic response. It shows how we need to shift away
from health systems designed around single diseases towards health
systems designed for the multidimensional needs of individuals. As
part of the pandemic responses, addressing and managing risks
related to NCDs and prevention of their complications are critical
to improve outcomes for vulnerable people like Lee.
How to design and deliver
successful integrated care
The challenge for the successful
transformation of healthcare is to tailor care system-wide to
population needs. A 2016 WHO Framework on integrated
people-centered health services developed a set of five general
strategies for countries to progress towards people-centered and
sustainable health systems, calling for a fundamental
transformation not only in the way health services are delivered,
but also in the way they are financed
and managed. These strategies call for countries
to:
- Engage and empower people / communities: an integrated care
system must mobilize everyone to work together using all available
resources, especially when continuity of essential health and
community services for NCDs are at risk of being undermined.
- Strengthen governance and accountability, so that integration
emphasizes rather than weakens leadership in every part of the
system, and ensure that NCDs are included in national COVID-19
plans and future essential health services.
- Reorient the model of care to put the needs and perspectives of
each person / family at the center of care planning and outcome
measurement, rather than institutions.
- Coordinate services within and across sectors, for example,
integrate inter-disciplinary medical care with social care,
addressing wider socio-economic, environmental and behavioral
determinants of health.
- Create an enabling environment, with clear objectives,
supportive financing, regulations and insurance coverage for
integrated care, including the development and use of systemic
digital health care solutions.
Whether due to an unexpected
pandemic or a gradual increase in the burden of NCDs, each person
could face many health threats across the life-course.
Only systems that dynamically
assess each person’s complex health needs and address them through
a timely, well-coordinated and tailored mix of health and social
care services will be able to deliver desired health outcomes over
the longer term, ensuring an uninterrupted good quality of life for
Lee and many others like her.
Conclusion:
In all nations, investing in
healthcare organizations to enable them to become true “learning
health care systems,” aiming at continual quality improvement,
would yield major population health and health system
gains.
The COVID-19 pandemic underscores
the importance for health systems to be learning systems. Once the
dust settles, we need to focus, collectively, on learning from this
experience and adapting our health systems to be more resilient for
the next one. This implies a need for commitment to and investment
in global health cooperation, improvement in health care
leadership, and change management.
Also, we need equally strong
political, managerial, and financial commitment to continually
improving & high-quality health services.