Transforming health systems
How do societies set health goals, and how do they go about achieving them? How do different parts of the health system such as research, policy and implementation, interact to improve healthcare?
The right to good health and healthcare is enshrined in the UN Universal Declaration of Human Rights. Achieving good health is possible through a combination of different policies, organisations, people and processes that together form health systems. By examining how these systems work, we can build evidence on what works well, identify areas which can be improved and ultimately improve health and healthcare for all.
The challenges are considerable. According to WHO more than one billion people cannot obtain the health services they need, because they are inaccessible, unavailable, unaffordable or of poor quality. It also estimates there is a global workforce shortage of over 17 million workers. These problems exist on a daily basis and are made worse in times of crisis due to disease outbreak, civil unrest or environmental disaster. Strong health systems can overcome many of these challenges.
The goal of health systems research at The George Institute is to tackle the challenges of delivering affordable, high-quality health services and programs to communities across the globe. We focus on solutions for non-communicable disease and injury, but recognise that often a whole of system approach is needed rather than condition specific strategies.
We work with civil society, health services, other academic groups, industry, government and non-government organisations to determine how health systems around the world respond and adapt as they address health challenges and pursue better health outcomes that are affordable to people and society at large.
Our work aligns closely with Health Systems Global adaptation of the WHO Health Systems framework – which describes health systems in terms of six core components or ‘building blocks’, including service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/governance. Of critical importance, these should be built in consultation with the people who are ultimately the end users of the system.
People centred solutions
We are developing ways to support other primary healthcare workers to ease the pressure on doctors who are in scarce supply in many parts of the world. In India, a program has proved very successful, for example, in training community care workers to help people with heart disease or diabetes to take medication and monitor their health.
In Australia we are working with Aboriginal and Torres Strait Islander people, policy makers, burn clinicians and a multidisciplinary team to develop transformational models of care that address cultural safety and focus on high quality, patient centred care. In India, we are working with actors across the system from policy makers to care providers, addressing barriers to ongoing care for burns. We also stress the importance of going beyond the health system, taking an inter-sectoral approach, to address equity, gender, human rights and social determinants of health, to improve recovery outcomes for burns survivors.
The Community-Eye-Care (C-EYE-C) initiative in Westmead Hospital is an optometrist led triage clinic for two common chronic eye diseases - glaucoma and diabetic eye disease. This new model of care has demonstrated cost savings to the health system and reduced waiting time for outpatient appointments with an ophthalmologist in the hospital eye clinic.
We also work in a cross-disciplinary way improving how people analyse and share health information. People make significant healthcare decisions based on what they read in newspapers or see on television and therefore it is important that health journalism and communications are evidence-based. To help with this we’ve developed a toolkit for journalism students that aims to improve critical appraisal skills. The toolkit has been piloted in India and recently introduced in China.
We are working with organisations across the globe to explore how the use of digital technology can improve healthcare delivery. In Australia we jointly hosted the first International Digital Health Symposium to hear from international and domestic experts and discuss global advancement of digital health policy, digital health support for clinical quality and safety, as well as challenges in healthcare interoperability and management of global public health priorities. We will be supporting the Indian government in the hosting of next symposium.
Researchers are looking into technology to help with healthcare delivery, such as through digital health, mobile phones or simple text messaging. A text can remind people to take the right dose of medication at the right time.
Another example is our SMARThealth program that began in Australia in 2013 with a trial of an electronic decision support tool for improving chronic care in Aboriginal Medical Services and general practices. The program has now grown to multiple locations in India, Indonesia and Thailand to provide screening and care for patients with hypertension, cardiovascular disease, kidney disease, mental health and recently diabetes care in China.
Affordable, essential medicines
Access to essential medicines varies greatly worldwide and is strongly driven by wealth of the nation and the individual. Global surveys of people with heart disease and stroke have shown that the majority of the world’s poor are not receiving any guideline recommended medicines at all. One strategy we are testing is a large program of work looking a low-cost combination polypills. One study in Sri Lanka looked at a new low dose three in one pill to treat hypertension. Such strategies could transform the way high blood pressure is treated around the world.
The George Institute is looking at strategies to maximise uptake of this technology, including examining the acceptability of the Triple Pill approach with patients and their doctors, as well as cost-effectiveness which will be important for governments and other payers to consider.
Looking at the dollars
A key goal on the journey toward achieving Universal Health Coverage is making healthcare more affordable. Understanding optimal ways to pay for health and healthcare and to identify wastage and inefficiency is an essential step in developing and implementing new policies and programs.
The National Health Protection Scheme (aka Modicare) in India is boldly aiming to provide financial protection to 500M people across India (making it the biggest such program in the world). We are currently analysing the potential costs and coverage of the program in various Indian states relative to the current system and hoping to generate policy relevant outcomes that will inform how the program can be strengthened as it develops over time.
In Australia, we are examining the economics of preventing high cost conditions in patients at high risk of non-communicable disease. This project aims to understand the factors that lead to inappropriate, high cost healthcare services and identify strategies for more appropriate, cost-effective care in a private health insurance setting. We are also raising awareness about conditions that often get misdiagnosed. We worked with the Australian Sepsis Network to launch a national action plan to drive improvements in the treatment and recovery of patients and reduce the number of people who lose their lives each year to sepsis - a life threatening illness that occurs when the body’s response to infection injures tissues and organs.
We are also working with eight member countries of the Association of Southeast Asian Nations (ASEAN) to explore the economic effects of cancer. Cancer can be a major cause of poverty, a concern that particularly affects countries that lack comprehensive social health insurance systems and other types of social safety nets. We are working with a cross-section of public and private hospitals as well as cancer centres to raise awareness of the extent of the cancer problem in Southeast Asia and its breadth in terms of its financial implications for households and the communities in which cancer patients live. We aim to identify priorities for further research and create a catalyst for implementation of effective cancer control policies.
Input to policy
We are working with governments around the world to explore how better food systems can improve consumer food choices. Our FoodSwitch program tracks the healthiness of national food supplies by collating detailed information about the nutritional value of food products for sale. FoodSwitch currently holds data on more than 500,000 items from a dozen countries. In Australia it has driven enhancements to the national Health Star Rating system, a world-leading food labelling program. We have also supported strategy development for salt and sugar reduction in Hong Kong, are supporting the development of a national salt reduction strategy for China and are working with government partners in the Pacific Islands to improve local food supplies.
We conduct large scale work to influence global health policies. For example, a large scale cohort study recruiting 40,000 people in 21 low and middle income countries is informing development of better fracture care in resource poor settings. In India we have reviewed national injury surveillance systems and made recommendations to Government regarding their strengthening and expansion. We evaluated the pilot cashless scheme of health insurance for road crashes victims, and made recommendations for effective coverage and performance benchmarking. The findings have contributed to expansion of the scheme across all National Highway’s in India, under The Motor Vehicle (amendment) Bill 2016.
Using the example of diabetes in pregnancy and focusing on a British South Asian sample, Professor Trish Greenhalgh of University of Oxford illustrates how narrative research can go beyond the dry and under-theorised assumptions of behaviourism and illustrate the complex socio-cultural webs in which ‘lifestyle choices’ are suspended. Listen to the audio of this talk here:
Professor Trish Greenhalgh talks about why technology projects in health and social care fail.
Professor Trish Greenhalgh talks about why technology projects in health and social care fail.