Health Care Challenges in the “Post-American World”

May 29, 2008 at 8:07 pm · Filed under Policy Makers, International Best Practices, Business of Health, International Health

Fareed Zakaria argues in his new book “The Post-American World“, that the problem America faces in the new emerging international sphere is not so much domestic decline, but rather more “the rise of the rest.” By this he means that countries all over the world “have been experiencing rates of economic growth that were once unthinkable.” This is resulting in shifting of the balance of power, the movement from a unipower world with America at the center, to a world of “many actors, state and non-state” where there is no center. The challenge in such a world, according to Zakaria, is “how to stop the forces of global growth from turning into the forces of global disorder and disintegration.”

In this new “Post-American World”, Zakaria asks “will international life be substantially different in a world in which the non-Western powers have enormous weight?” Will Washington be able to “adjust and adapt to a world in which others have moved up?” And can we thrive in a world we cannot dominate? In America, “new thinking about the world is sorely lacking” and our isolationism has left us quite unaware of the world beyond our borders.

We also suffer from a “dysfunctional politics”, Zakaria writes, one characterized by gridlock and partisanship, which prevents us from beginning “a generous effort to engage the world.” The future is already here.

The task for today is to construct a new approach for a new era, one that responds to a global system in which power is far more diffuse than ever before and in which everyone feels empowered.

And organizing coalitions has become a primary form of power. Real solutions require,

creating a much broader coalition that includes the private sector, nongovernmental groups, cities and localities, and the media. In a globalized, democratized, and decentralized world, we need to get individuals to alter their behavior.

Now here is where health care begins to enter into the “Post-American” picture.

While Zakaria complains that health care costs “have risen to point that there is a significant competitive disadvantage to hiring American workers,” — and will not be an easy fix — he strongly believes that “America will remain a vital, vibrant economy, at the forefront of the next revolution in science, technology and industry — as long as it can embrace and adjust to the challenges confronting it.” The United States “has been and can be the world’s most important continuing source of new ideas, big and small, technical and creative, economic and political.”

In fact two of the industries he cites as examples are nanotechnology and biotechnology.

So where does Zakaria’s analysis leave those of us in health care. Here are a few thoughts.

• Health care reform in the US is not just a domestic priority but an international one as well. It is both part of the problem and part of the solution to America’s future position in international affairs.
• As I have argued a number of times before( here, here, and here ) American health care can become a stronger component of our international ’soft power’ because it is a valuable and desired center around which international coalitions can be formed.
• The world (and the US) has yet to full advantage of the emergence and development of Health 2.0. What an opportunity for a technology which emphasizes social networks to bring the world a bit closer together around a major concern of all countries– health care.
• The time to bring America’s involvement in world health care to the next level is now.

Health care can help to renew America’s legitimacy to act, in Zakaria’s words as an “honest broker’ in world affairs. It is time for US health activists to think global and take leadership in this important challenge.

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Bill Hsiao: China’s Health Care System at A Crossroad

March 24, 2008 at 1:25 pm · Filed under Policy Makers, International Best Practices, International Health

Bill Hsiao, a respected Harvard China healthcare scholar, along with co-author Winnie Yip, also at Harvard, have in this most recent issue of Health Affairs describe the challenges China faces in healthcare reform very succinctly:

China is at a loss as to how to transform its new money into efficient and effective health care. To tackle the root cause of unaffordable health care—rapid cost inflation caused by an irrational and wasteful health care delivery system, the very same issue confronting the United States—China needs to decide how to reform its health care delivery and payment systems; otherwise, most of the new money is likely to be captured by providers as higher income and profits.

By injecting substantial government funding to provide basic health care universally, China has taken giant steps forward to address its problems of unaffordable access and medical impoverishment. But these initiatives are silent on how China intends to tackle a fundamental cause of its problems: rapid cost inflation and inefficiencies of the delivery system.

The decisions that China needs to make are complex, and there is no silver-bullet solution. In light of the potential scale and magnitude of their impacts, it would be advisable for China to take a step-by-step approach, guided by pilot experimentation and objective, evidence-based evaluation.

As I have argued before, the expansion of coverage without paying serious attention to the outcomes of that care, will be a very expensive and troubling experience for China.

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China’s Doctors Continue to Experience Patient Violence

February 25, 2008 at 11:19 pm · Filed under Uncategorized, International Health

I’ve written before on the growing concern over violence between patients and medical workers in China. Now Xinhua, China’s official news agency, reports on the results of a new survey of doctors co-sponsored by the China Youth Daily and Dingxiangyuan, a Chinese online medical forum. The press analysis of this study — some cautioned may be warranted here — includes some disturbing findings:

• Some 60 percent of China’s doctors have personally experienced, or have seen their colleagues subjected to, on-the-job violence from patients or their families;
• Of the 4,353 respondents, all of whom were medical practitioners aged between 25-45, 40 percent admitted to being under severe stress and “sometimes on the verge of a breakdown.” This was not because of career or financial concerns but because of suspicion and mistrust from patients and the public;
• Some 63 percent of the respondents said that they felt their health had deteriorated and 54 percent had never exercised in the past six months due to long working hours; and
• More than half of the respondents said that they had considered leaving medicine and about 36 percent said they were still considering the idea.

China’s health care system needs to bring some institutionalize response to the plight of its medical practitioners. This has to take the form of a more organized social and economic mediation effort that can absorb some of the enormous tension now burdening Chinese health care. Some officials recognize that there could be a positive future role for malpractice insurers and private health plans in helping to mitigate these types of disputes which frequency escalate into broader social instability. Let’s hope that the reported emerging health care reform measures begin to address this increasingly worrisome problem.

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Google’s “Hybrid Philanthropy” Promotes Global Health

February 12, 2008 at 1:56 pm · Filed under Prevention and Health Promotion, International Health

Larry Brilliant writes in Slate about Google’s work to come to terms with the direction of its philanthropic giving. Google.org, the relatively new face of this effort, will be funded with 1 percent of Google’s equity and profits in some form, as well as employee time — thus its ‘hybrid’ nature. Brilliant says Google asked three broad questions: 1) Where can Google work to help the poorest and weakest of the world? 2) Is it a big enough idea? and 3) Did Google have particular expertise for each potential project?

Five initiatives were decided upon all with strong health implications. They are, according to Brilliant:

Predict and Prevent: We plan to identify hot spots where there is a high risk of emerging threats, such as infectious disease or climate risk, and enable a rapid, coordinated response.

Inform and Empower to Improve Public Services: Our goal is to use information to help spur citizens, communities, providers, and policymakers to improve the delivery of essential public services such as education, health, water, and sanitation.

Fuel the Growth of Small and Medium-Sized Enterprises: As described above, we want to increase the flow of risk capital to small and medium-sized businesses in the developing world.

Develop Renewable Energy Cheaper Than Coal (RE<C): Our goal is to create utility-scale electricity from clean renewable energy sources that is cheaper than electricity produced from coal.

Accelerate the Commercialization of Plug-In Vehicles (RechargeIT): We want to plant the seeds for innovation, demonstrate vehicle electrification and vehicle-to-grid technology, inform the policy debate, and stimulate market demand to foster mass commercialization of electric vehicles.

Google’s Predict and Prevent initiative, in particular, seeks to improve the “vulnerability mapping” of disease “hot spots” and create systems to detect threats better enabling early warning and a rapid response. The development of a wiki early warning capability for pandemics, a concept Brilliant has discussed before, is certainly a fantastic match for the resources and talent that Google can bring to the global health table.

The ‘hybrid’ flexibility embedded in these new philanthropic programs is a typically smart and innovative — as well as bold– Google move. Let’s hope that people like Brilliant can put this together in a way that has a real global impact on health care.

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Collecting the Many Futures of Global Health Care

January 25, 2008 at 3:47 pm · Filed under Policy Makers, International Health

In my last post, I ran through a number of predictions about the future of U.S. health care distilled from the increasing panoply of reports crossing my desk (or my computer screen!). In looking through similar reports on the future of global health care it occurred to me put out an invitation to World Health Care Blog readers to share your thoughts — or those of others you respect — on the future of global health care. What condition will the world’s health be in by the end of the next decade and what changes to health care delivery will there be ? Let’s see if our little exercise in the web’s power to aggregate collective intelligence can flush out some interesting thinking.

To help things along, here’s a few observations on the future of global health gleaned from various sources.

• Health spending for OECD countries (Organization for Economic Co-operation and Development) will more than triple to $10 trillion by 2020. (PWC)

• Half the people that smoke today -that is about 650 million people- will eventually be killed by tobacco. (WHO)

• If current trends continue, average levels of body mass index are projected to increase in almost all countries. By 2015, it is estimated that over 1.5 billion people will be overweight. (IBM/WHO)

• Over the next 10 years, the global incidence of chronic disease is predicted to increase by 17 percent, further fueling the global burden of disease. (IBM/WHO)

• Asia is poised to be the largest pharmaceutical consumer and pharmaceutical producer in the world. (PWC)

• Fueled by the unrelenting pressures of cost, quality, and access, we believe the first two decades of the 21st century are the era in which health care systems around the globe will be driven into crisis. . . the growth in health care demand is increasing more rapidly than the willingness and, more ominously, the ability to pay for it. . . health care systems will likely “hit the wall”– be unable to continue on the current path – and then, require immediate and major forced restructuring. (IBM)

• Health care, which has remained largely regional and local to date, has not escaped globalization unscathed. The financial pressure arising from globalization is having the greatest and most obvious impact on health care systems. . . Globalization is . . . laying the foundation for health care without borders. (IBM)

• We believe these five inhibitors – financial constraints, societal expectations and norms, misaligned incentives, short-term thinking, and the proliferation of information – are and will continue to create resistance to change in health care systems throughout the world. Each will have to be overcome in the process of mapping and navigating a new, sustainable health care path. (IBM)

• Medical diplomacy . . .the exportation of ideas, personnel, and equipment from the U.S. to developing countries as a distinct medical
  industry. . . is emerging as a different and more positive approach to foreign policy than the one the United States has today . . . (Deloite)

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China Announces New Health Care Reform Effort

January 11, 2008 at 2:39 pm · Filed under Uncategorized, International Health

China’s Health Ministry has announced the “China 2020″ program that promises to “provide a universal national health service and promote equal access to public services,” according to a BBC News report. The program is intended “to reform the health system and provide a national service for all citizens, including the rural population.” According to the BBC, commentators see in this announcement a move towards a British NHS model of health care.

In a Reuters report quoting China’s Health Minister, Chen Zhu,

“Public medical and health agencies’ operating mechanisms are not adapted to the needs of the public, the improvement of health personnel’s ability is still weak and the development of the health insurance system is lagging.”

Chen said last week that market forces must not come to dominate China’s health service, as they lead only to inequality and cause the vast and poor countryside to be ignored.

So the question of the day, given these pronouncements, is what will be the emerging role of private health insurance in China? There is no way that private health insurance could ever dominate health care in China. But how big is that window of opportunity going to be? Private health insurers can bring a lot to the health care table that would be of value to China. Let’s hope they continue to have a seat as the country’s health reform effort moves forward.

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Health Care Privacy and the Surveillance State: The Struggle for Balance

January 1, 2008 at 8:21 pm · Filed under Policy Makers, Regulators, Transparency/Public Disclosure, International Health, Ethics

Health care privacy is part of the bigger picture of a society’s respect for human rights and individual persons. Balancing privacy, security as well as transparency and openness is a cultural and political challenge for any nation. Surveillance is the modern compromise for living in a dangerous world. But how much, who, where and when are choices and decision-points by authorities that affect us all. And consequently, the way we manage the tensions between privacy and legitimate surveillance generally, will impact the way we think about the privacy of medical information.

Privacy International has come out with their international privacy rankings and determinations of the world’ leading surveillance societies. The 2007 rankings indicate “an overall worsening of privacy protection across the world, reflecting an increase in surveillance and a declining performance of privacy safeguards.” One category the report is the surveillance of “medical and financial movement” in which countries like the U.S. and the U.K. (and others) are deemed countries with the worst records providing “weak protections of financial and medical privacy.”

A few weeks ago I attended the World Healthcare Innovation and Technology Conference (WHIT 3.0) where a different perspective was being advocated, namely that health care privacy laws were too strict and impeding progress in the implementation of information technologies and new media that’s needed to improve quality, access and constrain cost. Figures such as Adam Bosworth were unequivocal: Government is “trading off the deaths of hundreds of thousands of people to prevent the exposure of very few” with these laws against “possible and rare risks to privacy.” In that conference, no one contested his position. I could imagine a very different conference, say of privacy or health care activists, who would find Bosworth’s position an extreme one indeed.

I once visited a thriving hospital in Beijing where patients were lined up outside just to get services. Once inside the hospital physician’s office, they sat across the desk from the doctor along with the next few patients in the waiting line, who watched and even participated in an open door, open seating and open discussion of the patient’s problems. Certainly a surprise to westerners, but it is a normal practice at many of China’s public hospitals.

The point is, the struggle to find balance in this area is going to run up against a strong phalanx of opinion and cultural differences no matter where one sits. And it is by no means clear or self-evident, despite all manner of strong assertions to the contrary, where that balance point resides.

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China Sees Dramatic Increase in Blogs in 2007 — Important Development for Health Care

December 28, 2007 at 2:00 pm · Filed under Uncategorized, Blog News, Policy Makers, International Health

The China Internet Network Information Center(CNNIC) reports that by the end of November 2007, China had almost 73 million blog “spaces” and 47 million bloggers. “By the end of 2006, the number of blog writers was 17.5 million, and within one year the increase reached nearly 30 million, indicating the large-scale growth in number of the blog writer group,” according to the CNNIC report.

While health care is not specifically mentioned, the report goes on to say that blogs cover “almost all the areas of people’s daily life, including the cultural, military, economic, tourist, living areas, etc.” and has become an “important channel for people to obtain information.”

We know that in the West internet use to obtain health information is major activity, with blogs becoming a serious source of consumer information and empowerment. Blogs, especially bridge blogs (those that translate information from one language to another), are critical entry points in developing countries where people can gain access to health information on a global scale. Just as important is that the reverse is also possible; the growth of these blogs also gives the West an opportunity to connect and interact with what I would call ‘local communication and health care leadership’.

Now there’s a great idea: Could a blog or internet service aggregate connections to those local blogs in such a way as to facilitate health care communications directly between East and West? Sort of a ‘Global Voices’ for health care? Consumers to consumers? Doctors to doctors?

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China to Rank Physician Ethical Behavior

December 23, 2007 at 8:56 pm · Filed under Policy Makers, Consumer Engagement, Transparency/Public Disclosure, Hospital Administration, International Health, Ethics

From a China Digital Times post translated from the China News Service:

China’s Ministry of Health and Chinese Medicine Administration have jointly issued a regulation that aims to set up a evaluation system to tally the medical ethics of doctors in various hospitals and other health care providers in the country. There are three components in the evaluation regime: self-assessment, departmental assessment and institutional assessment. A filing system will also be set up to store the records, in an effort to link the ethics scores with the doctor’s compensations and promotions. But there is one thing missing, as some commentaries point out: opinions from the patients and their families.

If I were a physician in China, this new initiative would make me extremely uncomfortable for a couple reasons. First, physicians working in a health care system characterized typically by a heavy top-down management style, and absent a strong peer advocacy group, are at a distinct disadvantage when it comes to disagreements about professional behavior. And second, political intolerance of dissent and social action is often framed as action against ethical misconduct. I do recognize that medical leaders and institutions do have responsibilities when it comes to the ethical behavior of those whom they oversee. But it is the cultural and political context that surrounds this new ranking approach that makes me uncomfortable.

As far as the absence of the public ranking of physicians in this new scheme, that, my friends, is simply a matter of time.

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Some Reflections on the WHIT 3.0 Conference

December 19, 2007 at 1:32 pm · Filed under Uncategorized, Consumer Engagement, Business of Health, International Health

As I’ve had some time now to think about the presentations at the recent WHIT 3.0 conference, a couple comments are in order.

The conference was almost totally focused on what was happening in U.S. health care. This made it exciting and relevant to us. But I can’t help thinking that we still need to better integrate a global perspective on health care. As I’ve talked about a number of times, our public discourse in health care is often too insular, too self-serving and thus irrelevant when it comes to the rest of the world; that the world, and health care with it, is changing in dramatic ways. And we are not paying enough attention to the above two points.

Health care is a complicated business. The seemingly intractable problems in health care are not all due to recalcitrance, ignorance or incompetence — or even the dominance of special interests. As much as I recognize that innovations in technology and consumerism are incredibly important to fixing health care, traditionally conservative health institutions have evolved their nature due to deeply embedded aspects of human nature and how we collectively define who we are and our responsibilities to each other. Information technology innovators still have to develop a more nuanced appreciation of these dynamics. We can build it, but they might not come. The true difficulty of fundamental change in health care should not be underestimated since it involves changes in mass behavior and culture. The social cost of these changes and the propensity of things to go very wrong should instill a certain caution in our thinking.

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