Where will the innovations needed to transform global health come from?
By JAKE MILLER
The nature of health care and health systems is undergoing a period of rapid change, with reform efforts under way around the world. What can different countries learn from each other as they work to improve health care for all? And what can resource-poor countries teach developed nations?
Those were some of the questions discussed Feb. 28 at a symposium on transforming global health that drew the former leaders of two immense health care systems—the United Kingdom’s and Mexico’s—to talk about a future that is well on its way.
“It's a remarkable thing when you can get, in an academic medical center, two people who have had the burden of leadership for developing health systems in the same room to think about what has been done in the past, what needs to be done now, and what is possible going forward,” said program moderator Paul Farmer, the Kolokotrones University Professor of Global Health and Social Medicine at Harvard and chief of the Division of Global Health Equity at Brigham and Women’s Hospital.
“We asked them to join us to think about transformations going forward, about their own experiences building health systems and about the problems that they’ve seen in the systems they’ve led and in others,” Farmer said of the discussion sponsored by the Department of Global Health and Social Medicine at Harvard Medical School, which he chairs, and the Harvard School of Public Health.
For Julio Frenk, Dean of the Faculty at Harvard School of Public Health and former Minister of Health of Mexico, one of the biggest challenges for health reform remains the false dilemmas that can separate what should be an integrated, holistic system—the idea that leaders must choose between individual health and population health, between prevention and treatment or between fighting poverty and providing health care.
“We know that improving health is one of the best ways to fight poverty,” Frenk said.
As Minister of Health in Mexico, Frenk introduced the comprehensive national health insurance known as Seguro Popular, which expanded access to health care for tens of millions of previously uninsured Mexicans.
He said that setting the health system itself aside as something that is somehow separate from the rest of life is another part of the problem.
“The health system is not something abstract,” said Frenk, also the T & G Angelopoulos Professor of Public Health and International Development, a joint appointment with HSPH and the Harvard Kennedy School of Government. He noted that discussions of health are a central part of social, political and ethical life. “It’s an integral part of the fabric of societies.”
“You have to think much more about society and how it is geared to enable people to live healthy lives,” said Lord Nigel Crisp, an independent crossbench member of the House of Lords and former chief executive of the United Kingdom’s National Health Service (NHS), who works mainly on international development and global health.
From 2000 to 2006, Crisp was both chief executive of the NHS, the largest health organization in the world, and permanent secretary of the UK Department of Health. He is also the author of Turning the World Upside Down: The search for global health in the 21st century; his most recent book is 24 Hours to Save the NHS: The Chief Executive's account of reform 2000 to 2006.
To meet the triple aim of health reform—improving population health, managing costs and reducing waste—Crisp said he would emphasize what he calls the triple gain: engaging people in the co-production of their own health, capitalizing on technological gains and changing the mix of skills that doctors, nurses and other health workers (and even patients) are trained and empowered to provide.
He noted examples like self-service dialysis centers in Europe, and nurses’ successfully performing cesarean deliveries in resource-poor settings in southern Africa.
Farmer, who is also a co-founder and chief strategist of Partners In Health, said that in its international work PIH has broken down some perceived barriers by, for example, using community health workers who visit the chronically ill in their own homes. These results have not been widely reproduced in the United States, in part because people don’t think of the home as a place to deliver health care, he said.
“Here in America when we say medical home, we don’t really mean the home, we mean the clinic,” Farmer said. “We can’t quite get bold enough to reach out to people in their homes. And that’s not because we want to do renal dialysis in people’s homes, or open-heart surgery on the porch, but because there are a lot of chronic illnesses that we know are going to be better managed there.”
Health care integration is key
The panelists emphasized that the kinds of partnerships necessary for health reform offer benefits to all of the partners. Tobacco taxes can raise revenue for public services and also benefit public health, they said. Bike lanes can alleviate pollution, ease transit crunches and encourage healthy lifestyles. Affluent nations can help support medical training in resource-poor countries and benefit from the innovative solutions that are being implemented around the world, where creativity is not stifled by rigidly compartmentalized systems, they said.
“People outside this room, in Africa and Asia, will get there ahead of us, because they’ve got less legacy to lean on,” Crisp said. “Everyone’s got something to teach. Everyone’s got something to learn.”