The class collaborated in creating this first analysis using EtherPad. It was amazing how many ideas we generated in a short period of time-after being primed by some excellent reading and discussion.
The Way Things Have Been
(and still are)
The health care system in the United States has
centered on improving health within its own borders with limited attention to
global health. The US system is extremely expensive with a growing amount of
the GNP spent on health care. In spite of the growing expenses associated with
health care, the outcomes remain unacceptable when compared to other
countries. http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror?omnicid=EALERT495214&mid=mh@cmwf.org
The US system is based on a capitalist model in
which individuals obtain private health insurance to cover the costs of
care. Within this predominant model, there are some large government-financed
and administered programs including Medicaid (for the poor), Medicare (for
those 65 and older) and the Veterans Health Administration. The predominant
financial model is disease-focused, provider-centric and based on fee for
service which incentivizes costly and often unnecessary diagnostic tests and
treatment. The system is highly focused on the use of specialists versus
effective primary care, with the majority of resources spent on treatment of
disease rather than prevention. The system is plagued by waste and
fragmentation which is inefficient and frustrating to care providers and
recipients and costly to the nation.
Core values that have contributed to this
paradigm are entrenched in a competitive, for-profit system with individualistic
values of freedom of choice and a restricted view of health. Because of the leading
role of the US in advances in science and medical technology (i.e., new
drugs, treatments, technologies) the prevailing view is that we are
superior to other countries even though this belief is not supported by
comparative outcomes. The top ten countries, as evidenced by life expectancy
and health care costs are Hong Kong, Singapore, Japan, Israel, Spain, Italy,
Australia, South Korea, Switzerland, Sweden (http://www.bloomberg.com/visual-data/best-and-worst/most-efficient-health-care-countries).This national arrogance prevents us from learning what works well
in other countries and in recognizing that health is now a global issue.
The Way Things are
Becoming
New legislation, The Affordable Care Act of 2010
http://www.hhs.gov/healthcare/rights/
is driving health care transformation in the US
including insurance reform, payment reform including value based purchasing and
bundled payments, population based care, health care homes, and patient/family
centered care models. Many of these new models of care will increase the focus
on prevention and will rely on the use of interprofessional teams to provide
“health” rather than “sick” care.
In addition, there is a growing realization that
the health of the world is interconnected. Notable are the realizations that
the risks for spread of infectious diseases are greater than ever. Rapid
spread of diseases, such as ebola, H1N1, SARS and now MARS, provide evidence
for the potential for international epidemics. Maps of international air travel
support the notion that a pandemic is only one plane ride away http://www.theguardian.com/world/ng-interactive/2014/aviation-100-years
Healthy People 2020, the US roadmap for
improving the health of the population http://www.healthypeople.gov/2020/default.aspx, now contains goals related to international health-but from the
perspective of how problems such as infectious diseases might affect the health
of US citizens. This approach sustains a nationalistic perspective.
The health care needs of the world population
are now converging in a new way. Improvements in worldwide health, especially
in prevention and treatment of communicable diseases, have led to increased
longevity in the developing world and concomitant rises in non-communicable
diseases including cardiovascular disease, diabetes and cancer. Issues related to demographic shifts in
population growth and the exponential growth of the elderly worldwide are
integral to the rise in chronic illness. As these common diseases increase, the
world demands the translation of known solutions to be put into practice and
for shifting the paradigm from disease to prevention. There is also a growing
recognition that effective solutions must be generated within the context of
local communities. The demand to “Think Global and Act Local” is particularly
salient to improving health at the community level.
The core values needed to advance health
globally will require a shift from a purely nationalistic perspective. here is much to be learned from other
countries if the US can move to a more open and collaborative framework. Other
countries can teach us about controlling costs, for example by not allowing
insurance providers to compete, as is done in Japan. In Hong Kong, touted the
most efficient health care system on the planet with health care costing 3.8%
of their GDP, most hospitals are public. A recent article in the Huffington
Post provides some startling infographics regarding the more efficient health
care systems across the world. http://www.huffingtonpost.com/2013/08/29/most-efficient-healthcare_n_3825477.html Ultimately a real shift in values to a more humanitarian and
altruistic approach will be needed to advance the health of our planet.
Key Drivers
The key forces that are contributing to this
shift include the rapid spread of business and markets from a national to a
global level. The economic conditions of the world are intertwined more than
ever before. Businesses care about the health of people from other countries as
these individuals are now their employees and the environments in other
countries contribute to to the health of US employees who may be working there.
International business models have even extended to selling health care with
the growth of the “health tourism” industry in countries like Mexico and India.
The ability to communicate cheaply through
enhanced computer and smart phone technology has created new international
networks, businesses, and communities. For example, Skype now has surpassed two
billion minutes per day http://blogs.skype.com/2013/04/03/thanks-for-making-skype-a-part-of-your-daily-lives-2-billion-minutes-a-day/. The ability to travel easily across the globe has been another
major driver. In many regions (example the Eurozone), the ability to cross
borders has become more flexible. Major patterns of shifting immigrant and
refugee populations are diversifying the peoples within nations. Almost all
countries are becoming more diverse- multi-racial/ethnic and multicultural.
The international issues about the health of our
planet and predictions related to climate change are also leading to shared
global initiatives to protect our environment-our agricultural lands, water and
air. These factors are integral to the health of the world.
Challenges
The shift to a cooperative and collaborative
model to improve global health remains challenging in a world marked by terrorism,
war and revolution. How will unstable governments (dictatorships, theocracies,
etc.) affect global health (violence, refugees, etc.)? Where will refugees go
and who will be responsible for their health? Will a pandemic, natural disaster, or the
rising seas wipe out communities or countries?
Barriers to shifting to a paradigm of global
health include lack of understanding across cultures, corruption, a lack of
social or public trust, weariness and skepticism of governments, economic instability and a lack of resources and infrastructure.
Cultural definitions and values of health differ as well.
\
Question to Consider
Global agencies, (e,g. the UN, World Red
Cross and WHO) must take the lead and create international strategies to
raise awareness, promote collaboration, networking, shared learning and promote
effective policies. International business leaders must join forces with
governmental and nongovernmental partners to address issues relate to global
health. Local communities must engage and lead at the local level.
Major
questions to consider include:
1. How do we scale up and promote adoption
of interventions that work in a way that promotes their sustainability in
diverse communities?
2. How do we create low cost and feasible
solutions to some of the major barriers to advancing health? The Bill and
Melinda Gates Foundation contest design effective toilets without water or
electricity is an excellent example http://www.gatesfoundation.org/media-center/press-releases/2012/08/bill-gates-names-winners-of-the-reinvent-the-toilet-challenge
3. How do we leverage technology to promote
health and encourage global collaboration?
4. How do we advance health without addressing
core determinants such as poverty, lack of education, and income?
5. How do we promote equity to all societal
members by decreasing barriers to health access, and decreasing gaps in quality
of care that go beyond race and socioeconomic status?
6. How to globally collaborate with each other
to solve inequity, environmental and other health issues?
7. How do we promote a value of learning from
each other to improve the health of the whole?
8. How do we identify and engage communities in
identifying their health priorities? How can we collaborate to address shared
priorities?
9. How do global communities respond to natural
catastrophes-earthquakes, hurricanes, tsunamis?
10. How do we engage all countries in preventing
the health and other consequences of climate change?
Some additional readings
and resources
Health People 2020
Top 20 Global Health Priorities
Ten facts on the state of global health
Social Determinants of Health
Created by Participants in Nursing 7106 Context
for Advancing Science (and Improving Health)
University of Utah College of Nursing PhD
Program Summer 2014
Submitted by Dr. Susan Beck (Lead Author)
Follow me on Twitter @Susan Larsen Beck
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