Wednesday, July 16, 2014

Analysis of Shifting Paradigms 1: National to Global (but Local)

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.
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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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