The latest edition of The Health Wrap investigates resilient health systems, COVID-19 vaccine supply chains, healthcare innovation in the United States, and how to improve care for patients with chronic and complex conditions.
Associate Professor Lesley Russell also provides an overview of the challenges facing health and healthcare in Afghanistan.
And don’t miss the featured video from the Aboriginal Medical Service Redfern; it will lift your spirits.
Lesley Russell writes:
One of the key things we have learned from the coronavirus pandemic is the importance of preparedness and forward planning. Epidemiologists are already warning us that there are other, new pandemics coming.
Aside from watching out for zoonotic disease spill over (or animal to human disease transmission), what else should be happening?
A paper from Boston University School of Public Health – commissioned by the Independent Panel for Pandemic Preparedness and Response and recently published in Nature Medicine – examines the pandemic responses of 28 countries for lessons and recommendations on how nations can better prepare for future health threats.
Australia is not included, but New Zealand is.
Health systems urgently need to invest in resiliency, it argues. Resilience here is defined as the capacity of a system to prepare for, recover from and absorb shocks, while maintaining core functions and serving the ongoing and acute care needs of their community. (It’s important to note that the focus here is on health systems, not just healthcare systems.)
Resilience is a core concept in disaster risk reduction, but its application to health systems is relatively new. In this research it was assessed by an analysis of governance and financing, the health workforce, medical products and technologies, public health functions, health service delivery and community engagement and how these came together to prevent and mitigate the spread of COVID-19.
The key findings of this research show that resilient health systems:
- Invest in pandemic-related planning and training of health workers.
- Ensure health workers’ physical, mental, and economic protection in the workplace and beyond.
- Have public health functions, including surveillance, testing and contact tracing, that are proactive, comprehensive, coordinated with the health system, and emphasise community engagement.
- Use community health workers as a key mechanism to ensure community engagement.
The paper concludes that enhancing resilience to future disease outbreaks requires long-term work to create high-quality healthcare systems and build community trust. Arguably no surprise there!
It makes recommendations for urgent action in six areas:
- Implementing a whole-of-government approach that incorporates all sectors across all levels and considers gender, race and human rights.
- Providing appropriate levels of financing to promote population health, ensure access to healthcare, and protect poor communities.
- Improving both the quantity and quality of health workers.
- Addressing the challenges to global supply chains for medicines and products.
- Investing in strong and well-funded primary care, with a skilled and protected workforce, with strengthened linkages to public health systems, and similarly, investing in the long-term care sector and care for older adults.
- Recognising that the digital technologies involved in public health functions such as testing and contact tracing have the potential to exacerbate inequalities and be the vehicle for human rights violations.
The conclusion is that health system resilience must go beyond technical and biomedical knowledge and actions, to engage with the broader social, economic and political factors in society.
The approach should be guided by equity concerns and requires community engagement as much as regulations and hospital capacity.
Here developed countries can learn from regions such as Asia and Africa, which have effectively mobilised community health workers and communities to extend the reach, capacity and quality of their health systems.
There is some excellent further information on the importance of community engagement for COVID-19 prevention and control in a 2020 paper in BMJ Global Health, which looks at how community engagement was used during the Ebola, Zika, SARS, Middle East respiratory syndrome and H1N1 epidemics.
And if we need any local examples of how important community engagement is during the pandemic, we need only look to south west Sydney or Walgett or Shepparton.
COVID-19 vaccine supply chains
If you’ve ever had anything to do with the manufacture of vaccines, then you know that it is an incredibly complicated operation – and that is after all the R&D is done and the approval processes navigated. (I am no expert on this, but I once worked for an international pharmaceutical company that develops and manufactures vaccines.)
A recent working paper from the US-based Peterson Institute for International Economics – ‘How vaccine supply chains emerged in the midst of a pandemic’ – looks at what is known about the manufacture of the COVID-19 vaccines of Pfizer/BioNTech, Moderna, AstraZeneca/Oxford, Johnson & Johnson, Novavax, and CureVac. (The Russian and Chinese vaccines are not covered.)
It describes how dozens of other companies at nearly 100 geographically distributed facilities had to work with the major manufacturers to scale up global manufacturing.
It also looks at major pandemic policy initiatives—such as Operation Warp Speed in the United States and COVAX — and how these have affected the timing and formation of the vaccine supply chains.
It concludes with this statement:
As increasingly detailed data emerge, researchers must investigate how production was scaled up and what impact policy had in order to shed light on two critical questions: Could more vaccine doses have been manufactured more quickly some other way? Would alternative policy choices have made a difference? Answers will hopefully help prepare policymakers for the next pandemic.”
The intertwined supply chains outlined highlight the international complexity of vaccine manufacture and why getting vaccines to low-income countries is about so much more than just waivers of intellectual property rights or compulsory licencing. (There’s a good discussion of these IP issues here.)
Not that Australia has been very cooperative internationally in that regard, as outlined in an article in The Saturday Paper (sadly behind a paywall).
Last year India and South Africa put forward a proposal (known as the TRIPS waiver) for a temporary waiver on intellectual property rights around coronavirus vaccines. This quickly garnered the support of two-thirds of World Trade Organization member states, including the United States.
Under the waiver, third parties would be able to manufacture generic vaccines. Developing countries could purchase these vaccines at a set price closer to the cost of production rather than the monopoly prices currently being charged. Well-off countries such as Australia would continue to purchase brand-name vaccines at prices set by the pharmaceutical companies.
However, Australia has been sitting on the fence, openly using pharmaceutical industry talking points, and thus helping other holdouts prolong the WTO negotiations. Apparently the Morrison Government claims its support for COVAX is sufficient!
(Read more on global vaccine equity issues in the latest media briefing from World Health Organization Director-General Dr Tedros Adhanom Ghebreyesus, and also in this Twitter thread, excerpted below.)
Designing for patients with chronic and complex conditions
It is often argued that current models of hospital care are not optimal for the care of the rising numbers of patients with multiple chronic conditions and older, frail patients.
A recent study in the National Health Service looked at important lessons from models of generalist and specialist care in smaller hospitals in England.
The study was published in February in Health Services and Delivery Research. It is discussed in some detail in a recent blog on the Nuffield Trust website.
Here are my take-outs:
- Models of care are rarely designed to meet (local) patient needs; they are usually developed in response to external pressures and the available resources.
- Little attention is paid to how a patient passes through the system (from admittance to discharge) and how each transfer of care impacts the patient, other parts of the hospital, and other parts of the healthcare system.
- Models should be designed for bad days (periods of high demand) rather than good days – there are almost always major gaps between how models are meant to work and how they actually work.
- Continuity of care matters, but discontinuity of care (changing consultants and care teams) is the norm and adds to the length of stay.
- Older consultants were generally more comfortable with older patients and those with multiple conditions; younger consultants, while happy to manage acute conditions, felt under-prepared in caring for these patients. This highlights training issues.
- Patients don’t care about models of care – they worry about having their needs met and the quality of care.
- There needs to be a much more deliberate approach to the design of systems of care and a move away from what is described as “a relentless focus on the front door of the hospital”.
The authors conclude that while the case-mix of the smaller hospitals studied was dominated by presentation that were amenable to generalist approaches, there is no evidence that any one model of care produces better patient outcomes.
While these take-outs are in response to a paper about smaller NHS hospitals, I feel they are largely applicable in Australia.
And it got me thinking about why health policy/planning people don’t do more to address the continuity of care of this cohort of patients?
This was a recommendation from the Productivity Commission in the Shifting the Dial report, which highlighted that care pathways, especially between primary and acute care (ie between GPs and hospitals), are often poorly coordinated.
There are structural barriers, such as incompatible information systems, weak linkages between the various health professionals, gaps in availability of services, and funding models which discourage integration.
To be honest, it comes up in nearly every report and piece of expert advice that has been provided to the Federal Government over the years.
It is there is the recently-released discussion paper from the Primary Care Reform Steering Group, which talks about a “person-centred health and care journey, focusing on one integrated system” and recommends a single integrated system focus where secondary (specialist) and tertiary (hospital) systems are reorientates to support primary health care to keep people well and out of hospital.
I went looking for responses to these recommendations. Intriguingly, the paper (still available on the Department of Health website) has disappeared off the Government’s consultation website and I can’t find where all the responses are collected.
However, many or most are available on the websites of the various organisations which have responded. It’s interesting to read the various responses.
Most striking for me – although hardly surprising – was the totally difference focus of the Australian Medical Association (AMA) compared to the Consumers Health Forum (CHF).
The AMA response is here.
The AMA supports the intention and direction of the [steering group] recommendations provided there is a commitment from Government that general practice funding is increased to 16 percent of total health expenditure and that a GP-led governance structure is put in place for implementation.”
The CHF response is here.
Care needs to be taken to make sure that the reforms do not create just another system developed by interest groups and experts. While these groups and people may believe they understand consumers and are developing person centred care, consumers must be equal partners in developing the systems that affect them, and in helping other partners to understand their health experiences and journeys.”
Learning from innovation in the United States
We all know what’s wrong with healthcare in the United States, but there are also many positive lessons to be learned from innovations in how healthcare is delivered and financed.
Way back in 2014, along with three colleagues who had lived and worked in the United States, I wrote a paper about what we could learn from American healthcare. Shockingly it’s still applicable today.
In this paper – and in my writing over the years – I often cite the work done by the Center for Innovation at the Center for Medicare and Medicaid Services (part of the Department of Health and Human Services) that was set up as part of the Affordable Care Act (Obamacare).
The article I wrote for Croakey Health Media when this was first established, back in November 2010, is here, with the headline, ‘Beyond hospital bed tallies: let’s hear about some innovation in health care’.
For the last two elections, the federal Labor Party had a policy that in government it would establish a permanent Healthcare Reform Commission, including a Centre for Medicare Innovation. It’s unclear if this has survived the current discarding of previous election commitments.
The 2020 Report to Congress from the Center for Medicare and Medicaid Innovation has just been released, with lots of insightful information for health policy wonks. And it’s interesting to note that this work continued under the chaos of the Trump Administration (probably because it was under their radar).
In the two years to 30 September, 2020, the CMS Innovation Center has been involved in 38 payment and service delivery models and initiatives and conducted six congressionally mandated or authorised demonstration projects.
The focus is on moving from a healthcare system that pays for volume to one that pays for value and encourages health care provider innovation. Alternative Payment Models tested include Accountable Care Organization (ACO) models, episode payment models (also known as bundled payment models), population health-focused payment models, and models that test integrated care for Medicare and Medicaid beneficiaries.
A number of the models trialled have been shown to deliver cost savings and improved quality. Others have not generated net savings but have provided valuable insights to inform the design and development of subsequent models.
The discussions about how tested models that did not work as well as planned have been examined and reworked are particularly valuable and highlight how even studies that fail can inform future work.
On the Health Affairs blog, the Biden appointed CMS Administrator Chiquita Brooks-LaSure and her colleagues outline the agenda for the next ten years.
In particular, they want to make sure that what is learned from the work supported by the Center for Innovation is incorporated into the operation of Medicare and Medicaid.
There are six key takeaways:
- The Innovation Center should make equity a centrepiece of every model.
- Offering too many models is overly complex, particularly when models overlap.
- The Innovation Center needs to re-evaluate how it designs financial incentives in its models to ensure meaningful provider participation.
- Providers find it challenging to accept downside risk if they do not have tools to enable and empower changes in care delivery.
- Challenges in setting financial benchmarks have undermined the models’ effectiveness.
- Innovation Center models can define success as encouraging lasting transformation and a broader array of quality investments, rather than focusing solely on each individual model’s cost and quality improvements.
As I said – so much Australia could learn here.
Afghanistan – a focus on healthcare
The news from Afghanistan is increasingly awful. I hesitate to venture into this political minefield, but thought it was worthwhile trying to summarise what the situation is with respect to healthcare services.
A quick summary is that it is dire now and can only get much worse.
After years of poverty and war, Afghanistan’s healthcare system is deteriorating and is often considered one of the world’s most “inferior.” Afghanistan ranked 170 out of 189 countries in the 2019 Human Development Index of the United Nations Development Programme
The Afghan economy has been almost totally supported by international aid (much of which we now realise has been siphoned off by corruption). This is also largely the case for the healthcare system. A 2019 study by the World Health Organization found that of the four percent of the national budget allotted to the Afghan Ministry of Public Health, 80 percent was funded by foreign donors.
In recent years healthcare facilities in Afghanistan have been attacked more often than almost anywhere in the world, forcing their temporary or permanent closure and depriving millions of people of access to vital medical services. The worsening humanitarian crisis has been compounded by the health and socioeconomic shocks of the coronavirus pandemic.
A Médecins Sans Frontières briefing document from May 2021 outlines the issues as they were a few months ago.
In August there was an update from MSF on how the growing violence and heavy fighting was severely exacerbating people’s access to care. COVID-19 has overwhelmed the healthcare system even further.
As one doctor interviewed said: “People have one hundred problems and COVID is just one of them.”
The WHO recorded 152,411 confirmed cases of COVID-19 and 7,047 deaths in Afghanistan between 3 January and 19 August. Given the limited testing this is certainly a severe under-estimate.
The country was at the end of a third wave of infections with the number of cases dropping. Now crowding at health facilities and camps for displaced people will limit implementation of infection prevention protocols, increasing the risk of COVID-19 transmission and outbreaks of other diseases.
According to WHO, the nation of 40 million people had administered a total of 1,872,268 vaccine doses by 14 August. Vaccine supplies have been limited; there has been a few million doses from India and China and half a million doses from COVAX. Evacuations and disruptions at the airport are delaying urgently needed essential health supplies and vaccines.
Now health officials say they are “in a kind of a limbo, waiting to see who will be in charge. Let’s see if donors will continue supporting the system.”
A particular fear is for women’s health. In the previous Taliban era women were denied access to most healthcare facilities and female health professionals were not allowed to work. As Professor Mike Toole wrote in Croakey, maternal mortality soared, as did preventable diseases and childhood malnutrition.
A recent Human Rights Watch report on Afghan women’s access to health care shows that the delivery of health services for women remains far below international standards. It is eroded because pre- and post-natal care, even the most basic information about family planning, and preventive services such as cervical cancer screening and mammograms are rarely available.
In conclusion – I will return to the politics and history. For me, the most insightful explanations of what is happening in Afghanistan and why have been from an American expert, Sarah Chayes. She talked about the corruption that the United States ignored on a recent edition of the PBS NewHour here. Her blog, regularly updated, is here.
The best of Croakey
Don’t miss these two articles by journalist Cate Carrigan, who lives in south west Sydney. [Croakey thanks donors to our public interest journalism funding pool who supported these stories.]
Read: ‘To improve pandemic control, listen to the community leaders of western and south west Sydney’.
Read: ‘Shocking stories from the frontlines drive calls for innovative mental health solutions’.
The good news story
The good news story just has to be the Aboriginal Medical Service Redfern team dancing to the beat – and encouraging COVID-19 vaccination. Who could resist their energy and enthusiasm?
Watch the video here.
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.
Previous editions of The Health Wrap can be read here.
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