Global health is a story of the good, the bad and the ugly....
The good. There have been extraordinary gains in longevity and health. Between 1990 and 2015, the global infant mortality rate fell by 42% and the child mortality rate by
53%. Over the past 60 years global life expectancy has increased by more than 20 years – with people living well into their eighties in many wealthy, industrialized countries.
The bad. Millions of people continue to suffer and die from health conditions that can be easily and inexpensively prevented or treated with existing knowledge and tools. In
2014, nearly 6 million children died before celebrating their fifth birthday (the majority from prematurity and vaccinepreventable infectious diseases) and an estimated 642
million people will be living with diabetes by the year 2040, representing an increase of more than 50% from 415 million today.
The ugly. Gross disparities are made apparent by juxtaposing our most impressive global health achievements with our most dismal failures. At the international level,
there are drastic differences in life expectancy between high- and low-income countries, ranging from Japan at 83 years to Sierra Leone at 45. Massive disparities also occur at the national level – within the same health system. In the
United States, the maternal mortality rate for black women is almost three times higher than for white women, although the prevalence of the most common birth complications
is roughly similar. A recent review of health indicators (including child mortality, life expectancy and obesity) among indigenous populations in over 20 countries found almost
universally poor outcomes relative to corresponding nonindigenous populations. In Australia, Canada, Cameroon and Kenya, the life expectancies of indigenous populations
were at least 10 years lower than in the general population and over 20 years in Cameroon.
The world’s health deficits are especially disconcerting given indications of wasted resources within health systems in both rich and poor countries. In 2013, the United States
spent nearly 50% more on healthcare as a percentage of GDP than the next highest OECD spender, France, without superior health outcomes, such as life expectancy. That
same year, Paraguay achieved similar health outcomes in terms of life expectancy and child mortality as El Salvador – despite spending 34% more per person on healthcare and
having similar per capita income. The world aspires to erase its glaring health deficits, as underscored by the 2015 Millennium Development Goals and the 2030 Sustainable Development Goals. The main
focus has been, and continues to be, on increasing the scale and efficiency of resources devoted to:
1. medical interventions (e.g., the provision of drugs, vaccines and primary healthcare);
2. non-medical health interventions (e.g., the expansion and strengthening of health delivery systems, the widening and deepening of human resources for health, and the more widespread provision of safe water and sanitation); and
3. non-health interventions that can have a powerful impact on health outcomes (e.g., governance, education, housing and the social conditions that influence daily life). Globally, many laudable initiatives
are under way to extend potential longevity and enhance overall well-being, with technological, social and institutional innovation featuring prominently in the effort.
The misalignments perspective takes a step back and looks across the field of players to see how their delivery of healthcare is affected by the way they interact with each other, the barriers in their paths and the size of the
field. Reaching beyond the realities of each stakeholder community and looking at these disconnects with an open mind and creativity has shown us that these are issues
of paramount importance to almost every stakeholder community, and there are compelling examples of alignment from which we can draw lessons to apply to a wide range of
issues within the health sector. Fortunately, where misalignments can be identified, they can potentially be corrected. Better aligned systems may yield either of two positive results:
1. maximizing health outcomes and healthcare delivery for a given amount of spending; or
2. minimizing spending while maintaining the same level of health. More specifically, we estimate that if used more effectively, current patterns of
national health spending could potentially raise global life expectancy by over four years. Alternatively, current patterns of life expectancy could potentially be achieved with as little
as one-third the current level of health spending. Whether viewed in terms of money for health, or health for money, these analyses are suggestive of considerable waste and
The objectives set out to:
1. better understand misalignment among stakeholders (such as patients, regulators, pharmaceutical and device manufacturers, providers, insurers, academia, policy-makers and investors);
2. articulate a vision of more fully aligned health systems and the ways in which they will improve health outcomes;
3. design a plan for how to achieve it; and
4. estimate the potential health and economic gains associated with better alignment.
Three specific disease areas within which to focus its attention so that practical recommendations could be generated within the resource and time constraints of the project. These disease areas –
cancer, diabetes and mental health – were chosen because of their significant and growing contribution to death and disability globally. The focus of this exercise was global, and it sought to
address the following questions for each of the three diseases:
–– How do misalignments among stakeholders lead to increased incidence of disease or poor quality of care?
–– What real-world examples demonstrate misalignment and its effects?
–– What are real-world examples in which stakeholders have reasonably aligned incentives or structures – and how does this manifest itself in terms of health outcomes?
–– What would it take for incentives, structures and priorities for each disease area to be more systematically aligned at local, national and global levels?
In terms of relevance and scale, it is rooted in analyses at the national level. The aim is to identify instances in which systemic flaws lead to suboptimal
outcomes. It is worth noting that did not consider cases of fraud or corruption for this study, though these represent a subject ripe for future research.
While fraud and corruption constitute a significant class of misalignment in many countries, adequately addressing the complexity of the problem and its solutions would require
a special focus beyond the scope of this text.
Problem of Misalignments...
The conceptualizes misalignments as situations in which the incentives, structures, or policies that shape the behaviour and interactions of health sector stakeholders
result in wasted resources or suboptimal health outcomes. Misalignments can often be corrected and aligned, but that requires a clear understanding of the nature of the
misalignment and the reasons for it. In this vein, our ultimate goal is to understand the steps that may be taken to achieve better aligned health systems.
A key premise of our analysis is that the vast majority of health sector stakeholders desire better health, even if their actions may be driven in part, or even dominated
by, alternative motivations. For example, governments may want their populations to be healthier to have more productive and cohesive societies. At the same time,
individual actors within governments may make decisions based on self-interest, as in seeking re-election. In this case, misalignments may occur when governmental structures
unnecessarily place political advancement at odds with the institution of sensible health policies.
Similarly, while stakeholders who sell therapeutic services (e.g., medical care) or curative products (e.g., pharmaceuticals) operate to improve health, they are
businesses that must weigh profit maximization and shareholder interests against optimizing health outcomes. This internal conflict in motivations is not a misalignment
in itself. Businesses exist to sell goods and services for financial gain. In the case of for-profit businesses, the situation becomes a misalignment when incentives, or other
forms of conflict, artificially divorce profit maximization from health optimization.
Taxonomy of Misalignments...
What are the most common misalignments? The research shows that three categories of misalignments stand out: those due to divergent objectives; power
asymmetries; and cooperation failures. But, as in any complex system, many examples do not fit neatly into one category and may cross over to other types. Further, we do not consider these categories to be an exhaustive list but
rather a synthesis of the most compelling ones that emerge from research.
Divergent objectives. This category covers divides between the long- and short-term interests of stakeholders, myopic targets or payment mechanisms (such as fee-forservice),
or inadequate data and tools for decision-making. Lack of reimbursement often deters clinicians from billing for over-the-phone or electronic consultation. As a result, most
patients cannot contact their physician for a rapid, remote consultation even though this may be the most efficient way to receive timely medical advice. Patient health may
deteriorate while they wait to see their provider in person, which can result in costlier treatments and worse health outcomes. In these circumstances, restrictive payment
mechanisms provide a disincentive for clinicians to act in the best interests of their patients and ultimately lead to excessive healthcare costs borne by public and private
payers. This misalignment affects care across many health systems.
Prioritizing immediate comfort over long-term consequences has driven a number of undesirable phenomena when it comes to the overuse of antibiotics. These include:
the large-scale use of antibiotics in commercial farming to promote growth and control infections; the improper prescription of antibiotics for infections that will not respond
to them; the rampant misuse of over-the-counter antibiotics in many countries; and the lack of adherence to antibiotic regimens, even when properly prescribed. As a result, antimicrobial resistance is increasing globally, creating a
transnational threat. Estimates show that drug resistant “superbugs” are likely to kill an additional 10 million people per year by 2050 – accounting for more deaths globally than
all cancers combined. The perceived immediate benefits of antibiotics to individuals are being given preference over the social appropriateness of their application, causing everyone
to face the stark long-term consequences of overuse. Power asymmetries. This category covers imbalances of power (economic, legal, informational, or political) that arise
among stakeholders and create waste – possibly because one stakeholder is able to impose their will in a way that severely restricts the ability of disadvantaged stakeholders
to impact decision-making.
The main goal of most private companies is to make a profit and the tobacco industry claims no immunity to this ambition. While the tobacco industry’s methods for
generating revenue clearly have negative consequences for public health, this fact alone does not constitute a misalignment. Misalignment arises when the tobacco
industry uses its economic power to threaten or instigate legal battles that governments do not have the finances to fight, preventing policy-makers from successfully
implementing tobacco-control laws, launching public health education campaigns, or utilizing other policy tools such as taxation. Without being able to employ legally and
publicly sanctioned tools that are typically used to protect public health, governments are left to bear the full costs of tobacco consumption in the form of increasing medical
costs and slowed economic growth due to premature death and disability. The council acknowledges that tobacco consumption is driven by a complex array of forces,
including addiction, cultural attitudes towards tobacco, and the diversity of economic and legal factors at play within unique national contexts. Nevertheless, power imbalances
between the tobacco industry and some governments significantly contribute to the problem by preventing officials from spending resources in a manner that would be most
effective for promoting health and thereby creating waste.
Those who enrol in Medicare (a social health insurance programme administered by the US government) can purchase prescription drug plans (PDPs) from private
insurance companies and pharmacy benefit managers in Medicare Part D. Federal law currently prohibits the government from negotiating prices with drug manufacturers
on behalf of Medicare, with the intent of encouraging the private companies that administer PDPs to negotiate directly for lower prices. However, evidence suggests that these
private companies fail to secure prices as low as those paid by federal programmes that can negotiate (such as the Veteran’s Health Administration and Medicaid). Recent
estimates show that the government could save $15.2 billion-$16 billion annually if it obtained the same drug prices for Medicare as obtained by other federal health
programmes. The legal regulations that restrict the government from negotiating on behalf of PDPs create an artificial power imbalance between the government and pharmaceutical
companies. As a result, the government pays higher prices for drugs under Medicare Part D than through other federal health plans, thereby wasting taxpayer resources for the
health outcomes achieved. It is worth noting that changes to this legislation have been included in the fiscal year 2017 budget from the Office of the US President and submitted to
Congress for revision and voting. Cooperation failures. This category covers barriers (such as cultural, operational and regulatory) that keep stakeholders from collaborating in their mutual best
interests. These failures generally reflect disconnected budgets, lack of leadership, or barriers to data-sharing.
In many countries, electronic medical records (EMR) systems have poor interoperability. Primary care providers, laboratories, specialists’ offices and hospitals may maintain
separate EMRs for a single patient, without passing any information between them. This lack of sharing and connectivity contributes to redundant testing, medical errors
and disjointed care, all of which can result in poorer health outcomes for patients and higher costs across the system. Experts contend that the main obstacles to correcting this
misalignment include the complexity of sharing information among hundreds of EMRs and the lack of incentives for manufacturers to collaborate on connecting their products.
Vendors are actually incentivized not to share information by default so that they can charge data exchange fees when they do choose to connect to other EMR systems.
While the stakeholders would stand to benefit as a whole from greater EMR interoperability, no single party will necessarily net a positive return if required to individually
fund a project to increase compatibility. Unless cooperation among stakeholders can be marshalled by implementing a mechanism through which costs are shared in proportion to
the benefits enjoyed, this issue is likely to remain unresolved.
Cooperation failures prevent providers, insurers and consumers from capitalizing on innovations that can improve patient health and quality of life. With diabetes,
new technologies such as wearable monitors, tele-health interfaces and predictive analytics to tailor treatments to each patient are all being underused. Medtech and
software developers find it difficult to get their products implemented across health systems because doctors do not see it as their job to select and “prescribe” these kinds
of innovations. Moreover, providers operate in fragmented systems and are most frequently compensated to provide drugs and treatments but not preventive technologies.
Moreover, difficulties in sharing health data at every level of the system prevent effective and meaningful use of the information these devices might be able to provide. As a
result of these barriers, technologies that hold tremendous potential for achieving health gains remain largely unused. Each stakeholder seems to be focused on immediate and
incremental gains – unwilling to pull together to achieve a much bigger transformation. As with EMR interoperability, a lack of cooperation keeps stakeholders from making a
collective investment in an innovation that would also yield collective benefits.
To Be Continue...