© professor rifat atun. imperial college london 2012 professor rifat atun mbbs mba frcgp ffph frcp...

© Professor Rifat Atun. Imperial College London 2012

Professor Rifat Atun MBBS MBA FRCGP FFPH FRCP

Professor of International Health Management

Imperial College Business School and Faculty of Medicine

Imperial College London

Innovation in Health Systems

Workshop to Improve the Design of the

Laboratory of Innovation in Health Systems and Services

Brazilian Ministry of Health

Strategic and Participatory Management Secretariat

Brasilia

15-16 August 2012

© Professor Rifat Atun. Imperial College London. 2012

Innovation is critical to improved health outcomes


Innovation and innovation adoption is critical to sustained health system improvements

World Health Report 1999


Innovation is key for addressing health inequities and health system challenges


Challenge 1: Rising health expenditures as a % of GDP

Source: OECD health data 2010


Health care expenditure is likely to continue to rise

A desire to take medicine is perhaps the greatest feature which distinguishes man from other animals

Sir William Osler


Challenge 2: Health Sector productivity (Real Sector Growth -Compound Annual Growth Rate-, Broken into Labour Productivity Growth and Employment Growth in Various Sectors of the U.S. Economy, 1990–2010)

Kocher R. Sahni NR. Rethinking Health Care Labor. N Engl J Med 2011; 365:1370-1372


Challenge 2: Health systems-productivity Perceptions on inefficiencies

“ I once asked a worker at a crematorium who had a curiously contented look on his face, what he found so satisfying about his work. He replied that what fascinated him was the way in which so much went in and so little came out.

I thought of advising him to get a job in the [health system]...”

Modified after late Archie Cochrane


Challenge 2: Health systems-productivity Inefficient hospitals

“Over the last ten years, there has been significant real growth in the resources going into the NHS…. The evidence shows that productivity in the same period has gone down, particularly in hospitals.”

Amyas Morse, head of the National Audit Office, 17 December 2010


Challenge 3: Slow Adoption of health innovations


Health innovations diffuse slowly

• 1601: James Lancaster demonstrates that lemon juice cures scurvy

• 1749: Experiment repeated by Lind – 1753 “A treatise of the scurvy”

• 1795: Royal Navy acts on evidence

• 1865: Merchant Navy acts on evidence 254 years later!


Coverage for interventions across the care continuum: 68 priority countries (2000‐06)


Nandakumar A et al. Health Aff 2009;28:986-995

©2009 by Project HOPE - The People-to-People Health Foundation, Inc.


Poor uptake of innovations mean missed opportunities for reducing mortality as well as morbidity and creating health and wealth


Key barrier 1: linear view of innovation adoption

Input Output Outcome


Key barrier 2: limited evidence

Methodological challenges in generating evidence

What works in practice and what has worked less well

Scale and learning effects?

1

2

3

Suboptimal

innovation

solutions

implemented

Sources of resistance to innovation adoption


Key barrier 3: asymmetric industrial and health policies

Industrial policies encourage technology push, but health systems constrain innovation:

– Not enough emphasis on demand side factors– Inadequate incentives and downstream rewards

for adoption– Inefficiency/ineffectiveness tolerated– No incentives for innovation

Atun RA, Gurol-Urganci I, Sheridan D. Uptake and diffusion of pharmaceutical innovations in health systems.

International Journal of Innovation Management 2007; 11 (2): 299-321


Medical Research Council Investment by research stage (% of total)


UK Department of Health Investment by research stage (percent of total)


The translation gaps

Cooksey Report 2006


Key barrier 4: institutional logic

• Resistance to innovation


Key barrier 5: Wrong kind of innovation


Need a holistic and systems approach to innovation


Framework for analysing adoption and diffusion of innovations in health systems

InnovationAdoption

System

Broad Context

Broad Context

Health System

Problem

Institutions

Atun R. Health Systems, Systems Thinking and Innovation, Health Policy and Planning 2012


A systems approach to innovation

1. Problem perception

1. Innovation

2. Adoption System

3. Health System

4. Context

• Burden• Necessity and urgency

• Complexity• Scalability

• Receptivity• Opportunity

• Feasibility

• Desirability• Logic

Atun et al. Health Policy and Planning 2010


The Problem

• Necessity and Urgency• Burden

– Economic and social consequences

• Perceived and real• Social Narrative

• Transmission dynamics


The Intervention

• Complexity

• Scalability

• Simpler to more complex*

• Replicability

• Standardisability

* See next slide


Intervention: simple versus complex

Single episode

Multiple episodes

Few elements

Multipleelements

Less complex

More complex

Atun R, de Jongh T, Secci F, et al, Integration of targeted health interventions into health systems: a conceptual framework for analysis., Health Policy Plan, 2010; 25:104-111



Few stakeholders

Multiple stakeholders

Few levels

Multiplelevels

Less complex

More complex




User engagement lower

User engagement higher

Technologydominates

Less complex

More complex

Behaviourdominates



The Adoption System

• Receptivity

• Individual & team and institutional

• Political economy• Incentives

– agency/provider/user incentive alignment

• Legitimacy– Cognitive

– Technical

– Normative

– Economic


Health System Characteristics

• Feasibility

• Governance– Regulatory environment– Structure and organization

• Financing– Provider payment methods– Resource availability

• Service delivery

• M&E systems– Ability to monitor results


The Context

• Sustainability

• Attributability

• Fiscal space– Overall and health sector

specific

• Reporting need to link cause and effect


The Context

• Opportunity

• Desirability

• Critical events– Visibility

• Synergy

• Technology availability

• Political economy

• Socio-cultural factors


Innovation needs a balance of push and pull incentives with enabling platforms

Push strategies Pull strategies

Enabling platforms

Adoption

system

Institutions


Innovation needs a balance of push and pull incentives with enabling platforms

Push strategies Pull strategies

Enabling platforms

Adoption

system

Institutions

Supply side incentivesDemand creation

Signalling

Empowerment

Institutionalisation


Commissioning for Quality and Innovation (CQUIN) payment framework

Bring clarity to quality – standards

Measure quality

Publish quality performance

Recognise and reward quality

Clinical leadership

Safeguard quality

Stay ahead

•Expanded role for NICE

•NHS Evidence

•Metrics – local, national, international

•Clinical dashboards

•Quality accounts

• International measures

•CQUIN

•Normative tariffs

•Clinical Excellence Awards

•QOF

•PBC, Service line reporting, Social Enterprise

•Medical Directors; clinical advisory groups

•National Quality Board

•Care Quality Commission

•Professional Regulation

•Duty to innovate

• Innovation funds and prizes

•Academic Health Science Centres

•Health Innovation and Education Clusters

© professor rifat atun. imperial college london 2012 professor rifat atun mbbs mba frcgp ffph frcp...

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