The importance of targets and a national strategy for the public health service

Martin McKeeLondon School of Hygiene & Tropical

Medicine

European Observatory on Health Systems & Policies

Basic questions about health systems

What are we actually trying to achieve?Improved health outcomes?Greater profits for providers?Responding to popular demand?Services that maximise patient

choice?Financial protection against

catastrophic expenditure?Cost containment?

If we can’t answer this question, then it is difficult to answer any others

Who is responsible for achieving whatever we want to achieve?

Deaths amenable to health care

Room for improvementDiabetes: lower limb amputation rate

Admission rate for COPD

Source: OECD

Admission rate: hypertension

Profits for providers?

Responding to popular demands

If so, then they will provide many things, but not necessarily those that do any good to those who receive them.

They may make them poorer and unhealthier as providers sell them things that cost money and do no good

Patient choice

Out of pocket expenditure and catastrophic payments

Xu et al, Lancet 2003

Cost containmentAre you really containing

costs or simply transferring them to patients?

How do you balance cost cutting with incentives for innovation?

Do short-term cuts inhibit long term investment?

Are you simply transferring costs to future generations?

Or something else?

to improve population health

to respond to the legitimate expectations of the population

to collect the necessary finances in a fair way

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But what is the “health system”

All resources, organizations and actors that undertake or support health actions are considered to be part of the health system.

A health action is an action whose primary intent is to promote, protect or improve health

Source: WHR 2000

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Yet this is not how we normally think of health systems Normally includes delivery of personal health

careOften excludes some activities:

Social careHealth promotionEnvironmental healthHealth research & developmentHigher education of health professionals

And some sectors:Prison healthMilitary healthOccupational healthSports medicine

So first step is to define what we are talking about

Let’s assume we can define the health system - is anyone in charge?

If we are to move towards a strategy for a health system we must first agree lines of accountability

In most countries it is far from clear whether anyone is in charge

Yet governments consistently sign up to WHO and UN resolutions assuming responsibility

Unresolved issues include:Multiple sectorsMultiple ministriesMultiple tiers of government

Lesson 1

There is no need to reinvent the wheel

The evolution of global and regional health strategies

1974 Canada Lalonde Report

1979 WHO Alma Ata conference Health for All policy

1984 WHO EUROHealth for All by the Year 20006 themes, 38 targets

1999 WHO EUROHealth 2121 targets

2007 PAHOHealth agenda for the America

2013 WHOHealth 2020

And national

Health strategies face technical and political challenges

Lesson 2

Technical challengesUnderstanding the web of disease causation

linking indicators to risk factors to health outcomesFinding the data

Often much more difficult than you thinkUnderstanding time lags

how long will it take for a policy to impact on health?Going beyond the easy to measure

indicators for mental health?Health for all?

Improvement in average masks gains and losses Understanding what works

Again, more difficult than you might thinkWorks for whom, where, in what circumstances

The web of causation

Source: adapted from Global Health Risks (WHO 2009)

Finding the dataWhat risk factors?

E.g. overweight, alcohol, smokingHow measured

Alcohol – average consumption per week, amount drunk at one go, quantity/frequency?Can heavy drinkers remember?

Weight – self-reported/ objectively measuredPeople overestimate height and underestimate weight

Smoking – validated with cotinine measures? In countries where it is stigmatised, women smokers may

deny the habitIn whom?

Age groups (many surveys omit those under 18 or over 65)

Selective bias excluding ethnic minorities/ homeless – may need to oversample?

Practical adequacy

‘optimal ignorance’ – neglect the irrelevant

“…the importance of knowing what it is worth knowing… It is far, far easier to demand more and more information than it is to abstain from demanding it” (Chambers, 1980)

‘proportionate accuracy’ – practical adequacy over scientific perfection

“Especially in surveys, much of the data collected has a degree of accuracy which is unnecessary. Orders of magnitude, and directions of change, are often all that is needed or that will be used” (Chambers, 1980)

Understanding time lags:Understanding time lags:Some effects occur almost Some effects occur almost instantly:instantly:Injuries, poisoning and violence mortalityInjuries, poisoning and violence mortality(excluding acute alcohol poisoning)(excluding acute alcohol poisoning)Russia: Men aged 30-59Russia: Men aged 30-59

0

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1965 1970 1975 1980 1985 1990 199510

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er capita consumption litres pure alcohol/year

Mortality rateMortality rate

Alcohol Alcohol consumptionconsumption

Some take a little time:Some take a little time:Liver cirrhosis mortalityLiver cirrhosis mortalityMen aged 30-59Men aged 30-59

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1965 1970 1975 1980 1985 1990 199510

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er capita consumption litres pure alcohol/year

Mortality rateMortality rate

Alcohol Alcohol consumptionconsumption

Smoking and lung cancer in Smoking and lung cancer in British men British men A lagged effectA lagged effect

0

500

1000

1500

2000

2500

3000

3500

4000

4500

1911- 1921- 1931- 1941- 1951- 1961- 1971- 1981-0

200

400

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800

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1200

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Age-standardised m

ortality rate per million

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tes

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ita Cigarettes per capita Cigarettes per capita

per yearper year

Lung cancer Lung cancer mortality ratemortality rate

Data for men aged 15+Source : HOAB and Wald

Getting it wrongIn the UK, Primary Care Trusts were given a

target to reduce forecast cancer mortality 5 and 10 years in the future

Government forecasts were based on simple extrapolation of all cause all age cancer mortality over past decade

No recognition of the existence of cohort effectsIn one PCT, trends heavily influenced by short-term

peak in bladder cancer mortality due to past exposure in rubber industry

No recognition of impact of almost 30% mobility to/from PCT per annumTo reduce cancer mortality 10 years from now,

intervene in Mogadishu now?

“Not everything that can be counted, counts, and not everything that counts can be counted”

Albert Einstein

Going beyond the easy to measure

English Department of Health insisted in including suicide rates as indicator of performance of health authorities in mental health “Suicide Bridge” Archway Road

Health for all?

What works?Evidence of effectiveness

Cochrane collaborationCampbell Collaboration

What works where and for whomRealistic evaluation

What are the critical factors determining whether something might be applicable in a given setting?Tax rises on cigarettes less likely to be effective if

extensive smuggling exists and is not tackledMany road safety measures depend on a police

force that is not hopelessly corruptDo we fully understand the context?

Political challengesReally getting health on the agenda across

governmentespecially the Ministry of Finance(e.g. opposition to strengthening EU Tobacco

Products Directive by governments of Poland, Romania and Bulgaria)

Making the invisible visibleanalysis and advocacy

Securing commitment from other sectorsdo they realise they have a role to play?

Maintaining consistency across the electoral cycleHealth of the nation becomes Our Healthier

Nation!

In practicePriority setting

“None of the procedures that have been used to define health priorities was judged, on its own, to be entirely satisfactory for Geneva”

“we thus used three complementary approaches including

traditional mortality indicators (potential years of life lost), disability adjusted years of life lost, and a Delphi survey, to identify a set of robust priorities by triangulating results between the three methods.

Lesson 3

Some people are not very interested in health and others are downright hostile

There are many people who have a strong vested interest in making life more complicated

Well researched examples include:tobacco industry and passive smokingoil industry and lead in petrolasbestos industryfood industry and salt

Extensive evidence that food and alcohol industries learning from tobacco industry

The tobacco industry and passive smoking ..

Lesson 4

Targets can be a valuable instrument, if used appropriately

Targets should be SMARTSpecificMeasurableAccurateRealisticTime bound

Source: DANIDA

Making targets credibleTargets should be based on sound and

convincing evidenceDevelopment of local targets should be

encouragedProcess targets should supplement

outcomes locally and nationally and should be part of performance management

Targets: the downside A conflict arose between ambulance providers, whose target was to

reach patients within eight minutes (requiring large numbers of ambulances to be available), and emergency departments, whose target was to transfer or discharge patients within four hours. The emergency departments did not want to accept patients from ambulances until they were ready for them so the ambulances were used as “target-free” waiting areas. The solution identified by the ambulance providers was to purchase tents to erect in hospital car parks.

A target to treat all patients on a waiting list for non-urgent surgery was achieved by keeping patients on the untargeted waiting list for the initial outpatient appointment (which was required for them to join the targeted waiting list) as long as possible.

A target to ensure that all patients obtained an appointment with a general practitioner within 48 hours was achieved by preventing patients from making appointments more than 48 hours in advance. This meant that they had to spend lengthy periods on the telephone on the morning of the day before they wanted an appointment.

Patients waiting for non-urgent surgery can legitimately be removed from the waiting list if they are offered an operation but do not take it up. Several hospitals call large number of patient in mid summer or jut before Christmas, in the expectation that many will be unable to come into hospital.

Primary Care Trusts are judged on their achievement of a target to get smokers to quit for at least four weeks. One trust achieved this by paying smokers to do so.

Lesson 5

Devolution/ federations/ confederations bring opportunities

The benefits of devolved government

It is possible to move faster than national governments

It may be easier to get agreement among relevant groups

North Rhine Westphalia

Catalonia

Lesson 6

Multi-sectoral working brings challenges and opportunities

Benefits of multi-sectoral workingAccess to dataKnowledge of local contextOften key to the implementation of any

strategyProvide links to the communityJoint ownershipShared workloadReach wider audience

Challenges of multi-sectoral working

Who is accountableCompeting agendasCompeting ethosParalysis by analysis

Lesson 7

Evaluate the process and the outcome of the strategy

Few health strategies have formally been evaluated so it is

very difficult to know what works and what does not

The English Health of the Nation strategy is a rare exception

Fulop N, Elston J, Hensher M, McKee M, Walters R. Eur J Publ Health 2000; 10: 11-17.

The need for a defining philosophy

The individual versus the collective

McKee & Raine, Lancet 2005

Matrix working

Alcohol

Diet

Body weight

Heart health

Physical exercise

Mental health

Osteoporosis

Y

ou

th

E

lderly

D

ep

rive

d g

roup

s

Settings

Source: European Commission

Who leads on health?Should the health system have lead

responsibility for a health strategy?Health is a shared responsibility but the

health system, where it has a strong public health function, has a key role to play

Whoever is responsible, it should be clear to all those involved

Sustaining momentumThe strategy must be firmly embedded in a

performance management framework. This should include:

monitoring the process of implementation as well as the outcome;

identification, isolation and monitoring of resources connected with the strategy.

Communicating the strategyThe strategy must be communicated

within the health system Within the health system, ownership

should not be limited to public health departments

It must also be communicated widely outside the health system

Involving stakeholdersIt is essential to increase the role of key stakeholderspublicprivate sector primary care.

Resourcing the strategyShould there be new funding?In the absence of ring-fenced funding, HOTN had only a transient impact on expenditure on health promotion

A key role for central governmentThere must be a consistent message

across government that is in support of the health strategy (‘on message’).

Giving in to Bernie Ecclestone on the proposed tobacco advertising ban in Formula 1 was one of the worst things that could have been done

Central government should also foster the development and dissemination of an evidence base.

Learning from experienceLeadership by Ministry of HealthBroad coalition represented on 19

technical committees Explicit learning from experience

elsewhereClear statement of values

Effectiveness, equity, engagementQuantitative targets, but carefully thought

through

Rosenberg E, Lev B, Ben Nun G, McKee M, Rosen L. Healthy Israel 2020: A visionary national health targeting initiative. Public Health 2008; 122: 1217-1225

Thank you for your attention

@martinmckee