Jo Ivey Boufford

Human resources for health: overcoming the crisis

In this analysis of the global workforce, the Joint Learning Initiative-a consortium of more than 100 health leaders-proposes that mobilisation and strengthening of human resources for health, neglected yet critical, is central to combating health crises in some of the worlds poorest countries and for building sustainable health systems in all countries. Nearly all countries are challenged by worker shortage, skill mix imbalance, maldistribution, negative work environment, and weak knowledge base. Especially in the poorest countries, the workforce is under assault by HIV/AIDS, out-migration, and inadequate investment. Effective country strategies should be backed by international reinforcement. Ultimately, the crisis in human resources is a shared problem requiring shared responsibility for cooperative action. Alliances for action are recommended to strengthen the performance of all existing actors while expanding space and energy for fresh actors.

The Lancet Commission on pollution and health

Philip J Landrigan, Richard Fuller, Nereus J R Acosta, Olusoji Adeyi, Robert Arnold, Niladri (Nil) Basu, Abdoulaye Bibi Baldé, Roberto Bertollini, Stephan Bose-O’Reilly, Jo Ivey Boufford, Patrick N Breysse, Thomas Chiles, Chulabhorn Mahidol, Awa M Coll-Seck, Maureen L Cropper, Julius Fobil, Valentin Fuster, Michael Greenstone, Andy Haines, David Hanrahan, David Hunter, Mukesh Khare, Alan Krupnick, Bruce Lanphear, Bindu Lohani, Keith Martin, Karen V Mathiasen, Maureen A McTeer, Christopher J L Murray, Johanita D Ndahimananjara, Frederica Perera, Janez Potočnik, Alexander S Preker, Jairam Ramesh, Johan Rockström, Carlos Salinas, Leona D Samson, Karti Sandilya, Peter D Sly, Kirk R Smith, Achim Steiner, Richard B Stewart, William A Suk, Onno C P van Schayck, Gautam N Yadama, Kandeh Yumkella, Ma Zhong

Healthcare in a land called PeoplePower: nothing about me without me

In a 5‐day retreat at a Salzburg Seminar attended by 64 individuals from 29 countries, teams of health professionals, patient advocates, artists, reporters and social scientists adopted the guiding principle of ‘nothing about me without me’ and created the country of PeoplePower. Designed to shift health care from ‘biomedicine’ to ‘infomedicine’, patients and health workers throughout PeoplePower join in informed, shared decision‐making and governance. Drawing, where possible, on computer‐based guidance and communication technologies, patients and clinicians contribute actively to the patient record, transcripts of clinical encounters are shared, and patient education occurs primarily in the home, school and community‐based organizations. Patients and clinicians jointly develop individual ‘quality contracts’, serving as building blocks for quality measurement and improvement systems that aggregate data, while reflecting unique attributes of individual patients and clinicians. Patients donate process and outcome data to national data banks that fuel epidemiological research and evidence‐based improvement systems. In PeoplePower hospitals, constant patient and employee feedback informs quality improvement work teams of patients and health professionals. Volunteers work actively in all units, patient rooms are information centres that transform their shape and decor as needs and individual preferences dictate, and arts and humanities programmes nourish the spirit. In the community, from the earliest school days the citizenry works with health professionals to adopt responsible health behaviours. Communities join in selecting and educating health professionals and barter systems improve access to care. Finally, lay individuals partner with professionals on all local, regional and national governmental and private health agencies.

The Challenge of Attribution: Responsibility for Population Health in the Context of Accountable Care

One of the three goals for accountable care organizations is to improve population health. This will require that accountable care organizations bridge the schism between clinical care and public health. But do healthcare delivery organizations and public health agencies share a concept of “population”? The authors think not: whereas delivery systems define populations in terms of people receiving care, public health agencies typically measure health on the basis of geography. This creates an attribution problem, particularly in large urban centers, where multiple healthcare providers often serve any given neighborhood. The current paper makes suggestions for potential innovations that could allow urban accountable care organizations to accept accountability, and rewards, for measurably improving population health. The U.S. has the highest per capita investment in health care of any nation in the world,1 but the health of Americans is poorer than that of people in other industrialized nations. The U.S. ranks 36th for life expectancy and 39th for infant mortality,2 and has a higher diabetes prevalence than any country in Western Europe.3 Improving health in America will require a greater emphasis on public health programming because the delivery of medical care, which consumes most health-related spending, has a relatively modest impact on population-level measures of mortality.4,5 As it happens, the U.S. in the midst of reforming its healthcare financing and delivery system. Does this afford an opportunity to improve population health? A central instrument of reform is accountable care contracting, which occurs when a healthcare payer forms an agreement with an incorporated group of healthcare providers, called an accountable care organization (ACO), that commits to delivering an integrated range of healthcare services including prevention, care coordination, and disease management. The Patient Protection and Affordable Care Act6 authorizes the Centers for Medicare and Medicaid Services (CMS) to issue accountable care contracts to providers caring for Medicare beneficiaries. Patients will be retrospectively assigned to an ACO based on their history of health services utilization, such that participation in a particular ACO would reflect choices an individual has already been making regarding where they seek their care.7 An accountable care contract has the potential to align financial incentives across a system of care such that quality outcomes improve and reductions are achieved in unnecessary procedures and preventable hospitalizations. If the overall cost of care for an ACO’s patients decreases, and quality benchmarks are met, the ACO shares in the savings. In some models, the ACO may also bear financial risk if targets are not achieved.8 The primary goals of the Medicare ACO program are to reduce fragmentation of care, reduce healthcare costs, and improve population health. In some rural or suburban areas where a single ACO may be dominant, the ACO’s prevention and disease management efforts might naturally align with population health improvement programs being implemented and measured by local health departments. However, in the complex urban areas that collectively contain 80% of the U.S. population, it has been found that population-level interventions undertaken by ACOs for their patients are unlikely to align with those of public health agencies in a geographic community.9

Urban health in the post-2015 agenda

With the rapid rate of urbanisation in developing countries across Asia and Africa, about 70% of the worlds population is expected to be living in cities by 2050.1 In their density and complexity, cities often drive national economies, provide a rich array of specialised services, ideas and innovation, with diverse social and cultural populations. However, with an estimated one billion people living in slums—according to UN Habitat, cities are also sites of extreme poverty and environmental degradation with some missing basic infrastructure and services including sanitation, electricity, and health care.

US and UK health care reforms: reflections on quality.

Jo Ivey Boufford, a paediatrician and formerly President of New York City public hospital system spent almost four years working in the UK, 20 months as Director of the Kings Fund College. She returned to the United States in September 1993 and now has a pivotal role in developing and implementing the public health care sector as part of the Clinton reforms. Below are some of her reflections on the NHS in the United Kingdom.

Advancing Health and Wellbeing in the Changing Urban Environment

This book addresses up-to-date urban health issues from a systems perspective and provides an appealing integrated urban development strategy based on a 10-year global interdisciplinary research programme created by the International Council for Science (ICSU), and sponsored by the InterAcademy Partnership (IAP) and the United Nations University (UNU). The unique feature of this book is its “systems approach” to urban health and wellbeing: solution-oriented for science and society and not purely theoretical, it can be applied in the context of decision-making, and has the potential to unlock cities’ unused potential by promoting health and wellbeing. Furthermore, the inter- and transdisciplinary urban issues addressed in this book are examined from a cross-sectoral perspective – e.g. the transport sector is addressed in connection with air pollution, respiratory and cardiovascular diseases and the loss of productivity. The interconnected thinking to urban health and wellbeing makes the book a particularly valuable resource. Decision makers in city administrations and civil society organizations from different geographical regions will find the book an informative and inspiring guide for delivering towards the goals of the New Urban Agenda, for which health can be the vital indicator of progress. Graduate students and researchers will be attracted by the case studies, systems methods and models provided in the book.

Innovating healthcare delivery to address noncommunicable diseases in low-income settings: the example of hypertension.

London Dialogue event, The Hospital Club, 24 Endell St, London, WC2H 9HQ, London, UK, 1 December 2015 Hypertension is a global health issue causing almost 10 million deaths annually, with a disproportionate number occurring in low- and middle-income countries. The condition can be managed effectively, but there is a need for innovation in healthcare delivery to alleviate its burden. This paper presents a number of innovative delivery models from a number of different countries, including Kenya, Ghana, Barbados and India. These models were presented at the London Dialogue event, which was cohosted by the Novartis Foundation and the London School of Hygiene & Tropical Medicine Centre for Global Noncommunicable Diseases on 1 December 2015. It is argued that these models are applicable not only to hypertension, but provide valuable lessons to address other noncommunicable diseases.

Systems Science Simulation Modeling to Inform Urban Health Policy and Planning

More than half of the population in the world lives in cities and urban populations are still rapidly expanding. Increasing population growth in cities inevitably brings about the intensification of urban health problems. The multidimensional nature of factors associated with health together with the dynamic, interconnected environment of cities moderates the effects of policies and interventions that are designed to improve population health. With the emergence of the “Internet of Things” and the availability of “Big Data,” policymakers and practitioners are in need of a new set of analytical tools to comprehensively understand the social, behavioral, and environmental factors that shape population health in cities. Systems science, an interdisciplinary field that draws concepts, theories, and evidence from fields such as computer science, engineering, social planning, economics, psychology, and epidemiology, has shown promise in providing practical conceptual and analytical approaches that can be used to solve urban health problems. This chapter describes the level of complexity that characterizes urban health problems and provides an overview of systems science features and methods that have shown great promise to address urban health challenges. We provide two specific examples to showcase systems science thinking: one using a system dynamics model to prioritize interventions that involve multiple social determinants of health in Toronto, Canada, and the other using an agent-based model to evaluate the impact of different food policies on dietary behaviors in NewYork City. These examples suggest that systems science has the potential to foster collaboration among researchers, practitioners, and policymakers from different disciplines to evaluate interconnected data and address challenging urban health problems.

Advancing an Age-Friendly NYC

In 2006, the World Health Organization (WHO) launched the Global Age-friendly Cities project in recognition of the converging trends of urbanization and population aging. The leaders of the initiative asked 35 cities to lead discussions with their older residents to explore the strengths and challenges of aging in cities. The information gathered through this research, with the help of The New York Academy of Medicine, was used to develop a guide for global age-friendly cities. Beginning in 2007, Mayor Michael Bloomberg, City Council Speaker Christine Quinn, and the Academy launched Age-friendly New York City with its first undertaking being a comprehensive assessment of the city’s age-friendliness across the WHO’s eight domains of an age-friendly city: The domains are (1) outdoor spaces and buildings, (2) transportation, (3) housing, (4) social participation, (5) respect and social inclusion, (6) civic participation and employment, (7) communication and information, and (8) community support and health services. The assessment included guided conversations with more than 1500 older adults across the city in six languages, roundtable discussions with hundreds of professionals, a literature review, and extensive mapping. In the fall of 2008, the Academy released the findings of the assessment process in BToward an Age-friendly City: A Findings Report.^ In response to the findings of the community assessment, the Office of the Mayor and the New York City Council asked all city agencies to consider how they could improve the way they integrate and serve older adults through their work. Out of this review, in 2009, the city announced 59 initiatives to improve the quality of life of older adults, which are outlined in BAgefriendly NYC: Enhancing Our City’s Livability for Older New Yorkers.^ Some of the resulting improvements include a reduction in senior pedestrian fatalities by 16%, increased walkability through the addition of thousands of new benches, more than 3000 redesigned bus shelters, and new recreational and cultural programming for older people. The mayor Bill de Blasio’s office is currently in the process of developing a new set of commitments to build upon the successes of the first phase of implementation and respond to emerging needs. Age-friendly NYC is an initiative of OneNYC, the city’s strategic plan for growth, sustainability, resilience and equity. Appointed by the mayor and staffed by the Academy, the Commission for an Age-friendly NYC is composed of civic leaders from across sectors and disciplines, working to develop the overall strategy for Agefriendly NYC and to engage private organizations in changing the culture of New York City to become more inclusive of older people. Convened for the first time in 2010 and reseated in 2015, the Age-friendly NYC Commission has helped New York City become a global leader in the age-friendly city movement through an array of innovative pilot projects, many of which have been replicated or adapted in other parts of the world. J Urban Health (2017) 94:317–318 DOI 10.1007/s11524-017-0173-y