Patrick T. Lee

Managing the demand for global health education.

Vanessa Kerry and colleagues discuss how to manage the unprecedented growth in and demand for global health programs in the United States, Europe and other high-income countries.

A United Nations General Assembly Special Session for Mental, Neurological, and Substance Use Disorders: The Time Has Come

Vikram Patel and other global mental health leaders call for a special session of the UN General Assembly to discuss and debate action needed on mental, neurological, and substance use disorders, which have been left off the international NCDs agenda.

A model for ‘reverse innovation’ in health care

Abstract‘Reverse innovation,’ a principle well established in the business world, describes the flow of ideas from emerging to more developed economies. There is strong and growing interest in applying this concept to health care, yet there is currently no framework for describing the stages of reverse innovation or identifying opportunities to accelerate the development process. This paper combines the business concept of reverse innovation with diffusion of innovation theory to propose a model for reverse innovation as a way to innovate in health care. Our model includes the following steps: (1) identifying a problem common to lower- and higher-income countries; (2) innovation and spread in the low-income country (LIC); (3) crossover to the higher-income country (HIC); and (4) innovation and spread in the HIC. The crucial populations in this pathway, drawing from diffusion of innovation theory, are LIC innovators, LIC early adopters, and HIC innovators. We illustrate the model with three examples of current reverse innovations. We then propose four sets of specific actions that forward-looking policymakers, entrepreneurs, health system leaders, and researchers may take to accelerate the movement of promising solutions through the reverse innovation pipeline: (1) identify high-priority problems shared by HICs and LICs; (2) create slack for change, especially for LIC innovators, LIC early adopters, and HIC innovators; (3) create spannable social distances between LIC early adopters and HIC innovators; and (4) measure reverse innovation activity globally.

Improving quality in resource poor settings: observational study from rural Rwanda

PROBLEM Hospitals in rural Africa, such as in Rwanda, often lack electricity, supplies, and staff. In our setting, basic care processes, such monitoring vital signs, giving drugs, and laboratory testing, were performed unreliably, resulting in delays in treatment owing to lack of information needed for clinical decision making. DESIGN Simple quality improvement tools, including plan-do-study-act cycles and process maps, were used to improve system level processes in a stepwise fashion; resources were augmented where necessary. SETTING 50 bed district hospital in rural Rwanda. MEASUREMENT OF IMPROVEMENT: Three key indicators (percentage of vital signs taken by 9 am, drugs given as prescribed, and laboratory tests performed and documented) were tracked daily. Data were collected from a random sample of 25 charts from six inpatient wards. STRATEGY FOR CHANGE Our intervention had two components: staff education on quality improvement and routine care processes, and stepwise implementation of system level interventions. Real time performance data were reported to staff daily, with a goal of 95% performance for each indicator within two weeks. A Rwandan quality improvement team was trained to run the hospitals quality improvement initiatives. EFFECTS OF CHANGES: Within two weeks, all indicators achieved the 95% goal. The data for the three objectives were analysed by using time series analysis. Progress was compared against time by using run chart rules for statistical significance of improvement, showing significant improvement for all indicators. Doctors and nurses subjectively reported improved patient care and higher staff morale. LESSONS LEARNT Four lessons are highlighted: making data visible and using them to inform subsequent interventions can promote change in resource poor settings; improvements can be made in advance of resource inputs, but sustained change in resource poor settings requires additional resources; local leadership is essential for success; and early successes were crucial for encouraging staff and motivating buy-in.

Bridging the global health training gap: Design and evaluation of a new clinical global health course at Harvard Medical School

Background: Medical student and resident interest in global health has been growing rapidly. Meanwhile, educational opportunities for trainees remain limited, and many trainees participate in global health experiences abroad without adequate preparation. Medical institutions are attempting to respond to this training gap by developing global health curricula. Aims: We describe a novel clinical skills-based curriculum recently established among Harvard medical students and residents with the primary objective of providing essential clinical knowledge and skills to work effectively in resource-limited settings. Methods: The course consisted of 10 evening sessions taught by a multidisciplinary faculty and focusing on practical management of the leading causes of the global burden of disease. Didactic discussions were reinforced by case studies and practical skills sessions, such as tropical microscopy, basic bedside ultrasound, simple dental extraction, and newborn resuscitation. Results: Student mean knowledge scores increased significantly, from 64.5% (SD 8.9) before the course to 79.5% (SD 8.6) after the course (p < 0.001). Students also gave strongly positive evaluations and particularly valued the courses practical skills-building and the horizontal and vertical mentorship that developed among the diverse student, resident, and faculty participants. Conclusions: This clinical course in global health may serve as one model for more effectively preparing trainees to work in developing countries.

A UN summit on global mental health

516 www.thelancet.com Vol 376 August 14, 2010 inequities exist in the available care for mental disorders between and within countries, accentuating socioeconomic gradients and worsening health outcomes across multiple conditions—a situation that has been described as a “‘failure of humanity”. There is no “health without mental health” and the massive unmet need for mental health care deserves global action. We therefore call on UNGA to convene a summit on global mental health in 2012. As with the Grand Challenges Initiative, which broadened its focus from traditional international health priorities to NCDs, and then to mental health, a similar path could be taken with a UN summit focusing on mental health in 2012. The major goal of the summit would be to issue a multilateral Declaration of Commitment on Global Mental Health with a clear prescription for action, milestones for measuring success, and specifi c actors responsible for each step. As the world responds to the rise of NCDs, we have a responsibility to align health priorities with our understanding of the global burden of disease. Mental disorders are the elephant in the room: we can no longer aff ord to ignore them.

Ambulatory training for primary care general internists: innovation with the affordable care act in mind.

BACKGROUND Although primary care general internists (PCGIs) are essential to the physician workforce and the success of the Affordable Care Act, they are becoming an endangered species. OBJECTIVE We describe an expanded program to educate PCGIs to meet the needs of a reformed health care system and detail the competencies PCGIs will need for their roles in team-based care. INTERVENTION We recommended 5 initiatives to stabilize and expand the PCGI workforce: (1) caring for a defined patient population, (2) leading and serving as members of multidisciplinary health care teams, (3) participating in a medical neighborhood, (4) improving capacity for serving complex patients in group practices and accountable care organizations, and (5) finding an academic role for PCGIs, including clinical, population health, and health services research. A revamped approach to PCGI education based in teaching health centers formed by community health center and academic medical center partnerships would facilitate these curricular innovations. ANTICIPATED OUTCOMES New approaches to primary care education would include multispecialty group practices facilitated by electronic consultation and clinical decision-support systems provided by the academic medical center partner. Multiprofessional and multidisciplinary education would prepare PCGI trainees with relevant skills for 21st century practice. The centers would also serve as sites for state and federal Medicaid graduate medical education (GME) expansion funding, making this funding more accountable to national health workforce priorities. CONCLUSIONS The proposed innovative approach to PCGI training would provide an innovative educational environment, enhance general internist recruitment, provide team-based care for underserved patients, and ensure accountability of GME funds.

Engaging the health community in global economic reform

www.thelancet.com Vol 373 March 21, 2009 987 is trained in the social determinants of health, and raise public awareness of these determinants. This Lancet Series shows that there is ample ability, if not capacity, within Palestinian society to address the third challenge. Addressing the fi rst challenge requires an end to the current conditions of occupation and siege. Addressing the second challenge requires an end both to factional government and the culture of donor dependency. For too long, the health and welfare of Palestinians within the occupied territory have been secondary to powerful outside interests. As Virchow might have put it, the solution lies in justice, sovereignty, and self-determination for the people of the West Bank and Gaza Strip.

Transforming health professionals' education

In their Commission report (Dec 4, p 1923), Julio Frenk and colleagues highlight the expansion of “academic centres” to “academic systems” as a key process in the transformation of health profes sional education for a new century. New curricular strategies are fundamental for the realisation of their vision. In the medical education setting, increasing use of longitudinal integrated clerkships has provided initial insights for institu tions that wish to improve their clinical pro grammes. I write to propose an expansion of that concept to a “health-system-based clerkship”, adapting the ideas published in Brazil by my colleagues and I. Ideally, a health-system-based clerkship would provide clinical medical training nested into a national health system, encompassing regional networks of primary care centres, outpatient clinics, and hospitals, with primary care as the clinical backbone that coordinates and longitudinally integrates scenarios, practices, and training. Such a programme could enhance meaningful interprofessional education for medical students, favouring continuity of training and care, patient and communitycen tredness, and social accountability. This kind of pedagogic approach could cover the diversity and complexity of clinical experience and education expected for the new century’s doctors in an “academic system”.

Global Health Systems

• Sustainable, ethical engagement begins with careful listening, cultural sensitivity, and responsiveness to local preferences and conditions. • Few, if any, health systems provide ideal care; there are useful frameworks for improvement. • Health systems built upon economic, social, public health, and primary carebased interventions at the community level have been the most consistently successful. • Some outside efforts to buoy health systems have caused harm. • There is growing access to information on health systems and understanding of routes to successful reform. Chapter 3 Global Health Systems