"Ideas Don’t Happen Because They’re Good - They Happen Because People Believe in Them"

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Nov 26, 2012
by Louise Hallman
"Ideas Don’t Happen Because They’re Good - They Happen Because People Believe in Them"

Fellows present their plans for realizing the right to health

Rounding off an intensive five-day seminar on ‘Realizing the Right to Health’  at the Salzburg Global Seminar, World Bank president Jim Yong Kim publicly declared for the first time: “We fully embrace the rights-based approach to healthcare.”

Speaking via live video-link, Kim’s declaration drew exaltation from Leonardo Cubillos, senior health specialist at the World Bank Institute. “Mission accomplished,” he tweeted.

But while the long-time rights-based approach to health advocate has reason to celebrate, the seminar demonstrated through its lectures, group work and final presentations that there is much still to be accomplished in the realm of health and health care.  However, the seminar also demonstrated the dedication of the 75 Salzburg Global Fellows to this mission.

As Cubillos quoted from the UN in his opening remarks, despite the $6.5tn spent on health care per year, a little over one quarter of the world’s population still live without access to medicine or basic medical care.  Many people are clearly not able to exercise their right to health.

From November 9-14, Fellows and faculty from 22 countries across the world came together for a seminar examining ‘Realizing the Right to Health: How can a rights-based approach best contribute to the strengthening, sustainability and equity of access to medicines and health systems?’, hosted by Salzburg Global Seminar at its headquarters at Schloss Leopoldskron in Salzburg, Austria, and co-sponsored by session partners, the World Bank Institute (WBI) and the Dartmouth Center for Health Care Delivery Science (TDC).

Over the five days, world-renowned faculty presented on a range of issues relating to the challenges and potential solutions in realizing the right to health to a room-full of eager Fellows.

“When you don’t provide health care to people who need it, it is against their human rights,” Rwandan health minister Agnes Binagwaho stated bluntly on the first afternoon, via video-link from Kigali.

The Right to Health = The Right to Health Care, Food, Shelter and Information
 Repeatedly over the course of the seminar, Fellows heard that realizing the right to health is not just about the right to health care, but the right to other aspects that improve health, such as basics like food and shelter, as well as the right to information that helps individuals makes better informed ideas about their own health and that of their wider communities.

But, the right to health doesn’t necessarily mean the right to every single medicine available, Binagwaho clarified.  Resource constraints in many countries mean that delivery of expensive medicines and interventions is simply not possible. Rather, she said, realizing the right to health means ensuring the provision of all possible health care interventions to everyone who needs them in a given country, regardless of their class, race or gender.

As one Fellow put it, in Nepal the right to health might mean the right to access the most basic health care, while in Chile it could be the right to access the top available cancer drugs. But what must be ensured in all cases is that people are not denied their right to equitable access to health care services, just because they are a disadvantaged person belonging to an undesirable section of society, as proven in the case in Kenya where HIV-positive women were forcibly sterilized without their consent.

Resources are scarce in many countries, but they’re limited in all. No country has a bottomless pit of money for health care. Even in the richest countries, issues of fairness in the access to health care treatments arise; who more deserves an expensive course of cancer drugs – a 75-year-old who has paid into national health insurance for many years but has only a few more years to live, or a 25-year-old who hasn’t worked or paid taxes for as long but who will have a much longer life ahead of them (in which to be a greater contributor to society) should they be cured?

Fairness in the Process, not the Decision
“Fairness doesn’t ask you to treat everyone, it doesn’t ask you to give everything to everyone,” explained Cubillos after his presentation. “Fairness is not about unlimited generosity. Fairness is not about financial insustainability. Fairness is not about charity. Fairness is about being responsible with your resources, in allocating them in such a manner that all parties agree—not on the decision, but on the process.”

It is possible, Cubillos posited, to have two completely different outcomes which whilst opposite could both be deemed fair. “Fairness is not about the ultimate outcome – it is also about the process.”

Patients across the world deserve “the care they need and no less, the care they want and no more,” said Albert Mulley, director of the TDC, in his talk to Fellows about the role of shared decision making in realizing the right to health.  Patients should have access to the health care they need, but shouldn’t be made to accept treatment they don’t want.

“You have to recognize that different patients have different risk attitudes,” said Mulley. What works for one patient, won’t necessarily be what another wants owing to their own circumstances, and doctors should recognize the patient’s decision and personal expertise in their own condition and care.

One way to ensure the process of a health care decision is fair and also enables the patient to make the most-informed decision they can about their own care is to make the treatment availability and decision-making process as transparent as possible. But even this is no panacea.

“You can’t just dispense transparency – you must consider the reception of the information!” exclaimed Salzburg Global Seminar program director, John Lotherington.

Better – not just more – Information
 By empowering patients with understandable information, rather than just simply abundant information, those patients in turn would be better able to make well-informed decisions not only about their own health care, but also that of their communities.

The reverse of this, Lotherington pointed out, was visible in the MMR-Autism panic in the UK. A misleading and since disproven article relating the measles, mumps and rubella (MMR) vaccine to the increasing prevalence of the developmental disorder, autism, invoked panic in many parents who thus chose not immunize their children against three highly contagious diseases, potentially putting their children and the wider community at risk of infection.

Empowering communities needn’t come only through informational leaflets and talks, Fellows were told during the week. In one of the more interactive sessions of the seminar, Fellows heard from Mary Flanagan of Dartmouth College’s Tiltfactor – a “interdisciplinary innovation team” that designs and studies “games for social impact”.
By developing games such as ‘ZombiePOX’ – a game that challenges players to stop the spread of zombies through their community – players of all ages can learn and understand concepts such as systems thinking, resource allocation, strategic vaccinations and herd immunity.

Fellows themselves took part in a Tiltfactor designed game called ‘RePlay Health’, designed to help players understand the impact of different events and situations can have on health conditions, as a level playing field start to quickly reflect the unequal conditions many people face in the attempts to lead healthy lives.

As informative as the lectures, discussions and games were, the Right to Health Fellows were brought to Schloss Leopoldskron not just to listen and play, but to plan and do.
 The hastily thought of initiatives from the end of their ‘RePlay Health’ game provided some with a starting point as the Fellows spent the last two days of the seminar developing and refining plans for initiatives they could launch in their home countries or regions.

Building more than just Lego
 Working through a process called ‘rapid cycle prototyping’, the Fellows didn’t head straight to the seemingly ubiquitous flip charts, so favored throughout the week by seminar facilitators Reos; instead facilitators Joe McCarron and Zaid Hassan led the Fellows in building Lego models of their potential solutions.  But as McCarron pointed out, the Fellows were building much more than just Lego models.

“When you have a short amount of time and a diverse group of people, working on a complex project, a methodology that uses your head and your hands is much more effective in creating the early seeds of ideas than having a bunch of people negotiate around a flip chart,” explained McCarron. “The intangible element of what we were doing today is how you build commitment and how you build emotional attachment to these ideas.”

And these ideas will need commitment. Ranging from plans to improve governance in the health care system by involving the local communities in post-revolution Egypt; to a ‘Open Healthcare Info Bank’ – a platform for collecting, validating, processing and delivering health information, which would verify the amount, content and quality of the information, with the objective of enabling informed and knowledgeable decision-making in South Korea; plans to reorganize the procurement and distribution of medicines in the Brazilian state of Minas Gerais to ensure “the right medication, [get] to the right people at the right time”; and a cross-national group aimed at improving women’s health in Africa through greater social participation in health care delivery, the plans are nothing if not ambitious.

These plans all aim to meet a so far unmet need – stopping corruption in Nepal, improving efficiency and coverage in Mexico, increasing affordability of medicines in East Africa, and so forth – but they have been developed with specific “next steps”, methodologies and well-placed team-leaders in mind. The teams of Fellows have made commitments to each other to carry their proposals forward, with many opting to use the newly launched Salzburg Global Fellowship Yammer Network – a social network platform exclusively for SGS Fellows – to help co-ordinate and implement their plans.

The teams certainly haven’t been alone in putting together their plans. By repeatedly presenting their projects to their peers during the rapid cycle prototyping exercise and receiving feedback from the whole group each time, the Fellows’ projects have gone from being built by five people to 50 thanks to the constant input, explained McCarron.
 They’ve also received feedback from two world-renowned experts in health care delivery – Jim Yong Kim, president of the World Bank and former president of Dartmouth College, home of the Dartmouth College for Health Care Delivery Science, and Binagwaho, who joined the Fellows again at the end of the week to dispense her advice.  Kim praised the Fellows on their efforts, with Binagwaho offering to continue giving help and support online.

Only time will tell which of these projects eventually come to fruition, but as Hassan said at the end of the week’s presentations: “Ideas don’t happen because they’re good; they happen because people believe in them.”

Let’s hope their belief in their projects continues long after the Fellows pass back through the iron gates of Schloss Leopoldskron.