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Healthcare Session - Day Three: Seventh and eighth blocks
Participants vote on matters of confusion in healthcare improvement
Healthcare Session - Day Three: Seventh and eighth blocks
Louise Hallman 
Presented by Ed Kelley, Head of Strategic Programs and Coordinator, WHO Patient Safety, Geneva, Switzerland, the session considered the existing building blocks inadequate in improving the healthcare systems of lower and middle income countries. Published in 2010, the WHO “six building blocks of health systems” cover:
  1. Service delivery
  2. Health workforce
  3. Information
  4. Medical products, vaccines and technologies
  5. Financing
  6. Leadership and governance (stewardship)
In his summary, Kelley said, “It is clear that the ‘six building blocks’…include major action areas where the application of improvement methods can achieve significant results.” However, common concern amongst the Seminar contested that community mobilization and patient perspective should also be added to the existing list. Reflecting on all the comments and suggestions made through the group work of the afternoon, Kelley added in his summary: “Though [its] a broad set of areas to address, key lessons emerged that may form the beginnings of an overarching strategy to more explicitly link quality and safety improvement to the larger health systems strengthening effort.” These key lessons included mobilizing clients and reforming financing systems, strengthening quality in health information systems and building the healthcare workforce.
Talking Point: What role does consumer choice have in improving healthcare in lower and middle income countries? “Consumers’ choice is not really only related to the individual’s choice but it relates to the collective’s choice. If the choice for the collective consumer is limited then an individual’s right to choice ends where the rest of the collective’s start. ”  Jorge Hermida, Director, HCI Programs - Latin American Region, URC, Ecuador “I think it is fundamental if you want to improve healthcare, the quality of healthcare, consumers’ choice is a key element. That implies that first you have to recognize that, and second you have to give elements to the people so that they can make choices - giving information, allowing them to participants, empowerment. This is not an easy thing to do... If they have a choice in selecting a physician for their care, there are some areas with only one physician so they have no choice! ...But you have to it. I see it as a key element for pressing the system to provide quality health services. If that doesn’t happen, the health system won’t be as responsive as it should be.” Enrique Ruelas, Senior Fellow, Institute for Healthcare Improvement, Mexico “Consumers in most circumstances have less opportunities to make choices about their healthcare. The bulk of the population live below the poverty line and in the remote areas. It is not a matter of choice for them but rather a matter of access to the nearest health facility... In cities people have health facilities but then again the poorer tend to be going for public hospitals and they have limited choices. Those with better socioeconomic status and can afford better and higher quality prices for healthcare services, they will go for private hospitals because the perception is the quality is better... And then we have a small percentage of people who really can afford health services outside the country.” Mirwais Amiri, Senior Quality Improvement Advisor, URC, Afghanistan “The primary consumer in healthcare is the patient. So when we are talking about low and middle income countries, the only way consumers’ choice can even be an issue is when affordability and access to services are there. And before there is affordability and access, the only choice the consumers have will be to either live or die.” Ayman Sabae, Master’s Student, International Healthcare Management, Innsbruck, Austria/Egypt Click
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Healthcare Session - Day 2: HR voted greatest challenge, Community involvement close second
Healthcare Session - Day 2: HR voted greatest challenge, Community involvement close second
Louise Hallman 
Heated debates arose as participants reported back to the full room. Should “patients’ needs” be added to “patients’ preferences”? Could the issue of staff competency be considered in the same human resources issue bracket as the inadequate numbers of staff? Once the participants – from such wide-ranging backgrounds as physicians, academics, government officials and donors – had negotiated and agreed upon the nuances of the challenges, they were then asked to vote on what they believed were the two greatest challenges they faced in improving healthcare. Coming out resoundingly on top with 17 votes was human resources, including but not limited to inadequate numbers of health care workers, high turnover, maldistribution geographically, staff morale and unfilled training needs. Community and civil society involvement followed with 16 votes; this issue called for more civil society engagement and client-focus in advocacy, feedback, public protection and responsiveness. In third place was poor planning, encompassing lack of comprehensive operational plans, vertical programs that lack integration and inadequate harmonization of donor programs. Designing a system to meet patient preferences and needs and facilitating the process of addressing different perceptions of quality among providers, policymakers and the public both garnered 12 votes. Lagging behind were limited capacity and capability to implement QI strategies – 7; leadership behavior – 6; involvement of patients and staff in the process of improving care – 6; absence of QI skills in the head of frontline managers – 6; inadequate information and poor communication – 6; interface of strategy and implementation – 4; optimization of technical skills – 3; poorly articulated arguments to donors and decision makers about the value of improvement and the costs of poor health – 2; and finally inadequate leadership with just one vote.
Talking Point: Donors in Healthcare One issue that was raised in the day’s sessions was that of the role of donors in healthcare improvements. Several participants shared their views with Planning Committee Member Sylvia Sax. “I don’t want donor money because it has strings attached.”
 “Donors want short term solutions. When the money is gone after two years, we cannot continue the programs put in place.”
 “Donors come with their own solutions and expect them to be implemented. ”
 “Donors put in parallel initiatives and reporting systems.” SGS editor Louise Hallman asked donor representatives for their response.  “An intrinsic part of what donors are trying to do is support the governments, not to impose a specific agenda. Intrinsically, improvement has got to be owned by the government, by the country itself. And the solution is a product of dialogue between the donor and the country. ”
Jim Heiby, Medical Officer and Contracting Officer’s Technical Representative, USAID Health Care Improvement Project, Washington, DC, USA “Anything we do needs to be something that’s needed by the government and that they would like...
 The role of the donor is several fold: we can provide resources, in the form of money or in the form of technical inputs. But we can also use voice, often at a global level to try and move an entire sector a specific way...
 I think the best way we can have an affect and have impact is to support a country’s leadership and to try and leverage each other. We shouldn’t be independently investing here, there or wherever. The whole needs to be greater than the sum of its parts...
 So it’s about integrated work, led by governments.”
Mary Taylor, Senior Program Officer, The Bill and Melinda Gates Foundation, Seattle, USA “One of the important things for donors is to know the real situation of the governments, or what is going on in healthcare, what priorities there are, what exact problems there are, what the priorities of the ministry of health are. And then it’s very important to communicate with them and involve them in the process from the beginning...to help get them on your side while you are implementing something you know will be good for them and it will be easier to transfer to them after you leave.”
Shirin Kazimov, Health Project Management Specialist, USAID, Azerbaijan Monday afternoon’s session, led by Sheila Leatherman, Research Professor at Gillings School of Global Public Health, University of North Carolina, USA, saw participants to split into groups to identify challenges in two categories: how to improve quality and how to improve healthcare system delivery.
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Improving Health Care in Low Income Economies
Rashad Massoud speaking at the Salzburg Global Seminar
Improving Health Care in Low Income Economies
Louise Hallman 
Welcoming over 60 international healthcare professionals from more than 35 countries, Dr. M. Rashad Massoud expressed his excitement at the “wonderful journey” the participants would take over the next six days at Schloss Leopoldskron for the Salzburg Global Seminar session ‘Health and Healthcare Series IV: Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?’ The session has been two years in the making, and will follow on from previous sessions’ discussions to debate the progress made so far in meeting such targets as the Millennium Development Goals and the role of quality improvement in meeting such public health targets. Whilst improvements in health care have clearly been made in the past number of years, this progress has since “plateaued”, making it necessary for health care professionals to address the issues and challenges that still lie ahead. Joining the “crucially important meeting” via a pre-recorded video, Don Berwick, former president and CEO of the Institute for Healthcare Improvement, USA, highlighted the great opportunity such a global gathering of healthcare experts would experience over the coming week. “In developed healthcare systems in the Western developed world, we have a crust to drill through,” he said. “We have an existing legacy production system that for complex reasons has not been orientated around those six aims [safety, effectiveness, patient-centeredness, timeliness, efficiency and equity] for the continual improvement of performance as its primary driver… “I have the feeling that low and middle income countries have a thinner crust. There’s more opportunity there because in some senses you’re building on a relatively less developed platform of management and process thinking. The opportunity in lower and middle income countries is to do it right the first time. “I think the potential is enormous.” The Salzburg Statement: How to Improve Health in Low and Middle Income Economies, was produced at the end of the week-long intensive discussions. Click here to read Louise Hallman's daily newsletters for the session
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Healthcare Session - Day 1: Journey's Beginning
Healthcare Session - Day 1: Journey's Beginning
Ezequiel García-Elorrio 
The history of the Schloss Leopoldskron and the Salzburg Global Seminar are very impressive; since after World War II this organization has promoted the gathering of people around the world to provide solutions to global problems. The ambience is fantastic – it will surely make participants to give the most of themselves. During the opening remarks goals were set. The clearest one is to “set an agenda of coming years”. Reviewing where we are and how we got here. Constructing then the action plan for the times to come. Participants represented a wide variety of settings and realities from around the world. So far just listening to everyone’s introductions you can perceive the amount of experience and knowledge in the room. Surely clear objectives and a goal will come from this week-long discussion. This week-long seminar is described as the “beginning of a journey where we all will go together” confirming that we are “not sitting on plateau but moving ahead”. The audience is quite diverse, comprising government, patient representatives, international organizations, researchers and improvers. Almost every point of view is represented. Just to give a sense on the importance of our participation, the questions/debates posted before the seminar were presented to all participants to start the discussion. Hopefully conversations from Salzburg will reverberate around the world and feedback could be provided. Ezequiel García-Elorrio’s blog for the ISQua Knowledge Portal can be found online: isquaknowledge.org
Talking Point - Do We Need More Data? By Louise Hallman "Work that is not documented is not done, so definitely documentation would help to improve quality - at then end the day you have to be able to see what you have done. There are two issues: crediable documentation and also making documentation easier... If we have this system where you can plug in the information at the time the activity was going on, or at worst at the close of the day, then you cannot go back at the end of month and change the information for that day.”
Charles Nde Awasom, Medical Director, Ministry of Health, Cameroon “There’s data for public reporting purposes and there’s data for actual clinical management application. If you connect the two, you have a data source that serves two purposes and is essentially incredibly important to the clinicians themselves... You can’t improve something that you know nothing about. The vast majority of the time [in my research] the data element is collected and sent somewhere on a district level or a regional healthcare system or government’s national health system and the clinic never learns how it’s represented in public health records.”
Kedar Mate, Director for Developing Countries Programs, Institute for Healthcare Improvement, USA “It is helpful [to have more data], but you can do a lot without it, by sampling, by rigorous independent monitoring, particularly of vaccination programs, and having extensive documentation, like a lot of high income countries do, doesn’t necessarily mean that you use data more intelligently. ”
Sir Liam Donaldson, former Chief Medical Officer, UK “It is true that in developing country settings you do have a lack of data...so for sure documentation needs to be improved, but it’s really about what you do with it. In a lot of countries there is tons of data but it’s not developed with clinicians in mind so it’s not relevant and it’s not given to them even if it were relevant so they can do something with it.”
Ed Kelley, Head of Strategic Programs, WHO Patient Safety, Switzerland “A lot of our problems stem from inadequate documentation but more importantly, I think we generate a lot of data that is definitely not used optimally. We don’t have adequate information systems to connect information at community level. If you don’t have a health information system that works well across all levels, you are losing out a lot of vital information that will enable you to put interventions in place that are going to target the community best. ”
Nanthalile Mugala, Director for Technical Support, Integrated Systems Strengthening Program, Zambia
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Academy student's article cited on The Colbert Report
Academy student's article cited on The Colbert Report
Salzburg Academy Staff 
Rachel was a Salzburg Academy participant in 2008.
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Salzburg Global Program Director publishes book on news literacy
Salzburg Global Program Director publishes book on news literacy
Salzburg Global Staff Writer 
"Indispensable reading" and "well timed and much needed" represent a mere snapshot of the praise for Paul Mihailidis' latest book, News Literacy: Global Perspectives for the Newsroom and the Classroom. Mihailidis is both an Assistant professor, Dep. of marketing and communications at Emerson College in Boston, MA., and the Director of the Salzburg Academy on Media & Global Change, a Salzburg Global Seminar initiative. The Seminar takes special pride in the fact that News Literacy is a direct product of the Salzburg Academy program, developing the concepts and ideas drawn from the discussions and conversations that took place throughout the four years of the Academy’s existence. In the book, Mr. Mihailidis explores how the rise of digital age has changed the news and the entire media landscape, as well as how we can help empower civic voices through the classroom. The preface to this book was written by the President and the CEO of the Salzburg Global Seminar, Stephen Salyer, who discusses changes the rapid growth of digital media brought to the world, stresses out the vital role of educated citizenry and outlines the crucial task of the Salzburg Media Academy, established in 2007, in bringing together leading scholars and teachers in the fields of journalism and communications to design and shape issues around media literacy. Mr. Salyer kindly acknowledges all faculty members and a truly international cast of the Media Academy program as inspiration and coauthors of the new book. Paul Mihailidis’s has published widely on media literacy, global media and civil society, and on post-secondary learning outcomes in media programs. His research concerns the effectiveness of media education in teaching about media’s roles and responsibilities in civil society. Mr. Mihailidis is also the co-author of an upcoming book on Media Literacy, due in early 2012. News Literacy: Global Perspectives for the Newsroom and the Classroom is available online in hardcopy and paperback at Amazon.
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