A conversation between Jo Bibby, Director of Strategy at the Health Foundation, and Karabi Acharya, Director at the Robert Wood Johnson Foundation
What can we learn from each other? It was with this simple question in mind that earlier this year, the Health Foundation and the Robert Wood Johnson Foundation – organisations dedicated to improving health and health care in the UK and the United States respectively – brought together a group of people from all regions of the world with a myriad of expertise (from public health practice to architecture and city planning) for a convening of the Salzburg Seminar. Hooked on Health Care looked at the bias toward investing in health care versus cross-sector collaborations that promote and maintain health and wellbeing, and explored ways to overcome this bias.
Here Jo and Karabi discuss the value of this type of global learning, and how looking beyond our borders and preconceptions can help us all to overcome obstacles to improving health and wellbeing.
Jo Bibby, Health Foundation: Clearly so many of us are dealing with similar and very complex challenges. We don’t need to solve them all in isolation. Even when the solutions found in other countries are not directly transferable, simply being able to look beyond your own context provides a fresh perspective. You’re able to approach problems that may have seemed entrenched with a new confidence about your ability to tackle them.
Karabi Acharya, Robert Wood Johnson Foundation: I couldn’t agree more. But it can be challenging to put into practice. Although we’re a culturally diverse society, I think the United States is also one of the most insular. Our historical narrative has been about a melting pot versus a story of valuing difference. We get in the way of our own progress by presuming we know better than others.
We need to get ‘unstuck’. We’ve lived for a long time with the health care system we have today and we can have a difficult time imagining anything different – this includes those of us who have worked within the system. But even more important than the system itself are the cultural norms and values that created it. So yes, stepping outside – looking at how other systems work and how other countries view health and health care – provides perspective. It forces us to realise just how much the systems in which we live and work are social constructs that we have the ability to change.
Jo: The UK has already gone a long way to embrace population health, which is something I know many in the US aim to do. We’ve had a system of universal state-funded health care in place for nearly 70 years now, which encourages an emphasis on preventative care. This method for allocating funding to commissioners for geographical populations rather than payment for activity also incentivises earlier detection and management to reduce the demand for hospital care. As do payment incentives for things like regular check-ups and case reviews for those with chronic conditions. We have a built in requirement to look at the overall population benefit of our health care spending rather than simply individual benefit.
Karabi: The system you are describing is based on the premise that health care is a right provided by the government. As a result, the government has an incentive and a need to create cost-effective solutions, which include prevention.
This represents a real challenge to cross-border learning. We need to be aware of the values that guide the systems from which we want to learn so that we can consider how to adapt elements of those systems in countries where those values are not necessarily embraced.
Jo: While I think the US health care system can learn from the UK’s work so far on prevention and population health, there is also so much the UK needs to learn from the US regarding collaboration between government and society. Culturally, we’re inclined to look to the state to meet people’s needs rather than consider the role of community responsibility.
Karabi: I’ve heard from others in the UK that a reliance on the state system can inhibit innovation and entrepreneurial activity. The takeaway is that there is no perfect system; we can all benefit from taking the time to learn from each other. But it can be difficult to imagine how the ideas which inspire us from other countries can be adapted – how practical, ideological, and cultural differences can be overcome.
Jo: Even when something should be transferrable we can fail to grasp the ‘active ingredient’ that made a particular innovation work. We think we can simply, for example, replicate a technological solution or create a new role in a team. But often what has made things successful has been as much about the leadership provided or the skills and attitudes of the individuals involved. The real challenge and opportunity in global learning is to find a better way of describing all the elements that make successful innovations and help us transfer the ‘physiology’ of the innovation; we need to think about the ‘ecosystem’ in which the innovation thrived. We may not necessarily be able to replicate it, but we can at least understand what we might need to do differently.
Karabi: And it obviously goes much further than the US and the UK learning from each other – or even two high-income countries learning from each other. While progress is being made, many still need to get past the perceived differences between health in high-income countries and health in low- and middle-income countries and instead embrace the opportunity to learn from our peers who are overcoming similar challenges – often with less available resources.
When I was recently in Cuba with a group of leaders trying to improve health outcomes in their low-income communities in the US, we were excited to learn about HeberProt-P, a drug developed by scientists in Cuba to cure diabetic foot ulcer and prevent the need for amputations. What was most striking to me was that, while my US travelling companions were disappointed that they couldn’t get the drug back home because of our country’s embargo, our Cuban hosts saw use of the drug as a failure. With the emphasis on prevention in Cuba, their perspective was that it should never get as far as someone being at risk of losing a limb.
Jo: It’s also notable that, while the Millennium Development Goals emphasized wealthy countries aiding poor recipients, the new Sustainable Development Goals – which include ensuring healthy lives and promoting wellbeing for all – apply to EVERY country. The world has changed. Inequality within countries is now a greater issue than ever before. There are people living in the UK and in the US who face the same challenges to health and wellbeing as people in some of the poorest countries in the world.
Karabi: The Robert Wood Johnson Foundation is working to build a ‘culture of health’ that allows everyone in the United States to live the healthiest life possible, no matter how much you earn, where you live, what you do, or where you come from. It’s an ambitious goal and everyone has a role in helping to achieve it – within and across sectors. And I am confident – as I know you are – that we’re not going to be able to get there without learning across borders.