The Dartmouth Center for Health Care Delivery Science

Salzburg Diaries


Dec 2013
Five days in December: Daily dispatches from the front lines of health care delivery innovation.
by Emily Fletcher, TDC Presidential Fellow in Global Health

Leaders from the conference’s three co-organizers, the Salzburg Global Seminar, TDC, and the World Bank, welcome participants and set the stage for the week’s discussions.


Many participants traveled through the night to reach the Schloss Leopoldskron in Salzburg, Austria, but jet lag was no match for the sharp minds that came together on Sunday, December 8, to kick off the 507th Salzburg Global Seminar Session. The opening speakers set the tone for a week of discussions that would focus on how to achieve universal health coverage that incorporates patients’ preferences and the needs for building capacity in the areas that bring the highest value to individuals. Throughout the week, teams organized by countries and region would work to apply these principles to action plans they developed to tackle individual aspects of achieving universal health coverage.

In his opening remarks, co-host Dr. Al Mulley of TDC explained the importance of Dr. Jack Wennberg’s foundational work four decades ago studying health care variation in rural Vermont. Dr. Wennberg famously—and surprisingly—found that despite widespread geographic variation in utilization rates and costs for a variety of procedures, health outcomes were not inherently better in areas where people accessed more care and where costs were higher. Dr. Wennberg concluded that, troublingly, “geography is destiny” when it comes to health care. Around the United States, health care costs per capita today vary from roughly $6,000 per person in parts of Minnesota to about $17,000 per person in areas of Florida — with no correlation to positive outcomes. Health care delivery science, Dr. Mulley noted, must cut through complex adaptive system behaviors to develop ways to measure individuals’ wants and needs. The two guiding principles for the week would be: 1) No decision should be made in the face of avoidable ignorance, and 2) Respect for the individual is key.

The day’s remarks concluded with a reminder of the importance of a bi-directional exchange of information in the doctor-patient relationship. The speakers emphasized that every patient is capable of true empowerment with even the most limited resources, if one can harness them appropriately. In the words of one opening speaker, Dare to dare. “How would you build an ideal health care system if you had a blank slate?” Participants were posed this question on the opening night, and would consider it all week, developing creative solutions and harnessing bold ideas to work toward bringing health care to all.

The Kosovo team, including minister of health Ferid Agani, meet to outline possibilities for a Kosovar “action plan.”

Day 2

What would you do for your country’s health system with a one-time budget surplus of $10,000,000 if you were the minister of health? Dr. Glyn Elwyn of TDC posed this hypothetical situation and several other provocative questions to participants on the second day of the seminar. Elwyn’s interactive and lively activity was the last group session of the day, which had kicked off with a discussion about the definition and measurement of value in health care.

While economists define value most simply as outcomes over costs, Dr. Al Mulley said this definition must be unpacked to be useful in a health care context. Uncertainty will always exist in health care decisions, so health systems must measure patient preferences to determine what is valued in the face of this uncertainty, according to participants.

The example of end-of-life care in the United States was used to illustrate the failings of health care capacity building that disregards or does not measure patient preferences. Although the majority of Americans would prefer to die at home, 55 percent of those patients die in a hospital setting, because that is where end-of-life care capacity exists. Preference-sensitive health care capacity building can improve value as measured by the individuals whose quality of life and dignity of death are affected — and reduce costs at the same time.

Paul Hunt, a professor at the Human Rights Centre at the University of Essex and the former UN Special Rapporteur on the Right to Health, explained the importance of raising the profile of health as a human right and examining health care systems through a rights-based lens. He stressed the importance of accountability, and noted that acknowledging a right to health—defined by the United Nations as health care that is available, accessible, culturally appropriate, and of high quality—does not provide easy answers to complex policy issues.

When asked about the efficacy of rights-based approaches, Professor Hunt described research that found plausible levels of evidence that a human-rights based approach contributes to health gains for women and children. He also urged countries to build research, measurement, and feedback mechanisms into their health care systems.

Participants in several country groups remarked that the framework for a rights-based approach exists in their countries, including in their constitutions, but that major barriers, such as limited resources and a lack of political will, stand in the way of realizing this ideal. It was suggested that human rights—described as "ethics with teeth"—should be part of the fabric of education for health care professionals.

When Elwyn took the stage, he asked everyone to imagine themselves both as individuals defining health policy priorities and as patients in the health care system. Using “option grids” to aid in their decision making, participants-turned-patients debated whether to opt for optimal medical management or stenting to treat their hypothetical angina and discussed how patients can be empowered to make informed decisions that align with their preferences and values.

On the second day, participants also met formally for the first time to discuss priorities for developing country-specific action plans, which will span issues as diverse as mental health and electronic medical records.

Country team members work on formulating their action plans.

Day 3

The seminar’s third day included sessions that addressed how to apply a rights-based approach and citizen engagement in different contexts, what low-income countries can learn from other countries’ mistakes, and how reverse innovation can drive health care value up and costs down.

Dr. Jaime Bayona of TDC and the World Bank Institute described providing the first ambulatory treatment for MDR-TB in Peru, noting the crucial importance of providing social and other support beyond medical treatment. With three other panelists, Dr. Bayona discussed cancer care in Peru, tuberculosis in South African mineworkers, and community participation in health councils in Brazil.

In Peru, Club de la Mama has provided social support for women with breast cancer since 2006. The group promotes breast cancer awareness and facilitates knowledge sharing between patients, empowering them and providing an important service beyond medical care.

In South Africa, the high tuberculosis burden in mines is difficult to address due to the prevalence of migrant labor and little governmental accountability across borders. A lack of patient engagement has hindered past efforts to address the epidemic, though the main challenge now is how to include ex-mineworkers under the care system being developed.

Integration of care, decentralization, and citizen participation are codified in Brazil,  and the Brazilian team spoke about local and national health councils that include user, government, provider, and professional association representation to shape health policy in a bottom-up manner. Several participants seemed interested in how this model could be adapted to their country context.

In the session focused on learning from problems in different countries’ health care systems, Dr. Bob Drake of the Dartmouth Psychiatric Research Center described his experiences developing community-based mental health care programs in the United States. He encouraged participants to build mental health care programs that focus on vocational training and strengthening natural support systems.

Dr. Drake cautioned against building mental health care systems reliant on institutionalization, polypharmacy, and isolation of mental health care services from primary care—all pitfalls of the American system. Most patients, he said, are interested in functional recovery and community integration, not the complete annihilation of their symptoms.

In the same session, both Peru and Kosovo representatives said they see high rates of post-traumatic stress disorder in their populations. In 1999, after the Kosovo War, 25 percent of the population over 15 suffered from PTSD, and the country’s mental health care system was in shambles. Working with the World Health Organization, the Kosovar government developed a plan for mental health care that centered on seven community-based mental health care centers. Participants said that traditional healers can also serve as an entry point to mental health care and should be integrated into systems as capacity is built.

Later, TDC’s Chris Trimble, a faculty member at the Tuck School of Business, moderated a panel of five Indian medical entrepreneurs, who explained how standardization, task shifting, and capacity innovation have helped them reduce costs for procedures such as cataract surgery and dialysis by as much as 90-95 percent. In Dr. Srinivasan Aravind’s eye care centers, for example, a cadre of midlevel ophthalmological personnel—trained in a program developed by the Aravind Eye Care System—allows doctors to perform a much greater number of surgeries than is possible in other settings.  One panelist remarked that health care is about process, protocol, and price.

In India, the primary health care system is hampered by a lack of general practitioners, an out-of-pocket payment system, and a lack of integration of vertical programs.  The importance of sustainability in building primary health care capacity was emphasized—altruism is not enough to guarantee the success of a system.

The panelists urged budding entrepreneurs to seek out new opportunities, persevere in the face of setbacks, and focus on working well with a team to realize health care innovations.

In the evening, participants tapped into one another’s expertise and gathered for conversations addressing personal topics of interest, ranging from metrics for impact investing to translating health care innovations across national contexts.

Country teams met again to more thoroughly investigate the core issues and questions they’ve identified. The teams—composed of a mix of government officials, practitioners, non-profit advocates, civil servants, entrepreneurs, and others—represented the following countries and regions:

  • Brazil
  • Costa Rica
  • Mexico
  • Peru
  • East Asia
  • Kosovo
  • Egypt
  • Morocco
  • India
  • United States and Canada
  • Uganda
  • Rwanda
  • South Africa and Swaziland

Jean-Pierre Nyemazi, director of Monitoring, Evaluation, and Business Strategy at the Rwanda Biomedical Center, leads a discussion on Community Health Workers as a key tool in providing sustainable primary health care during the Knowledge Café.

Day 4

Seminar participants gathered on the fourth day for a “knowledge café,” in which six experts led small group discussions about their areas of expertise as they relate to the drive for universal health coverage. The room buzzed as participants moved from discussion to discussion, sharing experiences and asking colleagues about health system successes and failures and how they might be applied in other country contexts.

1. Mr. Sidi Abdellatif Idrissi Azzouzi focused his discussion on health care financing reform in Morocco. With a new national constitution in 2011, legal issues and political and social transition framed the conversation about how to involve the various stakeholders and actors and how to ensure accountability and responsibility in the system. Mr. Azzouzi said that the Regime d’Assistance Medicale (REMAD) covers about six million patients in Morocco. The Brazilian team also shared their experiences implementing a similar program several years earlier.

2. Salzburg Global’s Diasmer Bloe shared her experiences operationalizing the right to health in Liberia, a low-resource, post-conflict setting. Participants discussed the difficulties and management of politics, change, conflict environments, resources, and the various actors who have a stake in the system. In many countries, a disconnect exists between those making the policy, the health care workforce, and the patient populatino. Ms. Bloe led a discussion about the reason behind the push for a rights-based approach to health care in Liberia—a long conflict, the need to decentralize everything, and the importance of guaranteeing the rights to every state service. Members of the Brazilian delegation also mentioned their program in which godmothers ensure pregnant women are appropriately using the system.

3. Mr. David Garcia Junco Machado’s table discussed Mexico’s insurance programs, with a particular focus on Seguro Popular, in the context of the drive for universal health coverage. The national scheme provides insurance for citizens who are not covered under Mexico’s other insurance plans, though Mr. Garcia described the difficulty of standardizing protocols across the various programs. Participants were interested in how insurance can be used as a tool to expand health care access in different country contexts.

4. Mr. Emmauel Higenyi led a discussion about leveraging partnership innovations for universal health coverage in Uganda. He focused on involving the important stakeholders in the health care system, which in Uganda is based on a strong legal framework, and policy for public-private partnerships. While these partnerships initially focused on the pharmaceutical supply chain, they were then broadened to include general health care delivery. Participants were also interested in hearing about how communities can become involved in the health care system using technology, such as programs that allow health system users to provide feedback on the quality of care and any issues that arose via mobile phones.

5. Dr. Al Mulley’s table discussed how to create value out of lessons learned from variation in the health care system. Dr. Mulley said that countries currently investing in health care capacity should base their investments on revealed patient preferences in order to avoid the waste and harm—which constitute up to 40 percent of U.S. health care costs today—apparent in many existing systems. By studying widespread variation in health care costs per capita and service utilization rates throughout the United States, Dartmouth researchers have found that more care and more expensive care do not lead to better outcomes. No health care decisions at the individual or aggregate level should be made in the face of avoidable ignorance, Dr. Mulley said, and respect for patients and their preferences should be the cornerstone of health systems.

6. At Mr. Jean-Pierre Nyemazi’s table, discussion focused on realizing and sustaining universal health coverage in a limited resource setting, with Rwanda as the central example. The concentration in Rwanda, he said, was investing more in primary care, especially at the community level, to realize community involvement and ownership of the health care system and to reduce costs at the hospital level. Rwanda’s community health worker (CHW) program relies on women who are elected by their communities and receive an initial month of training, with periodic refresher training. There is an average rate of one CHW per 100 people, and the women visit households to administer basic care, promote health, and identify patients for referral to other services, according to Mr. Nyemazi. Participants were interested in how an incentive program that provides business capital to cooperatives of CHWs could be applied in other settings.

Participants of the Salzburg Global Seminar “The Drive for Universal Health Coverage” pose for a group portrait at the Schloss Leopoldskron, December 2013.

Day 5

On the fifth and final day of the session, participants polished their “changes strategies” and action plans to present to Rwandan Minister of Health Dr. Agnes Binagwaho. The groups worked to incorporate feedback they had previously received, and they were tasked with choosing one focused question to ask Dr. Binagwaho.

Connected by video link with Dr. Binagwaho, each country was given five minutes to summarize its action plan and ask a targeted question. The teams’ change strategies covered a wide range of issues in health care delivery, from the development of evidence-based clinical protocols to sustaining community engagement in the design of health care systems.

Several groups touched on maternal and child health as a key area of concern, while a few others focused on integrating disparate health systems and insurance plans to provide more thorough coverage to all citizens.

Dr. Binagwaho took each question in stride, answering thoughtfully and providing concrete suggestions on how to modify and implement action plans.

Participants met as a large group later in the day to begin work on a Salzburg Statement, which will serve as a call to action for policymakers in the drive for universal health coverage. After lively discussion of key principles around which to structure the statement, participants distilled their brainstormed ideas into nine principles that will form the scaffolding of the statement.

Individuals indicated the principle they were interested in defining, and working groups were created to continue refining the statement in the weeks following the session. Soon, a completed Salzburg Statement will be released to serve as a guiding document for those pushing forward the ideal of universal health coverage.

In the evening, participants gathered for a final farewell banquet, and animated conversations about health care delivery science, obstacles to achieving universal health coverage, and a rights-based approach to health continued well into the night. The next morning, participants departed, dispersing around the globe to continue working toward high-value health coverage worldwide.