WISH 2013
WORLD INNOVATION SUMMIT FOR HEALTH Report of the inaugural summit 10–11 December 2013, Doha, Qatar
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CONTENTS 1 A letter of thanks from Engineer Saad Al Muhannadi, President of Qatar Foundation 2
A letter of thanks from Professor The Lord Darzi
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Themes from WISH
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The Plenary Sessions – Day 2 10 John Dineen 11 The Global Diffusion of Health Innovation 14 The Innovation Showcase Plenary 17 The Closing Ceremony
3 Introduction 6
The Plenary Sessions – Day 1 6 The Opening Ceremony 8 Simon Stevens 8 Daw Aung San Suu Kyi 9 The Gala Dinner – Boris Johnson
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The Panel Discussions – Day 1 20 Mental Health 22 Patient and Family Engagement 24 Health and Ethics: End-of-Life Care 26 Road Traffic Injury and Trauma Care 28 Big Data and Health 30 Antimicrobial Resistance
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Next Steps
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The Panel Discussions – Day 2 32 Accountable Care 34 End-of-Life Care 36 Obesity
Sponsors and Academic Partners
Engineer Saad Al Muhannadi President of Qatar Foundation
Dear Colleagues On behalf of Qatar Foundation for Education, Science and Community Development, I want to thank all of you who attended the inaugural World Innovation Summit for Health (WISH) in December. Many of you interrupted busy schedules and travelled great distances to join us, reflecting the importance of this unique opportunity to find new approaches to the most urgent healthcare challenges. WISH was launched by Qatar Foundation under the patronage of Her Highness Sheikha Moza bint Nasser, Chairperson of Qatar Foundation. The purpose of WISH is to encourage collaboration on innovation in health policy, health systems and healthcare delivery and provide a platform for global leaders to share and learn from one another. Global demographic and lifestyle changes mean that public health issues often seem to proliferate faster than we can find solutions for them. But the sessions you attended, the information you shared, and the agreements you made are all cause for profound optimism. Together, we laid the foundations for a new international framework which will help to diffuse healthcare innovation quickly and efficiently. This vision is closely aligned with Qatar Foundation’s mission, and we were honored to launch an event which may prove to be a historic turning point in the development and delivery of healthcare around the world. With this in mind, I look forward to an even more successful Summit in 2015. Engineer Saad Al Muhannadi
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A letter of thanks
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A letter of thanks Professor The Lord Darzi Executive Chair of Wish, Qatar Foundation Director of the Institute of Global Health Innovation, Imperial College London
Dear Colleagues I would like to thank you all for attending the inaugural World Innovation Summit for Health (WISH) on 10-11 December in Doha, Qatar. The ambition for WISH is set high; to be the most impactful summit of its kind, bringing together the best ideas and the most influential people to tackle urgent health challenges facing populations globally. The feedback I have received from you suggests WISH achieved this. This would not have been possible without you; more than 1,000 delegates from 67 different countries who brought their knowledge, ideas, and experience to share with colleagues from around the world. It was a great privilege for me to chair this unique and inspiring event. I am very grateful to Her Highness Sheikha Moza bint Nasser for her vision in driving this forward, and to the Qatar Foundation for making such an event possible. Innovation is the answer to achieving better health for all of us and people’s commitment to making this a reality was inspiring to witness. This was evidenced by the rich exchange of ideas and dialogue that took place throughout the two days in both panel and plenary sessions. However, this is just the beginning. We have now created a global network of policymakers, academics, and industry leaders who together can change health and healthcare. WISH will continue to grow in ambition, impact, and reach over the coming years and I will be in touch shortly with more details about the next summit. In the meantime this report outlines the main topics of discussion at WISH and what together we decided were priorities for action. Professor The Lord Darzi, PC, KBE, FRS
The inaugural World Innovation Summit for Health (WISH) took place in Doha, Qatar on 10-11 December 2013. The summit followed the Global Health Policy Summit that took place in London during the 2012 Olympics, where the idea was born to bring together the most influential leaders, policymakers, practitioners, and thinkers to discuss how innovation can transform healthcare around the world. More than 1,000 healthcare leaders from 67 countries met at the Qatar National Convention Centre, Doha’s state-of-the-art conference venue, for two days of intense debate about some of the world’s most pressing health challenges. The distinguished guests included HRH The Duke of York, HRH Princess Lalla Salma of Morocco, HRH Princess Ghida Talal of Jordan, and HRH Princess Dina Mired of Jordan, as well as a host of ministers and international experts. Between sessions the delegates visited the exhibition of 15 of the most successful health innovations from around the globe and exchanged ideas under Louise Bourgeois’ Maman, a towering steel and marble spider sculpture. Through the engaging panel discussions, inspiring keynote speeches and the practical examples of change in action, WISH achieved its ambition of catalyzing innovation and creating a network of global health leaders. Here we outline the key themes that emerged from the summit and bring you the highlights from the panel discussions and plenary sessions.
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Introduction
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Themes from WISH
The summit heard from keynote speakers including Her Highness Sheikha Moza bint Nasser, Simon Stevens, John Dineen, and Daw Aung San Suu Kyi. Nine panel discussions allowed delegates to engage with the world’s leading experts in particular policy areas and discuss the forum reports in more detail. As well as examining evidence-based policy solutions, WISH also explored how innovation is adopted and spread in health systems through the Global Diffusion of Healthcare Innovation study. The 15 Innovation Showcases in the exhibition space created an opportunity for delegates to see practical examples of change in action and meet inspiring innovators. A number of common themes emerged from these discussions that suggest how innovation can be successfully adopted and implemented in different healthcare systems around the world.
Patients must be empowered to lead change
Radical changes are needed
We need radical change and we need it now. The rise in non-communicable diseases, increasing demand, and spiraling costs are common factors across the world and governments, health leaders and frontline clinicians need to transform the way that healthcare is delivered in order to meet these challenges.
Innovation is the answer
It isn’t possible to tackle the urgent healthcare challenges the world faces by doing more of the same – instead we must innovate. We must do this not only through new technologies and treatments but also in how care is delivered, where it is delivered and who delivers it. WISH brought together evidence-based solutions from around the world and created an environment where experts, individuals, and countries can share their knowledge and experience with colleagues from across the globe, but more needs to be done.
Partnerships are key
We won’t solve the health challenges we face alone. As well as much closer engagement with patients and their families we need the support and involvement of other sectors including industry, education, transport, and agriculture. All of us must work together to tackle problems which have deep roots beyond the health sector such as road traffic injury, obesity, and antimicrobial resistance.
Many solutions are already out there
In many cases the solutions to problems already exist somewhere in the world. Understanding how these ideas can be identified and what enables them to spread across countries and systems will allow us to begin to close the gap between what we know and what we do. Critical to success will be to engage patients in this task as they remain an important untapped resource of knowledge about what works best.
We know more together than we do alone
Many of the global health problems currently faced are shared by developed and developing countries. Obesity is no longer the preserve of developed nations and issues such as end-oflife care affect us all. As well as partnerships across sectors, countries need to work together to share ideas and best practice in order to find solutions to the health challenges we face.
Healthcare is an investment, not a cost
Implementing many of the changes and innovations needed often requires initial investment – but this can bring profitable returns. Making changes now will improve the efficiency of health systems worldwide, improve the health of populations, and ultimately be beneficial for society.
World Innovation Summit for Health 2013
Engaging and empowering patients is central to all change that needs to take place. This is as true for the development and improvement of provider systems as it is for research and education. Patients must be at the heart of the decision-making processes to drive both behavior change and quality improvements.
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A synopsis of the plenary sessions Day 1 The Opening Ceremony Her Highness Sheikha Moza bint Nasser, Chairperson, Qatar Foundation Professor The Lord Darzi, Executive Chair of WISH, Qatar Foundation; Director of the Institute of Global Health Innovation, Imperial College London HRH Princess Lalla Salma of Morocco, President, Lalla Salma Foundation His Royal Highness Prince Andrew Duke of York, United Kingdom Donald Tsang, Former Chief Executive, Hong Kong Jonathan Dimbleby, Master of Ceremonies Lord Darzi welcomed distinguished guests and delegates and spoke of the shared commitment to reform and improve healthcare. He emphasized to this global network of health innovators that many countries share the same challenges such as a rising tide of disease, increasing expectations from patients and financial pressures, and that innovation is the solution.
“We must embrace the innovation we need to secure the health we want. Innovation is the answer.” Professor the Lord Darzi of Denham
Lord Darzi introduced the Global Diffusion of Health Innovation, a new and ambitious project that examines the factors that enable countries to take up and spread innovation, which he described as “a pulse check on the state of innovation that shows that more needs to be done” and called on the delegates to lead a health reform revolution for the many millions of people that they serve. Lord Darzi then invited Her Highness Sheikha Moza bint Nasser, Chairperson of the Qatar Foundation and the driving force behind WISH, to address the gathering. Her Highness described WISH as an important and historic summit, providing the ideal environment for the intellectual exchange of ideas and the opportunity to benefit from shared experiences – innovation is the critical factor in devising solutions to the health challenges faced across the world. Her Highness also spoke of Qatar’s ambitious approach to healthcare provision, including its plans to develop personalized medicine. “Qatar is embarking on a promising journey in gene sequencing,” she said. “This will revolutionize the prognosis, diagnosis and treatment of disease.” All the Plenary and Panel sessions can be viewed at http://www.wish-qatar.org/media-center/streaming
Her Highness Sheikha Moza bint Nasser
The panel then discussed the importance of innovation in transforming healthcare in countries across the world. HRH Princess Lalla Salma described how innovations in technology, treatment, and scientific research have had a huge impact on cancer care in Morocco and other countries in Africa. HRH The Duke of York said that collaboration between sectors such as health and business is key to developing and implementing successful innovations. And Donald Tsang highlighted the urgent need for innovation in the health sector in order to address the very pressing issues of increasing demand and costs faced by the health sector saying, “almost every year, in every country, the increase in public health spending outstrips the spending capacity of the country concerned”. The session concluded with the aspiration that WISH will provide a platform to focus on these issues, to share ideas and together find solutions to these challenges.
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“We hope this conference can be a catalyst for innovation and an environment in which innovation can flourish in the world of health.”
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The first plenary session
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Simon Stevens, UnitedHealth Group President of Global Health Mr Stevens spoke of the Middle East’s long history of innovation in the healthcare sector. He warned that that while new technologies are to be welcomed and will create dramatic change for populations, countries need to ensure they implement innovations appropriately to their own context avoiding “under supply of needed care, alongside the over supply of inappropriate care”. While innovations in medical technology and treatment will undoubtedly have an impact, Mr Stevens argued that the biggest impact on the health sector in the coming years will be from everyday technologies. This information will be used to transform where, when, and how patients are treated, as well as to inform research. Information will also be driving improvements in the quality of healthcare as health systems across the world become more transparent and publish more data about their performance and services. Mr Stevens went on to argue that most health systems will need to change radically if innovation is to flourish – moving away from traditional models of care. Cross sector partnerships will be part of the solution for all countries in providing innovative and effective healthcare. Delegates were urged to get serious about useful innovation and tackle the reshaping of our healthcare systems. He ended, “optimism is not wishful thinking, the desirable is not inevitable and making it happen is our responsibility.”
“It is high time that we put more of our energies into innovation. This is not just on the supply side of healthcare, but in potentially cost-saving demand-side innovations.” Simon Stevens
The second plenary session Daw Aung San Suu Kyi, Chairperson of the National League for Democracy, Burma Aung San Suu Kyi explained that because of the limited healthcare infrastructure in Burma, health system improvements will need to be based not on financial resources, but on the country’s most valuable asset – its people. Burma has a long tradition of people working in caring roles such as nursing and these values will help to transform healthcare in the country.
All the Plenary and Panel sessions can be viewed at http://www.wish-qatar.org/media-center/streaming
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“Spiritual health is just as important as physical and mental health. I hope we can work together so people can be healthy in every sense of the word.” Daw Aung San Suu Kyi
It was emphasized that recognizing the importance of the human spirit is vital when renovating old systems and progress will only be possible with a revolution of the spirit and the ability and courage to change oneself for the better. Daw Aung San Suu Kyi said that despite living in the best of times the world can improve further still, and in healthcare this will mean better health through innovation. Delegates were encouraged to think of healthcare not simply in terms of technology, training, and medical education, but to go back to the very basics of what makes people healthy which is rooted in human values and spirituality.
The Gala Dinner Mayor of London Boris Johnson gave the keynote address at the Gala Dinner. He spoke of London’s long history of medical and scientific innovation and the challenges of delivering healthcare in a major capital city.
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Day 2 The third plenary session John Dineen, President and CEO, GE Healthcare Mr Dineen focused on the changing environment and how this has influenced the way technology leaders invest. Like other sectors the healthcare technology sector has had to adapt to the financial crisis and do things differently, changing the way it thinks about and invests in new technology in order to improve quality, cost, and access at the same time. Mr Dineen said that often healthcare does not require new technologies, but instead requires the use of existing technology in different ways. This can reduce cost and improve clinical quality and patient experience. Miniaturization of the ultrasound has reduced the cost of a traditionally hospital based technology and enabled it to do very different things. VScan, a handheld pocketsized ultrasound technology, is used by the midwife community in Indonesia to help reduce maternal mortality rates in hard to reach rural settings.
“The glass is half full in the technology sector… we intend to fill this glass with technology that can help healthcare do more with less and improve access around the world. It just requires that we think a little differently.” John Dineen
The use of technology can also have a dramatic impact on the cost of healthcare. The healthcare sector must become more efficient. Mr Dineen identified an opportunity to increase the productivity of the health sector by learning from other industries’ use of technology and Information Technology. IT can have a real impact on the performance of healthcare, demonstrated by software technology used in a hospital setting to track patients and equipment helping to free up staff time, leading to greater efficiency and better outcomes for patients. Mr Dineen concluded it is necessary to develop technologies that are going to have both a technological and economic impact – the focus should be on seeking affordable technology that can make a real difference.
All the Plenary and Panel sessions can be viewed at http://www.wish-qatar.org/media-center/streaming
Jonathan Dimbleby, Moderator
The Panel Her Royal Highness Princess Ghida Talal, Chairperson, King Hussein Cancer Foundation, Jordan His Excellency Ali Talib al Hinai, Under Secretary for Planning, Oman Steven Buchsbaum, Deputy Director, Discovery & Translational Sciences, Bill & Melinda Gates Foundation Rt Hon Stephen Dorrell, Chair of Health Select Committee, UK Parliament Richard Horton, Editor in Chief, The Lancet Dr Greg Parston, Executive Director, Centre for Health Policy, Imperial College London
The Issue We all know the importance of creating new ideas, inventions and ways of working in the delivery of healthcare, but it simply takes too long at present for new ideas to become prevalent practice.
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The Global Diffusion of Health Innovation
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The Global Diffusion of Healthcare Innovation (GDHI) examines the importance and prevalence of the specific enablers and cultural dynamics, first identified as a framework for diffusion of healthcare innovation by the Institute of Global Health Innovation, Imperial College London, in its study ‘From innovation to transformation.’ The study focused on eight countries: Australia, Brazil, England, India, Qatar, South Africa, Spain, and the United States – chosen for their geographical spread, different healthcare delivery systems and economic conditions. The research covered more than 100 personal interviews with senior-level experts who were able to give an overview of their healthcare systems, as well as quantitative surveys of more than 1,500 healthcare professionals and more than 750 industry professionals from the fields of pharmaceuticals and medical technology. The hope is that this pioneering study will provide a strong basis for learning and dialogue, so that others can consider the relevance of these countries’ experiences and translate successful practices in their own healthcare organizations.
The Debate The findings show that countries are using different mixes of enablers to encourage the spread of innovation in healthcare. In the US, experts are clear that “incentives and rewards” have played an important role and they see the diffusion of innovation as being tied to the payment system. In England, by contrast, it is healthcare “standards and protocols” that are noted for having helped the spread of innovation by encouraging organizations to put in place innovative ways of improving their healthcare delivery processes. However, healthcare professionals in all eight countries identified behaviors related to engaging people – patient, staff and clinical champions – as the most prevalent cultural dynamics in their organizations, confirming that a focus on the frontline – where care is delivered and where change most needs to be fostered – can be very powerful in bringing about a more rapid diffusion of innovation.
“Do not wait for anybody to give you permission to take the opportunity to improve the service that is delivered… Nobody ever created radical change, which is the thing we need in the healthcare sector, by looking for permission from a bureaucrat.” Rt Hon Stephen Dorrell
To effect change in the diffusion of innovation across a health system, it appears to be important to focus on developing and using both local enablers and cultural dynamics simultaneously. The increased prevalence of one seems to go hand-in-hand with the increased prevalence of the other.
All the Plenary and Panel sessions can be viewed at http://www.wish-qatar.org/media-center/streaming
Examples from the audience and the panel noted that: • In Oman, due to limited resources, they have focused on practices and policies and within the primary care sector. • In Bangladesh, innovation has been targeted in child mortality and family planning programs. • In Rwanda, there has been increased use of mobile technologies – in areas including reporting of maternal deaths. It was noted by a member of the audience that health ministers from the developing world may need support to ensure health is seen as a priority. Giving patients a voice to drive improvements is an important aspect to achieving this goal.
The Conclusion The experts interviewed identified four areas where developments currently underway are likely to promote more rapid diffusion of innovation in future. They are: • Progress in the availability, accessibility, and capability of technology. • Government-led initiatives to set a clear vision and strategy. • The allocation of specific resources to identify and promote healthcare innovation. • Developing and maintaining an interest in innovations among healthcare professionals on the frontline. The findings also indicate, however, that there is still scope for considerable improvement in embedding the cultural dynamics within healthcare organizations in the future. Four of the dynamics – ‘creating space,’ ‘adapting innovation,’ ‘improving the next journey of system transformation’, and ‘eliminating old and ineffective ways of working (or delayering)’ – may not have been rated by healthcare professionals overall as being as prevalent as others. Yet these factors are important, and need attention, effort, and resources.
“The most difficult [one] is de-layering. I call this the paleontology of innovation. We see layer upon layer of innovation, without people getting rid of the old stuff. That can only increase cost, cut productivity and undermine effectiveness.” Dr Greg Parston
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In most countries, however, a gap is apparent between how important professionals believe the enablers to be and how prevalent they see them as being within their own organizations. This is not the case in Qatar, where the research team observed that the country’s smaller size and more geographically concentrated services can make change more easily manageable. In India and the US, this gap is relatively small, though consistent, while a slightly larger gap exists in Australia, Brazil, and South Africa.
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THE Innovation Showcase Plenary Jonathan Dimbleby, Moderator
The Panel Professor Victor Dzau, Chancellor for Health Affairs and Professor of Medicine, Duke University and President and CEO, Duke University Medical Center Health System Dr Prathap Reddy, Founder, Chairman, Apollo Hospitals Group Dr Paul Thompson, Rector, Royal College of Art
Innovation Showcase Winners Peter Hames, Co-founder, Sleepio Professor Andrew Kingsnorth, Director, Operation Hernia Mike Norman, Managing Director, eRanger
The Issue Fifteen of the most successful health innovations from around the world were on show during the summit, ranging from medical devices to design, business, and digital solutions. The ideas ranged from a solar-powered water purifier developed in Sweden and now used worldwide to improve access to clean water to a motorcycle ambulance developed in the UK and used to navigate rough terrain throughout Africa and India, providing healthcare in hard to reach areas.
All the Plenary and Panel sessions can be viewed at http://www.wish-qatar.org/media-center/streaming
Scalability – eRanger Design – Sleepio Harnessing people power – Operation Hernia
The Discussion The session opened with the panel members giving their perspectives on what makes an innovation successful. Professor Dzau said that innovation is much more than technology – there is frugal innovation, process innovation, and business model innovation.
“There is a tremendous opportunity for developed countries to learn from innovations that have been developed in poorer countries, in ‘reverse innovation’.” Professor Victor Dzau
The importance of ‘right skilling’ was highlighted, using workers trained at the right level and two showcases were good examples of this: Sala Uno has used standardization, lean processing and skill shifting to improve efficiency in cataract surgery; and One Family Health uses nurses to run micro clinics to deliver care locally and carry out procedures for some of the most common conditions. Innovations from the developing world can help to drive down costs and improve efficiency in countries such as the US and UK, but for reverse innovations like these to be adopted it will require reform of the regulatory environment and modernization of health systems. Dr Reddy focused on quality as a driver for innovation, pointing out that in healthcare quality cannot be compromised. By improving quality, often outcomes can be improved at the same time as costs are reduced. Dr Reddy used an example of cardiac surgery in India, where reducing morbidity (survival rates rose to 99 percent) and improving outcomes significantly brought down the cost of surgery from $50k to $3k. He said, “So it is possible, we can do this, and we need to do this with great speed because disease is progressing at a rapid rate.” Dr Thompson highlighted the role of design in successful innovation, pointing out that designers often see things differently. By involving designers at the beginning of a project they can help to solve problems before an idea goes into production. The problem solving skills and commercial instincts of designers could be invaluable to the health sector, as well as their ability to work well in teams – co-designing together with clinicians and patients.
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The showcase exhibition provided an opportunity to see the best of healthcare innovation in action. Delegates were encouraged to vote for their preferred innovation in three categories – scalability, design and harnessing people power. The following innovations received the highest number of votes in each category and their innovators were invited to join the panel discussion:
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Mr Dimbleby then invited the innovation showcase winners on stage to share the inspiration behind their ideas and how they turned them into successful, practical health solutions. Mr Norman from eRanger told the audience how his love of motorcycles and an appeal from a Non-Governmental Organization (NGO) inspired him to design a self-sustaining motorbike ambulance that helps patients in hard to reach areas across the world, helping to reduce maternal mortality. Mr Hames talked of how his personal experience of insomnia inspired him to design his evidence-based behavioral solution that can be accessed through simple technology such as a smartphone.
“We know the system works, people in countries know it works but unfortunately it’s a stumbling block with governments. People can’t rely on NGOs to put systems in that really a government should put in place for its people.” Mike Norman
Professor Kingsnorth spoke of the cost savings of using readily available mosquito netting in place of traditional surgical gauze for hernia operations in more than 25 countries around the world. The panel agreed that the common characteristic shared by all of the innovators was that they were visionaries with a drive and passion for finding a solution. They also agreed that all nations need to get better at taking up innovations like these and implementing them in their own health systems.
All the Plenary and Panel sessions can be viewed at http://www.wish-qatar.org/media-center/streaming
Professor Her Excellency Sheikha Dr Ghalia bint Mohammed Al Thani, Sidra Medical and Research Center Professor The Lord Darzi, Executive Chair of WISH, Qatar Foundation; Director of the Institute of Global Health Innovation, Imperial College London Jonathan Dimbleby, Master of Ceremonies Dr Ghalia highlighted the need to tailor innovation to meet a country’s unique set of health challenges. While Qatar has a small population and substantial financial resources, it needs to focus on building its own national capacity of physicians and nurses with the right skill set. WISH will help Qatar to learn new ways to innovate and also how to empower patients. It was recognized that technology will continually evolve and challenge us to innovate; for example many patients, including children, are now able to question their diagnosis because they have access to the internet. Patients are becoming more outspoken and healthcare professionals must be able to respond to this challenge. Lord Darzi said that what made WISH a success was the people present – the delegates from around the world, those that made the contributions to the reports and those on the panels. WISH created a unique opportunity for networking and exchanging ideas. The forum reports were very well received and in many cases led to very clear outputs. In the case of patient engagement, a pledge was signed by more than 200 people, while the End-of-Life panel focused on practical actions to improve access to pain relief in order to improve the quality of care at the end of life. Lord Darzi thanked all those who had contributed to the summit and called on the audience to take what they had learned from the summit back to their own countries and use it to influence and change healthcare.
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The Closing Ceremony
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The panel discussions – Day 1
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Mental health Mishal Husain, Moderator
The Panel Dr Abdulla Al Kaabi, Executive Vice Chief Medical Officer, Sidra Medical and Research Center, Doha Keshav Desiraju, Secretary, Department of Health and Family Welfare, Government of India His Excellency Dr Ali Hyasat, Minister of Health, Jordan Lord Layard, Director, Wellbeing Programme, Centre for Economic Performance, London School of Economics Professor Vikram Patel, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine and Professor of International Mental Health and Wellcome Trust Senior Research Fellow in Clinical Science Dr Shekhar Saxena, Director, Department of Mental Health and Substance Abuse, World Health Organization
The Issue More than 700 million people on our planet are affected by a mental health condition. Suicide alone kills more than 1 million a year. Many more feel the impact of mental health problems as primary care givers and family members. Overall, mental health problems represent 7.4 percent of the world’s total burden of health problems (as measured in disability-adjusted life years, or DALYs) and are the fifth leading cause of non-communicable diseases (NCDs). The report by the expert panel ‘Mental Health: Transforming lives, Enhancing communities: Innovations in mental health’ calls for decisive action to end suffering now and makes several recommendations including: • Empowering people with mental health problems. • Building a diverse mental health workforce. • Embedding community workers in collaborative teams as equal partners. • Using technology in a useful way to improve access, for example telemedicine and internet-based therapies to help bring treatment into the home. • Introducing strategies for early identification. • Most importantly – addressing the human rights scandal. Improving the quality of care and a range of strategies to address suicide.
All the Plenary and Panel sessions can be viewed at http://www.wish-qatar.org/media-center/streaming
The Debate
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The panel agreed that mental health is everyone’s business and highlighted the need to work collectively to make a difference and put strategies into action. Panelists said the time had come to pay more attention to mental health with the issue suffering from chronic underinvestment. Co-chair Dr Shekhar Saxena said that investment in mental health needs to increase and that this will pay good dividends. This should be investment across all areas – in a trained, skilled, and competent workforce and in improving access to available therapies. The panel discussed the many barriers and agreed that change will require leadership and commitment. In some countries it requires not simply a cultural change but also a change to the legislative framework.
“We have a large amount of evidence as to what works. What we really need to do is to put it into practice. Rich and poor countries all require more work to be done and innovations to be used… It is truly a global issue.” Dr Shekhar Saxena The Conclusion
The panel called for: • All countries to do more, from the richest to the poorest. • The need to enshrine the right to care as a basic human right. • A need to back action with the necessary resources. • Greater investment in research.
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The Co-chairs introduced their forum as being about those who are already suffering and therefore deserve the most immediate attention. Co-chair Professor Patel explained that those with a mental health condition face discrimination in virtually every aspect of their lives, and that there is an urgent need to promote a life lived with dignity, autonomy, and inclusion.
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PATIENT AND FAMILY ENGAGEMENT Riz Khan, Moderator
The Panel Dr Hanan Al Kuwari, Managing Director, Hamad Medical Corporation Susan Edgman-Levitan, Executive Director, Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital Professor Dermot Kelleher, Dean, Faculty of Medicine, Imperial College London Tim Kelsey, Director of Information, NHS England Her Excellency Dr Mariam Matar, Chairperson, UAE Genetic Disease Association Margaret Murphy, Lead Advisor, Patients for Patient Safety, World Health Organization
The Issue Health ministers face a dizzying array of possibilities for improving the health of their nations. The most important experts however – ordinary people managing their own health – are typically left out of the equation. The report by an international expert group chaired by Ms Edgman-Levitan ‘Partnering with patients, families and communities for health: a global imperative’ said the energy of patients and the public who cared about improving their own health was “a huge untapped resource”. It called for: • A fundamental shift in the way care is provided to encourage increased involvement of patients and the public. • Improved education for medical staff to help them understand the patient perspective. • Technical innovations to enhance patient involvement such as the checklist for mothers being developed by the World Health Organization to allow them to identify danger signs in their babies.
The Debate Ms Edgman-Levitan said the relationship between doctors and patients should be one of equals. She quoted Robert Johnstone of the International Alliance of Patients’ Organizations who said: “Professionals need to get off their pedestals and patients need to get off their knees.” Dr Al Kuwari said a “paradigm shift” was required. “No organization has reached a level of being truly patient centered,” she said.
All the Plenary and Panel sessions can be viewed at http://www.wish-qatar.org/media-center/streaming
• A need to be aware of cultural sensitivities when asking people to play a greater role in the own healthcare. • The potential of technological developments such as smartphones to increase the involvement of individuals in their healthcare. • The role patients and public can play as “critical friends” of the healthcare system. • The importance of clinicians finding time to engage patients in their care, despite the pressures they are under.
“Virtually all of us are, or will be, patients at some point in our lives. Improving our ability to understand and manage our own health and diseases, teaching us how to communicate effectively with each other and how to navigate the complexities of the health system… is crucial and proven to be effective in achieving better health outcomes and quality of life.” Susan Edgman-Levitan The Conclusion More than 200 delegates signed a Declaration on Engagement for Global Health following the debate committing themselves to working to embed the principle in all health services. The panel also called on delegates to sponsor a Health Engagement Day in association with community partners and to participate in International Change Day on 3 March, 2014 at which health staff are invited to make personal pledges to improve care. The grassroots movement began last year when 189,000 NHS staff in England made similar commitments.
“I think the power of digital technology is an amazing benefit for us in liberating the power of people.” Tim Kelsey
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The themes to emerge from the debate were: • A switch in emphasis so doctors ask: “What matters to you?” not “What is the matter with you?”
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HEALTH AND ETHICS: END-OF-LIFE CARE Professor Mohammed Ghaly, Moderator Professor of Islam and Biomedical Ethics, Center for Islamic Legislation and Ethics, Qatar
The Panel Baroness Cumberlege, Peer, House of Lords Professor Sir Malcolm Grant, Chairman, NHS England Professor Aasim Padela, Director, Initiative on Islam and Medicine and Assistant Professor of Medicine, The University of Chicago Professor Tariq Ramadan, Executive Director, Center for Islamic Legislation and Ethics, Qatar, and Professor of Contemporary Islamic Studies, Oxford University
The Issue Recent biomedical advancements, especially in the field of epidemiology, have considerably influenced our perception of death and challenged many of our inherited notions. Until relatively recently death was seen as unpredictable, but this is no longer the case. This has presented the opportunity for individuals, and often also governments, to make decisions about things that were previously beyond their control. Many diseases that were previously terminal are no longer so. Diseases like cancer that were once death sentences can be treated, and sufferers’ lives extended by decades. And our definition of death is also changing – vegetative states, brain-dead, comas – people can have no natural brain function and still be kept alive. Ethical considerations related to one’s religion, culture, and philosophy of life usually play a critical role in this decision-making process. Healthcare ethics can help us translate these issues into policy, implementation, technology, and applicable philosophy.
The Debate The panel considered a range of issues that influence this complex subject, including the diverse cultures that exist in some countries, medical professionalism, legal frameworks, and of course, religious and ethical perspectives. The panel highlighted that listening to patients’ wishes and helping them to plan for the future is paramount. However, it was acknowledged that achieving is not simple and an example from the UK was discussed where despite it being normal for a patient’s wishes to be known by one healthcare provider, the system is large and not always connected enough to ensure that the information is known by all.
All the Plenary and Panel sessions can be viewed at http://www.wish-qatar.org/media-center/streaming
Baroness Cumberlege raised the important issue of trust and asked, “If it is the role of the doctors to assist someone to die, what does that then do for all of us in terms of our trust in the medical profession?” On the legal aspect Professor Grant commented, “The law is far too blunt an instrument to operate in an arena of such extraordinary sensitivity.” Professor Ramadan said that within the Islamic world medical ethics was not simply about applying a set of rules and objectives but that there were much more complex cultural sensitivities to consider that required a holistic approach.
“From an Islamic perspective the main problem that we have, when it comes to the holistic approach … is to be able to connect the Islamic rules we know with the Islamic objectives that we need to reach, and this is not just talking about the detail but is also about a philosophy of life and death as something which is essential.” Professor Tariq Ramadan
The panel agreed that many different aspects need to be considered when thinking about the ethics of End-of Life care, including: • Different ethical, religious, and cultural factors and traditions. • The lack of data about what patients want. • The personal and individual nature of ethics. • The new challenges that medical advances present – pain relief, brain death, and long-term sedation.
The Conclusion The panel concluded that this is a very complex issue and one that requires much further discussion and consideration. One certainty is that a good death, however this is defined in different cultural and ethical contexts, is a human right.
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The panel also discussed assisted dying and considered issues such as how this conflicts with a doctor’s professional and medical training, the safeguards that it requires and whether the system of legalized assisted dying in the Netherlands is working successfully.
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ROAD TRAFFIC INJURY AND TRAUMA CARE Riz Khan, Moderator
The Panel Gayle DiPietro, Global Road Safety Partnership Dr Abdul Ghaffar, Executive Director, Alliance for Health Policy and Systems Research, World Health Organization Professor Adnan Hyder, Professor, Department of International Health, John Hopkins Bloomberg School of Public Health Kelly Larson, Program Director, Bloomberg Global Road Safety Program, Bloomberg Philanthropies Dr Mohamad Fathy Saoud, Vice Chairperson and Chair of Executive Committee, Sidra Medical and Research Center Dr Hassan Al Thani, Head of Trauma, Vascular and General Surgery, Hamad General Hospital and Board Member, Hamad Medical Corporation
The Issue Road traffic injuries (RTIs) are the eighth leading cause of death globally, and the leading cause of death for young people between the ages of 15 and 29 years old. The global cost of dealing with the consequences of these crashes – including trauma care – runs into billions of dollars. While much has been done, the reality remains that more than a million people die each year from road traffic crashes, while many more are injured. The report, written by a group of international experts chaired by Professor Hyder ‘Road Traffic Injury and Trauma Care: Innovations for Policy (Road Trip)’ makes several key recommendations for different stakeholders to action in order to deliver change in RTI prevention and trauma care and looks at proven innovations from around the world and how these can be adopted and applied successfully in more countries worldwide. They include: • Urging all stakeholders including governments, NGOs, academic partners, and researchers to promote evidence-based innovations. • Calling on global leaders and decision-makers to actively make road safety and trauma care a key component of the health sector – working across sectors such as law, engineering, police, and education. • Investing in resources, both financial and in human and technical skills.
All the Plenary and Panel sessions can be viewed at http://www.wish-qatar.org/media-center/streaming
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Professor Hyder said that the report looked at “new ways of applying old solutions and very importantly, new mechanisms for taking effective solutions and implementing them across the world”. The panel agreed that it was vital for countries to prioritize the issue and take decisive action to avoid preventable deaths and injury which have a huge economic as well as human cost. The panel discussed the challenges of addressing this burden and some of the potential
”Every day, we lose young individuals and the suffering goes beyond the death. It impacts families and society and affects them not only socially and psychologically, but also financially.” Dr Hassan Al Thani
solutions. Panelists emphasized the importance of tailoring the solutions to individual countries due to the cultural and environmental differences – for example in some parts of the world alcohol consumption is the main contributing factor, in others it is a lack of speed enforcement or that the road layout lacks safe areas for pedestrians.
The Conclusion The panel concluded that this issue needs to be prioritized and requires political will at the highest level. It was also agreed that tackling this was not an issue for the health sector alone, but requires the involvement of the law enforcement agencies, transport sector, car industry, roads infrastructure, education and in some countries the alcohol industry. Professor Hyder challenged the audience to build on this knowledge and energy and to each think about an example of a global road safety solution that they could implement.
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Forum Chair Professor Hyder described the huge burden caused by death and disability from road traffic accidents, with 90 percent of deaths occurring in low-income countries.
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BIG DATA AND HEALTH Jonathan Dimbleby, Moderator
The Panel His Excellency Dr Mohammed Alyemeni, Deputy Minister for Planning and Health Economics, Saudi Arabia Professor Deborah Estrin, Professor of Computer Science, Cornell Tech Dr Michelle Holmes, Professor of Public Health, Harvard University Sir David Nicholson, Chief Executive, NHS England Professor Alex ‘Sandy’ Pentland, Director, Human Dynamics Laboratory, Massachusetts Institute of Technology Dr Miklos Szoscka, Minister of State for Health, Ministry of Human Resources, Hungary
The Issue In the last 50 years there have been immense advances in the scientific understanding of disease, but translating those advances into new treatments and, especially, better outcomes has proved more difficult – because of the huge variability of human behavior. By monitoring the stream of data generated by the electronic devices on which we rely – such as cell phones, security cameras, and loyalty cards – we can gain a far more complete picture of our collective mental and cultural life than has ever been available before. Professor Pentland said the use of Big Data heralded a “profound change”. The report of the international expert working group he chaired ‘Big data and health: revolutionizing medicine and public health’ said: • Through the use of Big Data we are already learning how to improve health, cut costs and even halt epidemics. • Protecting individuals’ privacy is vital to secure public confidence in the project. • An international charter for Open Data Sharing is required with updated privacy and data ownership policies.
All the Plenary and Panel sessions can be viewed at http://www.wish-qatar.org/media-center/streaming
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• Analysis of Big Data could play an important role in helping people take responsibility for their own health. • By tracking where people meet it has been possible to cut outbreaks of infectious disease by up to 20 percent. • New arrangements are needed to protect information which is private, but not medical, such as shopping habits.
“An important part of any Big Data initiative is to address who controls the data, who has access, and the level of security.” Professor Alex ‘Sandy’ Pentland
The Conclusion A new medical and health science is emerging based on Big Data. It requires: • Public-private partnerships to underwrite costs and accelerate development. • Policies to ensure data are accessible by patients and doctors and can be shared with government, industry and academic researchers. • Measures to safeguard the privacy of consumers. • Developing ‘open data commons’ – shared data available to all – to support research that enables improvements in health systems.
“If we can combine Big Data on healthcare with genetic diagnostic data and use the mobile capabilities of the critical mass of mobile devices around the world, that will change medicine.” Dr Miklos Szoscka
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The discussion focused on how to harness the benefits without infringing individual privacy. After sequencing the genome we need to “sequence the behaviorome,” Professor Pentland said.
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ANTIMICROBIAL RESISTANCE Mishal Husain, Moderator
The Panel Dr Richard Bergström, Director General, European Federation of Pharmaceutical Industries and Associations Dr Nils Daulaire, Assistant Secretary, Global Affairs, US Department of Health and Human Services Professor Dame Sally Davies, Chief Medical Officer for England, Department of Health Dr Keiji Fukuda, Assistant Director-General, Health Security and Environment, World Health Organization Professor Ann Marie Kimball, Senior Program Officer, Epidemiology and Surveillance, Bill and Melinda Gates Foundation Dr Edward Ogata, Chief Medical Officer, Sidra Medical and Research Center, Qatar
The Issue We are losing the fight against infectious diseases as bacteria become resistant to modern medicine. More than 500,000 people die from resistant infections globally every year. Unless steps are taken to combat the growth of resistance in a few years common surgery, such as hip replacements, may be deemed too dangerous to undertake. “What I learned scared me – not just as a doctor but as a mother, a wife and a friend,” said Chair of the international expert working group, Professor Davies. She compared the growth of resistance to climate change because “we are the ones doing it to ourselves.” The expert panel’s report ‘Antimicrobial Resistance: In search of a collaborative solution’ called for stronger regulation to limit the use of antibiotics in humans and animals, incentives for the development of new drugs, and international collaboration to monitor the spread of resistant organisms to reduce the “alarming number” of deaths worldwide.
“A vast number of antibiotics are used inappropriately… We are not conserving the antibiotics we have got and we need to think about how we conserve them.” Professor Dame Sally Davies
All the Plenary and Panel sessions can be viewed at http://www.wish-qatar.org/media-center/streaming
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• The growing threat should be raised at the World Health Assembly to seek agreement and galvanize support. • Tackling the threat will involve a broad range of measures including better hand hygiene and improved surveillance of infections. • Tighter controls on the prescribing of antibiotic drugs are needed combined with education of patients to improve awareness of the threat. • Tougher curbs on the use of antibiotics as growth promoters in animals are urgently required. • Only 16 countries are able to trace where antibiotics are used. This needs to be extended to all countries. • Closer working with the pharmaceutical industry is required to aid the development of new antibiotics.
“The key impact of antimicrobial resistance – and where it will hurt us the most – is directly on people, in terms of illnesses, death, and costs.” Dr Keiji Fukuda
The Conclusion All countries should develop national programs to increase awareness of the problem, promote antibiotic conservation and improve hygiene, sanitation, and infection control. • More than 70 percent of antibiotics produced are for animals, three-quarters of which are used as growth promoters. This non-therapeutic use should be banned. • Doctors must be educated in the need to reduce prescribing antibiotics and the threat of litigation for non-prescribing must be removed. • New incentives for pharmaceutical companies including higher prices, longer patents, and guaranteed income for innovators need to be explored. • A global back-to-basics drive is needed to improve hygiene and reduce infections.
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The longer we put off addressing the issue the worse it will become. It is a global problem that requires global solutions. The panel suggested:
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The panel discussions – Day 2
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ACCOUNTABLE CARE Nick Timmins, Moderator
The Panel Dr Jason Cheah, CEO, National Agency for Integrated Care, Singapore Dr Jennifer Dixon, Chief Executive, The Health Foundation Dr Mark McClellan, Senior Fellow and Director, Initiative on Value and Innovation in Healthcare, Engelberg Center for Health Care Reform, The Brookings Institution Dr Pradeep Philip, Secretary, Department of Health, Victoria Professor Gautam Sen, Chair and Co-Founder, Wellspring Healthcare Simon Stevens, President, Global Health Division, UnitedHealth Group
The Issue Across the world healthcare costs are rising faster than countries’ ability to meet them. Payments are based on services delivered – so there is no incentive to avoid costs, coordinate care across primary and secondary sectors, or shift to preventive care. Dr McClellan said the challenge was how to align payment systems more closely with “the care we want to see”. That means switching focus from the services delivered to the outcomes achieved. “Healthcare should be getting more personally focused,” he said. The report of the international working group he chaired ‘Focusing accountability on the outcomes that matter’, said there were five key components required for transformation: 1. A specified population for which providers are jointly accountable. 2. Target outcomes for the population – outcomes that matter to individuals. 3. Metrics and learning, to monitor performance on outcomes and to learn from variation. 4. Payments and incentives aligned with the target outcomes. 5. Coordinated delivery, across a range of providers, of the care necessary for achieving the desired outcomes.
“This is where our healthcare needs to head to be able to fulfill the needs of patients in the future.“ Dr Mark McClellan
All the Plenary and Panel sessions can be viewed at http://www.wish-qatar.org/media-center/streaming
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Dr Philip said accountable care helps move us from illness to well-being. It focuses attention on heavy users of the system (‘frequent flyers’) raising the question, “are they following the optimum pathway and can it be improved”? Dr Dixon raised the point that the benefits are chiefly in improving quality rather than saving costs. “It is worth doing because it is the right thing to do, not because of the savings to be made,” she said. A key objective is to get patients to do more for themselves. Dr Charles Alessi, from the National Association of Primary Care in the UK, said this was a real opportunity to turn people into activists. And Dr McClellan emphasized the importance that whether countries have competitive or collaborative systems, progress depends on focusing on what matters to patients.
“Unleashing the data that is sitting in captive data sets around the health system is going to be pretty important. At the moment, most countries are investing in gated black box electronic medical record systems in hospitals. This will not allow the kind of population perspective that is necessary to make any of this stuff real.” Simon Stevens
The Conclusion There is no magic elixir to improving care and cutting costs – it involves careful planning, communicating with patients, and paying attention to detail. And the process to get there will be an iterative one. • Policymakers must take a broader perspective than illness, switching from a supply-led to a demand-driven approach. • They must start to pay for outcomes by adjusting payments, not activity. • They must encourage collaboration, if necessary by adjusting the rules on competition. • Data sharing should be encouraged between organizations, with common standards and measures to protect privacy.
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Mr Stevens said the starting point in each country was different according to whether healthcare was block financed from tax, paid for out of pocket, or via a social insurance scheme and incentives must be aligned to achieve change. “Context matters and the starting point in each country will affect the trajectory,” he said.
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END-OF-LIFE CARE Mishal Husain, Moderator
The Panel Her Royal Highness Princess Dina Mired, Director General, King Hussein Cancer Foundation, Jordan Sir Thomas Hughes-Hallett, Executive Chair, Institute of Global Health Innovation, Imperial College London Professor Alex Jadad, Department of Anaesthesia, University of Toronto Professor Alexander Knuth, Medical Director, National Center for Cancer Care and Research, Qatar Professor Felicia Knaul, Director, Harvard Global Equity Initiative Professor Tariq Ramadan, Executive Director, Center for Islamic Legislation and Ethics, Qatar, and Professor of Contemporary Islamic Studies, Oxford University
The Issue Death and dying are taboo topics in many countries, resulting in a tragic lack of care for many of the most vulnerable. Each year more than 100 million people need palliative care, yet fewer than 8 percent receive it. For many as the end-of-life approaches, this lack of care, particularly in low- and middle-income countries where resources are scarce, leads to a vast amount of unnecessary suffering. Everyone faces death at some point, yet nowhere in the world is dying handled well. How we care for the dying is the mark of a civilized society, and we must work to ensure we can provide a pain-free and dignified death for all. The report by an international expert panel chaired by Sir Thomas Hughes-Hallett ‘Dying healed: transforming end-of-life care through innovation’ recommends that countries produce a national strategy for end-of-life care, make palliative care part of healthcare, and end restrictions on opioid drugs for the terminally ill.
The Debate End-of-life care is a new specialty, but it faces many barriers. Doctors are trained to cure people, but are often unable or unwilling to stop ineffective curative treatments in favor of palliative care. Enduring a painful death should be unacceptable, and there is a need for a global movement to educate patients, the public, and medical staff about death and dying. Countries that lack an end-of-life-care strategy are ignoring and avoiding some of their most vulnerable patients who deserve quality end-of-life care and a dignified death.
All the Plenary and Panel sessions can be viewed at http://www.wish-qatar.org/media-center/streaming
• Palliative care planning should involve a partnership between the patient, the doctors, and the family. • Access to palliative care, including opioid drugs for pain relief, should be seen as a human right. • The global community should agree minimum acceptable standards for end-of-life-care.
The Conclusion Care of the dying should be made a priority to reduce unnecessary suffering and promote education, training and research. • Governments should produce a national strategy and allocate a specific budget to end-of-life care. • Databases of programs highlighting good (and bad) practice should be created to improve learning. • Training in palliative care should be included in all professional healthcare programs.
“We need a global movement that will change the way we approach death. We must accept and normalize the inevitability of death in order to counter death’s current taboo.” Sir Thomas Hughes-Hallett
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The panel said that: • The language used is critical to allay fears and empower families with knowledge.
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Obesity Riz Khan, Moderator
The Panel His Excellency Dr Ahmed Al Sa’idi, Minister of Health, Oman Dr Louis Aronne, Medical Director, Center for Weight Management and Metabolic Clinical Research, and Professor of Clinical Medicine, Weill Cornell Medical College Dr Enis Baris, Director, Human Development and Sector Manager, Health, Nutrition and Population (Middle East and North Africa) The World Bank Baroness Blackstone, Member, House of Lords Professor Shiriki Kumanyika, Professor of Epidemiology, University of Pennsylvania Professor Javaid Sheikh, Dean, Weill Cornell Medical College in Qatar
The Issue There is a global pandemic of obesity which affects 500 million adults and is causing three million deaths a year. It is a major factor in heart disease, stroke, Type 2 diabetes, and some forms of cancer. Between 1990 and 2020, deaths from these non-communicable diseases are projected to increase by 77 percent, threatening to reverse 50 years of gains in life expectancy and place an enormous strain on national health systems. Reducing calorie intake and increasing activity extends beyond health to the education, retail, farming, and finance sectors.
“It has taken us by surprise and you could say that we were asleep at the wheel. We were doing all these great things, such as development, production and so on, but we did not realize that the unintended consequence of the sum total of this was that populations worldwide were going to become fatter, and sometimes at alarming rates.” Professor Shiriki Kumanyika
The Debate Although obesity is a relatively new problem, healthcare experts failed to predict it. It is a disease associated with social networks and one challenge is how to use these networks to contribute to a solution. All the Plenary and Panel sessions can be viewed at http://www.wish-qatar.org/media-center/streaming
• The supply and marketing of food by the food industry, and opportunities for physical activity are critical factors. • Solutions lie within schools, workplaces, and primary care – each of which needs to identify champions. • Consuming extra calories is easier than burning them off, hence the focus should be on curbing overeating. • Childhood obesity, which affects 40 million children worldwide, should be recognized as a disease because it damages the hypothalamus. • The priority for spending should be on prevention, with health ministers as champions, but also including ministers of education, food, sports, and transport.
“We have to be much more serious and aggressive at a very early stage in prevention, especially in children and in treating adults at earlier stages of obesity if we are going to make any progress.” Dr Louis Aronne The Conclusion Ministers of health must publicly champion the fight against obesity, set targets for changes in diet and activity, establish food labeling standards, and set nutritional guidelines. • Incentives and sanctions for the food industry should be considered. • Subsidies for sugar, dairy, and meat production should be cut if they currently lead to overconsumption. • Taxing foods high in sugar and fat and low on essential ingredients should be considered. • The World Bank should consider funding restrictions on countries that contribute to the obesogenic environment. • Countries should develop an obesity action agenda, taking into account the impact of obesity on health.
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The panel noted that: • Many of the drivers of obesity lie outside the control of the healthcare system.
We hope you found WISH 2013 as exciting and inspiring as we did. We are currently developing an even more impactful summit for next year and will be in touch with the date shortly. In the meantime, we look forward to continuing to work with the community of outstanding innovators and reformers that made WISH such a success and hope that you will be able to take forward some of what was discussed in your own countries. Collaboration across international borders and between different sectors is central to achieving change in health and we were privileged to witness the exchange of ideas that took place at WISH. As we further develop WISH, we welcome your thoughts and suggestions for improvement. If you would like to contribute ideas for future forum themes, find out more about the work we are doing, or would like to be involved in any other way, please contact
[email protected] or visit www.wish-qatar.org
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