Innovation in Health Systems
Workshop to Improve the Design of the
Laboratory of Innovation in Health Systems and Services
Brazilian Ministry of Health
Strategic and Participatory Management Secretariat
Brasilia
15-16 August 2012
Professor Rifat Atun MBBS MBA FRCGP FFPH FRCP
Professor of International Health Management
Imperial College Business School and Faculty of Medicine
Imperial College London
© Professor Rifat Atun. Imperial College London 2012
Innovation is critical to improved health
outcomes
© Professor Rifat Atun. Imperial College London. 2012
Innovation and innovation adoption is critical to
sustained health system improvements
World Health Report 1999
© Professor Rifat Atun. Imperial College London. 2012
Innovation is key for addressing
health inequities and health
system challenges
© Professor Rifat Atun. Imperial College London 2012
Challenge 1: Rising health expenditures as a % of GDP
18
16
14
12
10
8
6
4
2
Australia
Austria
Canada
France
Germany
Italy
Japan
Switzerland
United Kingdom
United States
0
Source: OECD health data 2010
© Professor Rifat Atun. Imperial College London. 2012
Health care expenditure is likely to continue to rise
A desire to take medicine is
perhaps the greatest
feature which
distinguishes man from
other animals
Sir William Osler
© Professor Rifat Atun. Imperial College London. 2012
Challenge 2: Health Sector productivity (Real Sector Growth Compound Annual Growth Rate-,
Broken into Labour Productivity Growth and
Employment Growth in Various Sectors of the U.S. Economy, 1990–2010)
Kocher R. Sahni NR. Rethinking Health Care Labor. N Engl J Med 2011; 365:1370-1372
© Professor Rifat Atun. Imperial College London. 2012
Challenge 2: Health systems-productivity
Perceptions on inefficiencies
“ I once asked a worker at a
crematorium who had a
curiously contented look on
his face, what he found so
satisfying about his work. He
replied that what fascinated
him was the way in which so
much went in and so little
came out.
I thought of advising him to get a
job in the [health system]...”
Modified after late Archie Cochrane
© Professor Rifat Atun. Imperial College London. 2012
Challenge 2: Health systems-productivity
Inefficient hospitals
“Over the last ten years, there
has been significant real growth
in the resources going into the
NHS…. The evidence shows that
productivity in the same period
has gone down, particularly in
hospitals.”
Amyas Morse, head of the
National Audit Office, 17
December 2010
© Professor Rifat Atun. Imperial College London. 2012
Challenge 3: Slow
Adoption of health
innovations
© Professor Rifat Atun. Imperial College London. 2012
© Professor Rifat Atun. Imperial College London. 2012
Health innovations diffuse slowly
• 1601: James Lancaster demonstrates that
lemon juice cures scurvy
• 1749: Experiment repeated by Lind
– 1753 “A treatise of the scurvy”
• 1795: Royal Navy acts on evidence
• 1865: Merchant Navy acts on evidence 254
years later!
© Professor Rifat Atun. Imperial College London. 2012
Coverage for interventions across the care
continuum: 68 priority countries (2000‐06)
© Professor Rifat Atun. Imperial College London. 2012
Nandakumar A et al. Health Aff 2009;28:986-995
©2009 by Project HOPE - The People-to-People Health Foundation, Inc.
© Professor Rifat Atun. Imperial College London. 2012
Poor uptake of
innovations mean
missed opportunities for
reducing mortality as well
as morbidity and creating
health and wealth
© Professor Rifat Atun. Imperial College London 2012
Key barrier 1: linear view of innovation adoption
Input
Output
Outcome
© Professor Rifat Atun. Imperial College London. 2012
Key barrier 2: limited evidence
Methodological challenges in
generating evidence
1
What works in practice and
what has worked less well
2
Sources of resistance to
innovation adoption
3
Scale and learning effects?
Suboptimal
innovation
solutions
implemented
© Professor Rifat Atun. Imperial College London. 2012
Key barrier 3: asymmetric industrial and health
policies
Industrial policies encourage technology push,
but health systems constrain innovation:
– Not enough emphasis on demand side factors
– Inadequate incentives and downstream rewards
for adoption
– Inefficiency/ineffectiveness tolerated
– No incentives for innovation
Atun RA, Gurol-Urganci I, Sheridan D. Uptake and diffusion of pharmaceutical innovations in health systems.
International Journal of Innovation Management 2007; 11 (2): 299-321
© Professor Rifat Atun. Imperial College London. 2012
Medical Research Council Investment by research stage (%
of total)
© Professor Rifat Atun. Imperial College London. 2012
UK Department of Health Investment by research
stage (percent of total)
© Professor Rifat Atun. Imperial College London. 2012
The translation gaps
Cooksey Report 2006
© Professor Rifat Atun. Imperial College London. 2012
Key barrier 4: institutional logic
• Resistance to
innovation
© Professor Rifat Atun. Imperial College London. 2012
Key barrier 5: Wrong kind of innovation
© Professor Rifat Atun. Imperial College London. 2012
© Professor Rifat Atun. Imperial College London. 2012
Need a holistic and systems
approach to innovation
© Professor Rifat Atun. Imperial College London. 2012
Framework for analysing adoption and diffusion of
innovations in health systems
Broad Context
Health System
Institutions
Adoption
System
Innovation
Problem
Broad Context
Atun R. Health Systems, Systems Thinking and Innovation, Health Policy and Planning 2012
© Professor Rifat Atun. Imperial College London. 2012
A systems approach to innovation
1. Problem perception
• Burden
• Necessity and urgency
1. Innovation
• Complexity
• Scalability
2. Adoption System
• Receptivity
• Opportunity
3. Health System
• Feasibility
4. Context
• Desirability
• Logic
Atun et al. Health Policy and Planning 2010
© Professor Rifat Atun. Imperial College London. 2012
The Problem
• Necessity and Urgency
• Burden
– Economic and social
consequences
• Perceived and real
• Social Narrative
• Transmission dynamics
© Professor Rifat Atun. Imperial College London. 2012
The Intervention
• Complexity
• Simpler to more complex*
• Scalability
• Replicability
• Standardisability
* See next slide
© Professor Rifat Atun. Imperial College London. 2012
Intervention: simple versus complex
Single episode
Less
complex
Multiple
elements
Few
elements
More
complex
Multiple episodes
Atun R, de Jongh T, Secci F, et al, Integration of targeted health interventions into health systems: a conceptual framework for analysis., Health Policy Plan, 2010;
25:104-111
© Professor Rifat Atun. Imperial College London. 2012
Intervention: simple versus complex
Few stakeholders
Less
complex
Multiple
levels
Few
levels
More
complex
Multiple stakeholders
Atun R, de Jongh T, Secci F, et al, Integration of targeted health interventions into health systems: a conceptual framework for analysis., Health Policy Plan, 2010;
25:104-111
© Professor Rifat Atun. Imperial College London. 2012
Intervention: simple versus complex
User engagement lower
Less
complex
Behaviour
dominates
Technology
dominates
More
complex
User engagement higher
Atun R, de Jongh T, Secci F, et al, Integration of targeted health interventions into health systems: a conceptual framework for analysis., Health Policy Plan, 2010;
25:104-111
© Professor Rifat Atun. Imperial College London. 2012
The Adoption System
• Receptivity
• Individual & team and
institutional
• Political economy
• Incentives
– agency/provider/user incentive
alignment
• Legitimacy
–
–
–
–
Cognitive
Technical
Normative
Economic
© Professor Rifat Atun. Imperial College London. 2012
Health System Characteristics
• Governance
• Feasibility
– Regulatory environment
– Structure and organization
• Financing
– Provider payment methods
– Resource availability
• Service delivery
• M&E systems
– Ability to monitor results
© Professor Rifat Atun. Imperial College London. 2012
The Context
• Sustainability
• Fiscal space
– Overall and health sector
specific
• Attributability
• Reporting need to link
cause and effect
© Professor Rifat Atun. Imperial College London. 2012
The Context
• Opportunity
• Critical events
– Visibility
• Synergy
• Technology availability
• Desirability
• Political economy
• Socio-cultural factors
© Professor Rifat Atun. Imperial College London. 2012
Innovation needs a balance of push and pull
incentives with enabling platforms
Institutions
Push strategies
Adoption
system
Pull strategies
Enabling platforms
© Professor Rifat Atun. Imperial College London. 2012
Innovation needs a balance of push and pull
incentives with enabling platforms
Demand creation
Signalling
Supply side incentives
Institutions
Push strategies
Adoption
system
Pull strategies
Enabling platforms
Empowerment
Institutionalisation
© Professor Rifat Atun. Imperial College London. 2012
Commissioning for Quality and Innovation
(CQUIN) payment framework
Bring
clarity to
quality –
standards
Measure
quality
• Expanded
• Metrics –
role for
NICE
• NHS
Evidence
local,
national,
international
• Clinical
dashboards
Publish
quality
performance
Recognise
and
reward
quality
• Quality
• CQUIN
accounts
• International
measures
• Normative
tariffs
• Clinical
Excellence
Awards
• QOF
Clinical
leadership
• PBC,
Service line
reporting,
Social
Enterprise
• Medical
Directors;
clinical
advisory
groups
• National
Quality
Board
Safeguard
quality
• Care Quality
Stay
ahead
• Duty to
Commission
innovate
• Professional
• Innovation
Regulation
funds and
prizes
• Academic
Health
Science
Centres
• Health
Innovation
and
Education
Clusters
© Professor Rifat Atun. Imperial College London. 2012
© Imperial College Business School
© Professor Rifat Atun. Imperial College London. 2012