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H20-Conference-Report-FINAL-for-distribution<\/a><\/p>\n

INTERNATIONAL
\nHEALTH SUMMITH20
\n13 & 14 November 2014 \u2022 Melbourne
\nHEALTHY PEOPLE
\nSUCCESSFUL ECONOMY
\nPRESENTED BY
\n\u00a9 2015 AMA Victoria. All rights reserved
\nTitle:
\nH20 International Health Summit Report of Proceedings
\nEditing and realisation:
\nWriting Partners Pty Ltd
\nPhotographs:
\nAMA Victoria Ltd
\nAustralian Medical Association (Victoria) Limited
\nABN 43 064 447 678
\n293 Royal Parade Parkville Victoria 3052
\nTelephone: 03 9280 8722
\nFacsimile: 03 9280 8786
\nCountry Freecall 1800 810 451
\nEmail: amavic@amavic.com.au
\nAMA Victoria\u2019s publications can also be downloaded from www.amavic.com.au.
\nAMA Victoria retains the copyright in this report. It must not be copied or reproduced in any
\nway without AMA Victoria\u2019s prior written consent.
\nDISCLAIMER: This report represents a wide range of views and interests of the individuals and
\norganisations participating at the Summit. Statements made during discussions are the personal opinions
\nof the speakers and do not necessarily reflect those of the organisers and sponsors of the Summit.
\nH20 International Health Summit
\nHealthy People – Successful Economy
\nReport of Proceedings
\nHotel Windsor
\nMelbourne, Australia
\n13 & 14 November 2014
\nWorld Medical Association
\nAustralian Medical Association
\nAMA Victoria
\nHEALTHY PEOPLE
\nSUCCESSFUL ECONOMY
\nH20 delegates on the steps of the Parliament House of Victoria (photo – AMA Victoria)
\nINTRODUCTION
\nPAGE 4 H20 SUMMIT REPORT OF PROCEEDINGS
\nH20HEALTH SUMMIT
\nINTERNATIONAL
\n13 & 14 November 2014 \u2022 Melbourne
\nThe inaugural H20 International Health Summit (H20) was held on 13 and 14 November
\n2014 at the Hotel Windsor in Melbourne. It was initiated and co-hosted by the World
\nMedical Association (WMA), the Australian Medical Association and AMA Victoria.
\nThe Summit welcomed health professionals, academics and thought leaders to discuss a wide
\nrange of health and related social issues on the eve of the G20 Leaders\u2019 Summit in Brisbane.
\nHealth is the foundation of economic growth, yet has been omitted from the global G20 agenda.
\nWhile the Brisbane G20 Summit pursued goals of economic stability and growth, the H20
\nemphasised the economic, social and personal importance of public health and health
\ninvestment. It argued that economics and health are not discrete, clearly bounded domains,
\nbut are intimately connected and dependent on each other for success. Poor health reduces
\neconomic productivity, increases social costs and affects individual quality of life. Adequate
\ninvestment in health is therefore a pre-requisite of national and global economic success.
\nThe H20 agenda, led by Australian and international speakers, revolved around four major topics:
\n1. Health as a wise investment
\n2. The burden of non-communicable diseases (NCDs)
\n3. Social determinants of health
\n4. Health effects of climate change
\nThe Summit challenged the common assumption that health spending in Australia is unduly
\nhigh or unsustainable. However, given rising public expectations and ongoing fiscal
\nconstraints, health systems must explore more effective ways to collaborate and target
\nresources to prevent illness and deliver better health outcomes for all. New funding models
\nshould reward outcomes rather than activities, while modern data collection and analysis
\nshould generate insights into population health dynamics. A health system focused on patients
\nand outcomes, rather than suppliers and processes, offers exciting opportunities for the future.
\nRecommendations of the H20 Summit were summarised in a communique issued to the
\nG20 leaders to underline the case for investing in health as \u2018the greatest social capital\u2019. The
\ncommunique called for a global effort across sectors to tackle the world\u2019s most pressing
\nhealth challenges through a renewed focus on preventative care, holistic government policy
\nand the social determinants of health.
\nThe H20 was sponsored by the Victorian Government, Avant Mutual Group, BOQ Specialist,
\nCSL, Global Health, MDA National, Medibank Private, Melbourne Pathology, NAB Health,
\nTelstra Health and TressCox Lawyers.
\nH20 SUMMIT REPORT OF PROCEEDINGS PAGE 5
\nHEALTHY PEOPLE
\nSUCCESSFUL ECONOMY
\nAt the H20 Summit (photo collage – AMA Victoria)
\nCONTENTS
\nPAGE 6 H20 SUMMIT REPORT OF PROCEEDINGS
\nH20HEALTH SUMMIT
\nINTERNATIONAL
\n13 & 14 November 2014 \u2022 Melbourne
\nEXECUTIVE SUMMARY ………………………………………………………………… 8
\nKEY RECOMMENDATIONS…………………………………………………………….12
\nSPEAKERS …………………………………………………………………………………14
\nREPORT OF PROCEEDINGS…………………………………………………………..18
\nDAY ONE
\nMORNING SESSION \u2013 WELCOME AND MINISTERIAL ADDRESSES………………………..18
\nLUNCH SESSION \u2013 HEALTH AS A WISE INVESTMENT …………………………………….25
\nAFTERNOON SESSION \u2013 GLOBAL HEALTH AND INVESTMENT…………………………….39
\nDAY TWO
\nMORNING SESSION \u2013 NON-COMMUNICABLE DISEASES (NCDs) &
\nTHE SOCIAL DETERMINANTS OF HEALTH ACROSS THE COMMUNITY ……………………51
\nLUNCH SESSION – THE SOCIAL DETERMINANTS OF HEALTH……………………………..76
\nAFTERNOON SESSION – CLIMATE AND HEALTH…………………………………………..83
\nNOTES AND REFERENCES …………………………………………………………………91
\nH20 SUMMIT REPORT OF PROCEEDINGS PAGE 7
\nHEALTHY PEOPLE
\nSUCCESSFUL ECONOMY
\nEXECUTIVE SUMMARY
\n\u2022 Health is the Foundation of Economic Growth
\nHealth should be included in the G20 global agenda. Political leaders must acknowledge that
\n\u201chealth is the greatest social capital a nation can have\u201d
\n1
\nand a major determinant in social
\nand economic success. Investment in public health and access to quality health care are
\ncore strategies to a fair, just and productive economy, and nations must approach global
\nhealth issues together.
\n\u2022 Health in Victoria
\nVictoria enjoys high standards of service, although issues of poor Indigenous health
\nremain. Commercial opportunities and improved health outcomes are generated by the
\nState\u2019s world-class research institutions and their professional and academic
\npartnerships. Victoria has also invested in improving the health of refugees in recent
\nyears. Moving forward, the funding responsibilities between federal and state
\ngovernments should be clarified, primary and preventative care improved and the flow of
\npatient information facilitated by modern technology. Victoria has a strong record of
\npublic health promotion and its Healthy Together Victoria programme is encouraging
\npositive lifestyles in schools and communities around the State.
\n\u2022 Health as a Wise Investment
\nPublic health spending should be reframed as a wise investment in economic growth and
\nsocial equity. Australia\u2019s health spending remains marginally below the Organisation for
\nEconomic Co-operation and Development (OECD) average, and its health system, although
\ncomplex, is held in high regard. However, an ageing population, growing patient
\nexpectations and technological developments are increasing budget pressure, and more
\nefficient pathways must be sought. The USA has worse outcomes than other OECD nations
\ndespite spending significantly more, for example, and debate should focus on the quality
\nand effectiveness of budget allocations, rather than obsess about aggregate figures or the
\nnumber of hospital beds. Governments must acknowledge and address the social
\ndeterminants of health in the nation as a whole, as well as indigenous communities. The
\nAustralian Medical Association (AMA) supports universal access to affordable health care
\nand will continue defending Australia\u2019s current health system. The \u2018creative dissatisfaction\u2019
\nof health professionals should be harnessed through meaningful consultation with policy
\nmakers to produce broadly supported reforms.
\nPAGE 8 H20 SUMMIT REPORT OF PROCEEDINGS
\nH20HEALTH SUMMIT
\nINTERNATIONAL
\n13 & 14 November 2014 \u2022 Melbourne
\n\u2022 Health Research
\nEvery $1 invested in Australian health research generates $2.17 in health benefits and
\ncommercial returns. Research has produced breakthroughs in global health, not least in
\nthe fight against acquired immune deficiency syndrome (AIDS). Research aggregates a
\nrange of basic, clinical, social and operational approaches and, alongside better public
\nhealth provision, will help combat new infectious threats spreading through global
\nconnections. Investment in multidisciplinary medical research and effective partnerships
\nshould remain a spending priority, with the bionic eye exemplifying what it can achieve.
\n\u2022 Value-Based Health Care
\nMeasuring and reporting patient outcomes to the individual physicians responsible presents a
\npowerful tool to improve personal, and therefore national, medical performance. While
\ndiscussions of cost immediately divide funders and services down predictable and intractable
\nlines, a focus on outcomes aligns the interests of all stakeholders. The standardisation of
\noutcome measurement builds evidence to support long-term planning and enables international
\ncomparisons and the adoption of best practice.
\n\u2022 Global Health and Investment
\nEconomic growth has improved global health, and countries such as China have made
\nsignificant strides, although spending in South Africa has been less effective. Corruption
\nand maladministration must also be acknowledged and tackled around the world to
\nmaximise budget outcomes. Australian aid strengthens health services in the Asia-Pacific
\nregion to improve health, growth and stability. The Red Cross faces increasing violence and
\nharassment in its work in conflict zones, and the security of health workers and facilities
\nmust be strengthened for its mission to succeed. World leaders must prioritise \u2018the health
\nperspective\u2019, preserve the health of the planet as well as its inhabitants, and address the
\nunderlying social determinants of health.
\n\u2022 Australian Support for Regional Health Services
\nThe Australian Government\u2019s aid program promotes Australian interests by encouraging
\nsustainable economic growth to reduce poverty in the Indo-Pacific. A stress on accountability
\nand outcomes strengthens its effectiveness. Australia also provides assistance to Africa and
\nelsewhere and has pledged $42 to international efforts against Ebola. The Government
\nintegrated AusAID and the Department of Foreign Affairs and Trade (DFAT) in 2013, aligning
\nthe aid and diplomatic arms of Australia\u2019s international policy agenda. Australian aid includes
\ngoods.
\nH20 SUMMIT REPORT OF PROCEEDINGS PAGE 9
\nHEALTHY PEOPLE
\nSUCCESSFUL ECONOMY
\nand services such as building health clinics and immunising children, strengthening local
\nservices, including health care, and encouraging policy dialogue and reform. It works with
\ngovernment partners, funds non-government organisations (NGOs) and contributes to
\ninternational agencies.
\n\u2022 The Social Determinants of Health
\nHealth outcomes are significantly affected by wider social factors, including early childhood
\ndevelopment, income inequality, social stratification, workplace and domestic stress, social
\nexclusion and discrimination, unemployment, community networks, substance abuse and
\nthe affordability of good food, housing and transportation. A sustained bi-partisan effort to
\nimprove public health must produce long-term investment in education, training, public
\ntransport and other infrastructure, instead of \u2018micro-shuffling\u2019 health administration.
\nCollaboration between government departments is vital as synergies from transport,
\nhousing, utilities and education can significantly improve \u2013 or degrade \u2013 public health.
\n\u2022 Health Care Reform
\nGiven rising demand and economic strictures, health providers must embrace the
\ntechnological and organisational innovations transforming other commercial sectors to
\ndeliver better patient outcomes at lower cost. Consideration of horizontal connections,
\nrather than in-depth analysis of isolated components, will offer many opportunities for
\nchange. Health must learn from modern commerce and offer personalised, customised
\nservices responsive to individual needs in a new world of technologically driven
\ncommunication, competition and choice.
\n\u2022 Health IT
\nThe collection and analysis of Big Data will improve service planning, and individual
\ndelivery while imbedded and wearable devices will help individuals achieve \u2018the quantified
\nself\u2019. Supply-driven systems based on procedures, hospitalisations and clinicians will
\nevolve into e-enabled platforms, organised around the patient experience, which prize
\nvalue and outcomes, drive down costs and improve safety and accountability. IT
\nsolutions should be designed and implemented in consultation with the clinicians who
\nwill use them to ensure their support and exploit the power, convenience and ubiquity of
\nsmartphones and mobile devices.
\nPAGE 10 H20 SUMMIT REPORT OF PROCEEDINGS
\nH20HEALTH SUMMIT
\nINTERNATIONAL
\n13 & 14 November 2014 \u2022 Melbourne
\n\u2022 Non-Communicable Diseases (NCDs)
\nNon-communicable diseases, including cardiovascular complaints, cancers, chronic
\nrespiratory failure and diabetes cause over 60% of global mortality. The NCD epidemic
\nthreatens service sustainability and population health in Australia and around the world. NCDs
\ncan be caused or exacerbated by tobacco, physical inactivity, alcohol misuse and unhealthy
\ndiets, but rather than blame patients for lifestyle choices, attention must be given to the social
\ndeterminants which drive them. Greater emphasis on primary care and health literacy will
\nreduce the incidence of diabetes, hypertension and other problems, while structured care
\nplans and clinician teamwork will reduce avoidable admissions to hospital. Action against
\nsmoking has been effective, and disinvestment in tobacco shares by Australia\u2019s superfunds
\nshould be pursued.
\n\u2022 Mental Health
\nNo condition is as prevalent, persistent or has the range of personal and social impacts as
\nmental illness. Early interventions and effective treatment must be complemented by policies
\nto address social inequality and other exacerbating factors. Improved professional training and
\nboth universal and targeted interventions should be delivered through a sustained and
\ncoordinated cross-government approach in partnership with NGOs and communities.
\n\u2022 Successful Ageing and Dementia
\nThe pursuit of \u2018successful ageing\u2019 could increase the quality of life and sustain the workforce
\nproductivity of Australia\u2019s ageing population while reducing disability and hospital expenses.
\nDementia is an increasing issue, but its incidence can be reduced through better health in
\nyouth and middle age, while the experience of suffers can be eased by better care and more
\ncommunity understanding. Dementia is not an inevitable part of ageing, and research into its
\ncauses and treatment must be pursued.
\n\u2022 Health and Climate Change
\nHuman health and modern society rely on a stable climate and biologically diverse
\nenvironment. Clinicians should therefore use their expertise and the respect in which they are
\nheld to urge prompt and decisive international action to reduce carbon emissions and limit the
\nextent and impact of climate change. Australia and other nations can maintain economic
\ngrowth while \u2018decarbonising\u2019 their economies through the electrification of transport, greater
\nenergy efficiency, the replacement of coal with renewable sources and reforestation.
\nEnlightened urban planning can also reduce heat stress and encourage physical activity,
\nimproving the state of both the planet and its ever growing population.
\nH20 SUMMIT REPORT OF PROCEEDINGS PAGE 11
\nHEALTHY PEOPLE
\nSUCCESSFUL ECONOMY
\nKEY RECOMMENDATIONS
\n1. Government should acknowledge health spending as a wise investment in future
\neconomic growth and social equity.
\n2. Health care systems should be organised around the patient experience, prioritise
\noutcomes rather than activities, drive down costs and improve quality and safety.
\nNew consumer-centric health services should deliver equity, choice,
\nautonomy, confidentiality and the local provision of services, as well as the
\nhighest standards of care.
\n3. Decision makers should put a greater emphasis on primary and preventative care to
\nlimit the incidence and severity of chronic disease and reduce acute admissions and
\nhospital expenses.
\n4. Health care systems should pursue excellence and effectiveness, as well as
\nefficiencies. There should be clear funding responsibilities to avoid duplication of
\nservices and minimise unmet need.
\n5. All government policies should consider their impact on health and coordinate to
\nsupport public health. Cross-departmental action on the social determinants of
\nhealth, from income inequality to poor housing and transport, will improve the
\nhealth and social outcomes for disadvantaged citizens and social groups.
\n6. Health literacy should be promoted to empower citizen lifestyle choices regarding
\ndiet, exercise, smoking, alcohol and related issues. Public health campaigns
\nshould broaden their scope and magnify their impact.
\n7. Action must be taken to improve the prevention and treatment of non-
\ncommunicable diseases through improving the social determinants of health for
\ndisadvantaged social groups and strengthening provision and collaboration in
\nprimary care.
\n8. \u2018Successful ageing\u2019 should be promoted across sectors to reduce the personal toll
\nand growing social costs of dementia in Australia\u2019s ageing society. Further
\nresearch into the causes and treatment of dementia must be pursued.
\n9. Action to tackle mental health issues should include greater funding for research,
\npublic education and early intervention.
\n10. Clinicians should be consulted in the design and implementation of health IT
\nand embrace its potential to gather, aggregate, analyse and share information to
\nimprove patient health outcomes and public health provision and efficiency.
\n11. The \u2018creative dissatisfaction\u2019 of health professionals should be harnessed through
\nmeaningful consultation with policy makers to produce broadly supported
\nreforms.
\nPAGE 12 H20 SUMMIT REPORT OF PROCEEDINGS
\nH20HEALTH SUMMIT
\nINTERNATIONAL
\n13 & 14 November 2014 \u2022 Melbourne
\n12. Investment in health research should be prioritised to unlock rich commercial
\nopportunities for the nation as well as dramatically improve health outcomes in
\na range of domestic and global health issues.
\n13. Modern methods of Big Data collection and analysis should be encouraged to
\ngenerate insights into population health dynamics.
\n14. Surgical and other patient outcomes should be discussed with the clinicians
\nresponsible to improve standards and ensure the use of best practice.
\nStandardisation of outcome measurements will support long-term planning and
\nallow national and international comparisons to be made.
\n15. Government should support international efforts to tackle newly emerging
\ninfectious threats such as Ebola as they pose a serious cross-border threat in
\ntoday\u2019s globalised society. Developed nations should work to strengthen
\ngovernment, growth and public health systems in low-income countries to
\nimprove their resilience and health provision.
\n16. Governments, military organisations and non-state actors should agree and
\nrespect effective measures to safeguard the security of emergency health workers
\nin combat zones.
\n17. Donor and recipient governments and supra-national organisations must
\nacknowledge and tackle corruption and maladministration in the provision of
\nhealth services in the developing and more developed world.
\n18. Heath professionals should organise and campaign for state and national health
\nreform and broad social change, as well as take concrete action in their local
\ncommunities.
\n19. Medical professionals should understand the potential health impacts of man-
\nmade climate change and lobby for effective action to reduce carbon emissions
\nworldwide and protect the biosphere humanity relies upon.
\nH20 SUMMIT REPORT OF PROCEEDINGS PAGE 13
\nHEALTHY PEOPLE
\nSUCCESSFUL ECONOMY
\nSPEAKERS
\nAssoc. Prof Nick Barnes
\nSenior Principal Researcher in the
\nComputer Vision Research Group at
\nNational ICT Australia (NICTA) and has
\nbeen at NICTA\u2019s Canberra Research
\nLaboratory since 2003. A\/Prof Barnes is
\na lead investigator of the Bionic Vision
\nAustralia consortium which aims to
\ndevelop a bionic eye, where he leads
\nVision Processing.
\nDr Tony Bartone
\nPresident of AMA Victoria and former
\nchair of the Section of GPs at AMA
\nVictoria, Dr Bartone has worked in
\ngeneral practice in Melbourne\u2019s North
\nfor over 27years. He has a keen interest
\nin preventative healthcare.
\nMr Roy Batterham
\nRoy Batterham, began his career as
\na physiotherapist with nine years in
\nclinical and management positions
\nmostly in rehabilitation. After
\ncompletion of his M.Ed. (Evaluation)
\nRoy worked for six years at the Centre
\nfor Health Program Evaluation. Roy s
\nresearch activities at CHPE were initially
\nin the field of disability and case
\nmanagement. From the end of 1999
\nto the start of 2010 Roy worked as an
\nindependent consultant, conducting
\ndozens of evaluations and freelance
\nresearch activities. He joined Deakin
\nUniversity\u2019s Public Health Innovation as
\na Senior Research and is project leader
\nfor a beyondblue funded project to
\ndevelop an internet-based intervention.
\nRoy is also working on self-management
\nsupport and health literacy projects in
\nThailand.
\nProf Dinesh Bhugra
\nProfessor Bhugra is the President of the
\nWorld Psychiatric Association. From
\n2008 to 2011 he was President of the
\nRoyal College of Psychiatrists in the
\nUK. Dinesh has also been Chair of the
\nMental Health Foundation from 2011 to
\n2014 of which he is currently President.
\nDr Robin Coupland
\nDr Coupland is a Medical Adviser in
\nthe International Committee of the Red
\nCross (ICRC). He joined the ICRC in
\n1987 and worked as a field surgeon
\naround the world. Robin has developed
\na health-oriented approach to a variety
\nof issues relating to violence and the
\ndesign and use of weapons and was a
\nFellow of the Royal College of Surgeons
\nin 1985. He has developed a public
\nhealth model of armed violence and
\nits effects as a tool for policy-making,
\nreporting and communication. Robin
\nhas published medical textbooks
\nabout care of wounded people and
\nmany articles relating to the surgical
\nmanagement of war wounds, the effects
\nof weapons and armed violence.
\nHon. David Davis MLC
\nMember for Southern Metropolitan
\nRegion, Minister Davis was first elected
\nto the Victorian Parliament as Member
\nfor East Yarra Province in 1996. David\u2019s
\nacademic background includes a
\nBachelor of Applied Science, a Bachelor
\nof Arts and a Graduate Diploma in
\nArts (Applied Philosophy). David held
\nmany positions in opposition including
\nShadow Health Minister and is currently
\nthe Leader of the Government in the
\nLegislative Council and Minister for
\nHealth and Minister for Ageing.
\nProf Phillip Davies
\nProf Davies has had more then 30
\nyears experience in health policy and
\nmanagement. He currently occupies the
\nfollowing positions: Deputy Director
\nGeneral \u2013 Queensland Health, Director
\n\u2013 Australian Medicare Local Aliance
\nand Director \u2013 Metro North Brisbane
\nMedicare Local.
\nDr Xavier Deau
\nDr Deau is currently the President of the
\nWMA and has been working since 1976
\nas General Practitioner in Epinal (East
\nof France). He is the President of the
\nEuropean and International Delegation
\nof the French Medical Council as well
\nas the President of the Departmental
\nCouncil of Medical Order of Vosges.
\nAt European and International level, Dr
\nDeau is the General Secretary of the
\nConference of Medical Councils from
\nFrench-speaking countries (CFOM)
\nand was until last October the General
\nSecretary of the European Council of
\nMedical Orders (CEOM).
\nDr Alessandro Demaio
\nPostdoctoral Fellow in Global Health
\nand NCDs at Harvard Medical School
\nand an Assistant Professor at the
\nCopenhagen School of Global Health,
\nDr Demaio trained and worked as
\na medical doctor in Melbourne,
\nAustralia. He completed a Masters in
\nPublic Health including field-work in
\nCambodia. In 2010, Dr Demaio
\nrelocated to Denmark and completed
\na PhD fellowship in Global Health with
\nthe University of Copenhagen, focusing
\non Non-Communicable Diseases
\n(NCDs). In 2013 Dr Demaio co-founded
\nNCDFREE, a global social movement
\nagainst NCDs. Currently, he holds a
\nPostdoctoral Fellowship at Harvard
\nMedical School and is currently serving
\non the Advisory Board of the EAT:
\nStockholm Food Forum.
\nDr Vanda Fortunato
\nDr Fortunato commenced her career
\nas an academic at Victoria University
\nfollowing the completion of her PhD and
\nPost-Doctoral fellowships. Currently she
\nis the CEO at Macedon Ranges North
\nWestern Medicare Local. Vanda has had
\nexperience in both the private and public
\nsectors having worked in private health
\ninsurance, pharmaceutical companies
\nand not-for-profit sector. Vanda also has
\nextensive experience in developing and
\nmanaging large scale health projects
\nand has worked in countries including:
\nPakistan, Egypt, China; Vietnam, and
\nMalaysia.
\nMr Andrew Goodsall
\nSenior healthcare analyst with UBS
\nAustralia. Andrew and the team have
\nbeen rated the number one healthcare
\nequities research team in major surveys
\nsince 2003. Andrew commenced as
\na sell side analyst in 1999 after an
\nextensive health policy background: he
\nwas senior adviser\/chief of staff to the
\nHealth Minister in the reformist Kennett
\nGovernment (Victoria, Australia), with
\nresponsibilities for advice on 120 public
\nhospitals, episodic funding, medical
\nresearch funding and privatisation
\nprogrammes (hospital and pathology).
\nAndrew holds MBA, BA (hons) and Grad
\nDip (Asian studies) qualifications.
\nH20HEALTH SUMMIT
\nINTERNATIONAL
\n13 & 14 November 2014 \u2022 Melbourne
\nDr Mzukisi Gootbroom
\nDr Grootboom specialized in
\nOrthopaedics and qualified as an
\nOrthopaedic Surgeon in 1987 and had a
\nstint at the King Edward VIII Hospital as
\na Consultant OS. He was the Founding
\nMember of the National Medical and
\nDental Association and was its Deputy
\nGeneral Secretary from 1989 \u2013 1990.
\nHe joined the South African Medical
\nAssociation (SAMA) in 1997 after the
\namalgamation of various associations \/
\ngroups in the country. He held various
\npositions at Branch (President for 2
\nterms) and National Level including the
\nChair of the Private Practice Committee.
\nDr Mukesh Haikerwal AO
\nGeneral Medical Practitioner in
\nMelbourne Victoria Australia. He is the
\nChair of Council of the World Medical
\nAssociation and was elected in May 2011
\nworking with 104+ Member National
\nMedical Associations (NMA). He is a
\nProfessor in the School of Medicine in the
\nFaculty of Health Sciences at Flinders
\nUniversity in Adelaide, South Australia.
\nHe is also Chair of the beyondblue
\nNational Doctors\u2019 Mental Health Program
\nand a Co-Chair of the Australian Asian
\nMedical Federation. He sits on the
\nAdvisory Board of Brain Injury Australia.
\nOn August 1st 2014, he was appointed as
\nChair of the Australian Institute of Health
\nand Welfare by the Hon. Peter Dutton,
\nMinister for Health and Minister for Sport.
\nProf Angang Hu
\nProfessor Hu is one of the pioneers
\nand leading authorities in the realm
\nof Contemporary China Studies.
\nHe now serves as the Dean of the
\nInstitute of Contemporary China
\nStudies of Tsinghua University
\nand Professor of School of Public
\nPolicy and Management of Tsinghua
\nUniversity. He is also a member of the
\nAdvisory Committee for the Thirteenth
\nand Twelfth Five-Year Plans under
\nNDRC, a member of the Advisory
\nCommittee of the National Disaster
\nMitigation Committee and a member
\nof the Advisory Committee of Beijing
\nMunicipal Government. He was elected
\nas the representative of the 18th CCP
\nNational Congress in 2012.
\nDr Masami Ishi
\nDr Ishi has worked as Medical Director
\nof the Neurosurgery Department of
\nIwaki Kyoritsu Hospital before opening
\nIshi Hospital of Neurosurgery &
\nOphthalmologyin 1985 and taking office
\nof the President of the Iwaki Medical
\nAssociation in 2002. He has served
\nas Vice-President of the Fukushima
\nMedical Association. Dr Ishi was elected
\nas the Executive Board Member of the
\nJapan Medical Association in April
\n2006, and re-elected forth. He is also
\nserving Vice-Chair of the Council of the
\nWorld Medical Association, Secretary
\nGeneral of the Confederation of Medical
\nAssociations in Asia and Oceania and
\nEditor-in-Chief of the JMA Journal, the
\nofficial English-language journal of the
\nJMA.
\nMr Gavin Jennings MLC
\nCurrently the Victorian Shadow Minster
\nfor Health and Mental Health as well
\nas Deputy Leader of the Opposition in
\nthe Legislative Council. He has been
\nan Australian Labor Party member of
\nthe Victorian Legislative Council since
\n1999, representing Melbourne Province
\nand then the South Eastern Metropolitan
\nRegion. Until December 2010 he was
\nthe Deputy Leader of the Government
\nin the Legislative Council and the state
\nMinister for Environment and Climate
\nChange and Minister for Innovation.
\nProf Frank Jones
\nFull time General Practitioner for
\n30 years Professor Jones is senior
\npartner at the Murray Medical group in
\nMandurah, a large progressive, multi-
\ndisciplinary, non-corporatised private
\npractice with a number of allied health
\nprofessionals working from the same
\nsite. Frank was a procedural obstetrics
\nGP for 25 years and still maintains
\nvisiting rights at Peel Health Campus
\nfor general medicine in-patients. Frank
\nis the national President of the RACGP
\nand is passionate about the vital role of
\nthe expert generalist in the provision of
\nquality healthcare.
\nMr David Kalisch
\nMr Kalisch has been Director (CEO)
\nof the Australian Institute of Health
\nand Welfare since December 2010. He
\nis an economist with over 30 years\u2019
\nexperience largely in the Commonwealth
\ngovernment across a range of social
\npolicy issues. David\u2019s professional
\nexperience has included appointments
\nas a Commissioner at the Productivity
\nCommission, Deputy Secretary in
\nthe Commonwealth Department of
\nHealth and Ageing, Senior Executive
\nroles in the Department of Family and
\nCommunity Services, Social Security
\nand Prime Minister and Cabinet, and
\ntwo appointments at the Organisation
\nfor Economic Co-operation and
\nDevelopment (OECD) in Paris. He\u2019s
\na Fellow of the Australian Institute
\nof Company Directors and a Public
\nPolicy Fellow at the Australian National
\nUniversity.
\nMr Roger Kilham
\nRoger Kilham had an 18-year career in
\nthe Australian Federal Treasury before
\njoining Access Economics. From 1989
\nuntil 2014, he worked as a consultant
\nto the Federal AMA, since 2011 as
\nan independent consultant. In that
\nperiod, he also undertook consultancy
\nprojects for health sector organizations,
\ngovernment, professional associations
\nand lobby groups.
\nDr Bronwyn King
\nDr King is a radiation oncologist at the
\nPeter MacCallum Cancer Centre and
\nEpworth Healthcare. In 2010 Bronwyn
\nfounded the Tobacco-Free Investment
\nInitiative after discovering her unwitting
\ninvestment in the tobacco industry,
\nvia her superannuation investments.
\nBronwyn is the Cancer Council Australia
\nTobacco Control Ambassador, the
\n2014 recipient of the Thoracic Society\u2019s
\nPresident\u2019s Award, an Australian
\nFinancial Review\/Westpac 100 Women
\nof Influence winner for 2014 and an
\nAustralia Day Ambassador.
\nDr Otmar Kloiber
\nCurrently secretary General of the World
\nMedical Association prior to that
\nDr Kloiber was Secretary of the German
\nMedical Association. Dr Kloiber has
\nserved on several committees including
\nthe WMA. Throughout his career he has
\nserved on many boards and influenced
\nmedicine at the highest levels. He
\nreceived an honorary doctorate of the
\nVictor Babes University for Medicine
\nand Pharmaceutics from Timisoara,
\nRomania.
\nMr Jonathon Kruger
\nGeneral Manager (Policy) at the
\nAustralian and New Zealand College
\nof Anaesthetists. Jonathon is a
\nphysiotherapist who has worked for
\nnearly two decades in the Australian
\npublic health system in senior
\nmanagement roles. He has a Master
\ndegree in Public Health, Graduate
\nCertificate in Governance and is
\ncurrently enrolled in a Master of
\nHealth and Medical Law. Jonathon has
\nsubstantial expertise and achievement
\nin analysing and influencing public
\nhealth policy and programs in areas
\nas diverse as workforce modelling and
\nclimate change and human health.
\nHEALTHY PEOPLE
\nSUCCESSFUL ECONOMY
\nSPEAKERS
\nMs Ann Larkins
\nAnn is the Chief Knowledge &
\nInformation Officer (CKIO) at Barwon
\nHealth. She is a Fellow at Deakin
\nUniversity \u2013 Pattern Recognition and
\nData Analytics (PRaDA), has a Masters
\nin Business and Technology (MBT)
\nUNSW, and is a Registered Critical Care
\nNurse with over 20 years\u2019 experience in
\nclinical practice, patient flow, hospital
\nadministration, ICT enabled projects and
\nstrategy in the health sector.
\nEmeritus Prof
\nStephen Leeder
\nEmeritus of Public Health and
\nCommunity Medicine at the University
\nof Sydney. Professor Leeder is currently
\nChair of the Western Sydney Local
\nHealth District Board, and Director,
\nResearch Network, Western Sydney
\nLocal Health District. Stephen was
\nappointed Editor-in-Chief, Medical
\nJournal of Australia, in 2013.
\nProf Sharon Lewin
\nSharon Lewin is the inaugural director
\nof the Doherty Institute for Infection
\nand Immunity at the University of
\nMelbourne; consultant physician,
\nAlfred Hospital, Melbourne, Australia;
\nand an Australian National Health and
\nMedical Research Council (NHMRC)
\nPractitioner Fellow. She was the local
\nco-chair of the 20th International AIDS
\nConference (AIDS2014) which was held
\nin Melbourne July 2014 and was the
\nlargest health conference ever held in
\nAustralia.
\nProf Lynn Madden
\nAssociate Dean, Learning and Teaching
\nat Notre Dame University. Prof Madden
\nhas been widely published in medical
\njournals throughout Australia and is key
\nacademic within the medical field.
\nDr Tim Malloy
\nDr Malloy has played an active role
\nwithin the College as Rural Chapter
\nChair, College Council representative
\nand educator. He is well known in the
\nrural community and network with
\nan impressive record in developing
\nand implementing \u2018Learning
\nEnvironments\u2019 for both undergraduate
\nand postgraduate GP training. He was
\nthe main driver behind setting up and
\nmaintaining the \u2018Centre of Excellence for
\nRural Primary Care – Te Whariki Teitei\u2019, a
\nmulti-disciplinary and inter-disciplinary
\neducation unit in collaboration with
\nWaitemata DHB. Tim took over the
\nposition of President at the NZ College
\nof GPs in December 2012.
\nMr Andrew McAuliffe
\nCurrently the Senior Director, Policy
\nand Networks Australian Healthcare and
\nHospitals Association (Public Sector),
\nMr McAuliffe has worked in Public
\nHealthcare since commencing his career
\nin 2004. He has profound understanding
\nof the Public Healthcare system.
\nMr Ewen McDonald
\nMr McDonald joined the Department of
\nForeign Affairs and Trade as a Deputy
\nSecretary in November 2013 following
\nthe integration of the department and
\nthe Australian Agency for International
\nDevelopment (AusAID). He commenced
\nat the Agency as Deputy Director
\nGeneral in 2011. From 2008, Mr
\nMcDonald was a Deputy Secretary in
\nthe former Department of Education,
\nEmployment and Workplace Relations
\n(DEEWR). Before taking up his Deputy
\nSecretary position, Mr McDonald
\nundertook senior management roles in
\neducation covering policy, program and
\ncorporate.
\nMs Franses Mirabelli
\nFrances was appointed a CEO of AMA
\nVictoria in January 2014. She has worked
\nin many senior roles across the health and
\naged care sectors, beginning in the acute
\ncare sector as a medical scientist and
\nadministrator, before spending five years
\nas Chief Operating Officer at Wintringham,
\nan innovative company which provides
\nhousing and care for the homeless. During
\nseven years as Chief Executive Officer of
\nthe Mayflower Group, which offers
\nretirement living and aged and
\ncommunity-based care, Frances oversaw
\nmassive expansion, redevelopment and a
\nreturn to profitability. She also served as
\nGeneral Manager (Operations) at Prestige
\nIn-Home Care before taking on the Deputy
\nCEO role at LASA Victoria, the peak body
\nfor the state\u2019s aged care industry.
\nFrances holds a Bachelor of Applied
\nScience from RMIT and a Masters in
\nBusiness Administration from Monash
\nUniversity. She is a graduate of the
\nAustralian Institute of Company Directors.
\nFrances has also served on a number of
\nstate and federal Ministerial Advisory
\nCommittees, as well as the boards of
\nseveral companies, including Whitehorse
\nCommunity Health, Yarra Community
\nHousing, and Bailey House.
\nProf Michael Moore
\nProfessor Moore is currently CEO of the
\nPublic Health Association of Australia
\nand Vice President\/President Elect of
\nthe World Federation of Public Health
\nAssociations. He is Adjunct Professor
\nat the University of Canberra and was
\nformerly a teacher and consultant having
\nserved four terms as an elected member
\nof the ACT Legislative Assembly from
\n1989 to 2001. Michael was Australia\u2019s
\nfirst independent Minister when he was
\nappointed as Minister of Health and
\nCommunity Care.
\nProf Vivienne
\nNathanson Professor Nathanson
\njoined the British Medical
\nAssociation in 1984 before being
\nappointed Scottish Secretary (Chief
\nExecutive) for the BMA 1990-1995, and then
\nas Head of Central Services and International
\nAffairs 1995-1996. She was then Director of
\nProfessional Activities at the BMA, and in April
\n2014 was appointed Senior Director. In 2004
\nVivienne Nathanson became an Honorary
\nProfessor of Public Health Ethics at Durham
\nUniversity. She was also awarded an Honorary
\nDoctor of Science by Strathclyde University. In
\n2008 Professor Nathanson was made a Fellow
\nof the Royal College of Physicians, and in
\n2013 she was awarded the Honorary
\nFellowship of the Faculty of Public Health.
\nAssoc. Prof Brian Owler
\nAssoc. Prof Brian Owler is a Consultant
\nNeurosurgeon and currently the President of
\nthe NSW AMA also representing surgeons
\non the Federal Council of the AMA. He is a
\nmember of the COAG Expert Panel on
\nEmergency Department and Elective Surgery
\nPerformance. A\/Prof Owler is a member of
\nthe International Society for Hydrocephalus
\nand CSF Disorders Board and is a Patron of
\nthe Hydrocephalus Association of NSW.
\nCurrently he is conducting a randomised
\ncontrolled trial of deep brain stimulation
\nsurgery for cerebral palsy.
\nDr Aktan Ozdemir
\nProfessor of General Surgery at
\nMarmara University Hospital, Istanbul,
\nTurkey. Author of 72 clinical and
\nexperimental research papers in SCI
\nindexed journals. Additionally, he
\nheld positions as the President of
\nIstanbul Medical Chamber 2006-2010;
\nVice President of Turkish Medical
\nAssociation 2010-2012 and President of
\nTurkish Medical Association 2012-2014.
\nDr Jitendra Patel
\nGraduated from the University of
\nSambalpur, Dr Patel specalises in
\nFamily Medicine\/Family Practice.
\nHaving worked and interned in major
\nhospitals Dr Patel has an in-depth
\nunderstanding of the medical system
\nand is currently the President of the
\nIndian Medical Association.
\nH20HEALTH SUMMIT
\nINTERNATIONAL
\n13 & 14 November 2014 \u2022 Melbourne
\nDr Mark Peterson
\nDr Mark Peterson previously held the roles of
\nNew Zealand Medical Association (NZMA)
\nDeputy Chair and Chair of the NZMA General
\nPractitioner Council. A graduate of Otago
\nUniversity, Dr Peterson has worked as a
\ngeneral practitioner in the Hawke\u2019s Bay for 25
\nyears where he is also Chief Medical Officer
\nPrimary Care with the local district health
\nboard. Dr Peterson isa past Chair of the
\nGeneral Practice Leaders Forum (GPLF) and
\nis currently a Board member of the Royal
\nNew Zealand College of General
\nPractitioners. In these roles he has served on
\na wide range of sector advisory groups.
\nDr Pradeep Philip
\nDr Pradeep Philip commenced as
\nSecretary, Department of Health
\nin 2012. Prior to working for the
\nDepartment of Health, Pradeep was
\nDeputy Secretary of the Policy and
\nCabinet Group at the Department of
\nPremier and Cabinet. Pradeep has
\nextensive experience in both state and
\nCommonwealth Government, including
\nas Director of Policy in the Prime
\nMinister\u2019s Office and as Associate
\nDirector-General in the Queensland
\nDepartment of Premier and Cabinet.
\nPradeep first joined government as an
\neconomist with the Commonwealth
\nDepartment of the Treasury, having been
\na tutor and lecturer at the University of
\nQueensland, Griffith University and the
\nAustralian National University.
\nMr Frank Quinlan
\nMr Quinlan is CEO of Mental Health
\nAustralia, and was previously the
\nExecutive Director of Catholic Social
\nServices Australia. Frank has a long
\nhistory of working in the not-for-profit
\nsector. He has held senior positions with
\nthe Alcohol and Other Drugs Council
\nof Australia and the Australian Medical
\nAssociation.
\nDr Neil Soderlund
\nDr Soderlund is a Senior Adviser in
\nThe Boston Consulting Group\u2019s Sydney
\noffice, having joined the firm in 2000.
\nHe currently leads BCG\u2019s healthcare
\npractice in Australia and New Zealand,
\nand the firm\u2019s broader big data and
\nanalytics work (across industries) in
\nAsia Pacific. He has a particular interest
\nin measuring health outcomes and
\nusing this data to simplify and improve
\nvalue for money in health care systems.
\nNeil is a qualified medical doctor and
\nhas masters and doctoral degrees in
\nHealth Economics from the London
\nSchool of Economics and Oxford
\nUniversity respectively.
\nProf Hon. John Thwaites
\nProfessorial Fellow at Monash
\nUniversity and Chair of ClimateWorks
\nAustralia and the Monash Sustainability
\nInstitute, John also chairs the Australian
\nBuilding Codes Board and the Peter
\nCullen Water and Environment Trust.
\nHe is Director of the Australian Green
\nBuilding Council and a member of
\nthe Leadership Council of the UN
\nSustainable Development Solutions
\nNetwork (\u201cSDSN\u201d). John was Deputy
\nPremier of Victoria from 1999 until his
\nretirement in 2007.
\nMr Jason Trethowan
\nJason Trethowan is the CEO of Barwon
\nMedicare Local and has held this
\nposition within the company since
\n2007. As part of his work at Barwon
\nMedicare Local he has been leading
\nthe organisation to work more closely
\nwith the community and health industry
\npartners to strengthen the primary care
\nsystem. Jason\u2019s experience includes
\npartnerships, business operations,
\nhealth system innovation and corporate
\ngovernance. He holds a masters degree
\nin business administration. Jason
\nis also the Deputy Chair of the G21
\nGeelong Region Alliance.
\nDr Robert Wah
\nDr Wah is President of the American
\nMedical Association and has served
\nover 23 years on Active Duty in the
\nNavy and was the Associate CIO for
\nthe Military Health System. At HHS,
\nDr Wah served as the first Deputy
\nNational Coordinator\/Chief Operating
\nOfficer, setting up the ONC (Office of the
\nNational Coordinator for Health IT). He
\nis CSC\u2019s Chief Medical Officer; has been
\nLead Client Executive and served on the
\nfaculties of Harvard Medical School,
\nUniversity of California, San Diego and
\nthe Uniformed Services University of
\nthe Health Sciences. Dr Wah trained at
\nNational Naval Medical Center Bethesda
\nand Harvard Medical School and is a
\ngraduate of the Advanced Management
\nProgram at the Harvard Business
\nSchool. Dr Wah currently sees patients,
\ndoes surgery and trains residents and
\nfellows at the NIH (National Institutes
\nof Health) and Walter Reed National
\nMilitary Medical Centre.
\nDr Andrew Wilson
\nDr Wilson was appointed Executive
\nGeneral Manager of Provider Networks
\nand Integrated Care in April 2013 and
\nis responsible for managing benefit
\noutlays, provider contracting, claims
\nauditing and improved model of care
\ninitiatives encompassing Medibank
\nPrivates relationships with hospitals and
\nmedical professionals. Andrew has 25
\nyears experience in the health sector,
\nand remains a practicing psychiatrist
\nand lecturer. Andrew was Co-founder
\nand Co-President of McKesson Asia-
\nPacific which was acquired by Medibank
\nin 2010.
\nMs Tana Wuliji
\nA health and pharmaceutical systems
\nperformance researcher, policy and
\nimprovement advisor, Tana leads
\nthe Health Workforce Development
\nUnit in the USAID Applying Science
\nto Strengthen and Improve Systems
\nProject (ASSIST) and is the Asia
\nPacific Region Lead at the Quality
\nand Performance Institute, University
\nResearch Co., LLC. Her work focuses
\non better understanding and improving
\nhealth worker performance and
\nproductivity in low resource settings.
\nShe received her PhD from the
\nUniversity of London and a BPharm
\nfrom the University of Otago.
\nAssoc. Prof Mark Yates
\nAssoc. Prof Yates is a Ballarat based
\nGeriatrician with interests in Dementia,
\nMedical Education and System
\nRedesign. He has been the Clinical
\nDirector of Subacute Medicine, Clinical
\nDirector of Internal Medicine and is
\ncurrently Deputy Chair of the BHS
\nMedical Staff Group. Assoc. Prof Yates
\nis currently a board member for AMA
\nVictoria.
\nProf Heather Yeatman
\nProf Yeatman is Head of the School
\nof Health and Society at University of
\nWollongong and President of the Public
\nHealth Association of Australia. She
\nhas experience working in government,
\nacademia and with community
\norganisations. Heather has worked
\nin food and nutrition policy across
\nthe spectrum of local, state, national
\nand international levels and has held
\nleadership positions on numerous
\ngovernment and non-government
\nboards and committees.
\nHEALTHY PEOPLE
\nSUCCESSFUL ECONOMY
\nREPORT OF PROCEEDINGS
\nDAY ONE MORNING SESSION \u2013 WELCOME AND MINISTERIAL ADDRESSES
\nWELCOME TO COUNTRY
\nMs Frances Mirabelli, Chief Executive Officer (CEO) of AMA Victoria, welcomed attendees to
\nthe H20 International Health Summit. She acknowledged the Wurundjeri Land Council and
\npaid respect to the Kulin Nation and the Wurundjeri community, the traditional owners of the
\nland, and their elders past and present. She welcomed Uncle Bill Nicholson to offer the
\nwelcome to country.
\nUncle Bill Nicholson spoke on behalf of the Wurundjeri community, welcoming guests on
\nbehalf of his people and acknowledging his elders for their strength in maintaining Indigenous
\nculture over time. He spoke of his people\u2019s spiritual connection with the Yarra River and their
\nmanagement of the land through fire. Noting the popularity of the Australian Football League
\n(AFL) in Melbourne, he said the Indigenous community played a similar game before
\ncolonisation to stay fit and healthy. Colonisation changed both the land and Indigenous
\nculture, and problems such as the health gap persist. He stressed the difficulties which
\nIndigenous people faced in securing their rights from the authorities and the intergenerational
\ntrauma which accrued. He noted the importance of education in binding Melbourne\u2019s
\nmulticultural society together and promoting understanding and reconciliation. The welcome
\nto country is part of traditional law and strengthened good relations between communities and
\ntheir messengers in previous times.
\nOFFICIAL SUMMIT WELCOME
\nAfter the Australian National Anthem, Assoc. Prof Brian Owler, President of the AMA and Dr
\nPradeep Philip, Secretary to the Victorian Department of Health, opened the debate.
\nProf Owler stressed the importance of health to the economic vitality and social welfare of
\nnations. The G20 Summit in Brisbane will argue that employment, education and economic
\ndevelopment lead to health, but all these factors are dependent on people being healthy
\nthemselves. He thanked Dr Mukesh Haikerwal for his efforts in organising the event and
\nwelcomed members from China, the USA, the UK, New Zealand and elsewhere to Melbourne,
\n\u2018the world\u2019s most liveable city\u2019.
\nPAGE 18 H20 SUMMIT REPORT OF PROCEEDINGS
\nH20HEALTH SUMMIT
\nINTERNATIONAL
\n13 & 14 November 2014 \u2022 Melbourne
\nDr Philip said world leaders had increased economic resilience and rebuilt economic relations
\nin the wake of the global financial crisis (GFC). The G20 Summit will pursue goals of economic
\nstability and growth, but health care is an equally important driver of wellbeing. Poor health
\nand preventable mortality reduce living standards, degrade quality of life and inhibit
\nopportunities for all. Economics and health are not discrete, clearly bounded domains, but are
\nintimately connected. Given sharply rising public expectations and ongoing fiscal constraints,
\ninternational health care systems are exploring new ways to drive efficiency, productivity and
\nbetter health outcomes. New pathways are taking patients to the right care at the right time,
\nwhile data mining reveals the health status of populations and understanding of the social
\ndeterminants of health inform more holistic strategies.
\nNew funding models and government structures should reward results, rather than
\nprocesses, and encourage innovation. Facing common challenges in times of common
\nconstraints encourages people to learn from each other in forging new directions in health
\ncare. The goal of citizens leading happier, healthier, more meaningful lives can be achieved
\nthrough professional partnerships across sectorial and national boundaries.
\nWMA President Dr Xavier Deau raised a series of health issues, from widening health
\ninequalities in developed nations to epidemics such as Ebola in developing ones. Health
\nspending should be seen as an investment for growth as the relationship between health and
\neconomic development is well documented, with high growth and low infant mortality closely
\ncorrelated. The importance of investment in public health and the achievement of the United
\nNations (UN) Millennium Development Goals are stressed in recent declarations by the WMA.
\nReducing poverty and health exclusion is a collective responsibility and must begin with
\nincreased investment in the health care sector. Humans have valued health throughout history
\nand it remains an aspiration for us all.
\nOPENING ADDRESS
\nDr Tony Bartone, President of AMA Victoria, welcomed Mr Gavin Jennings MLC, the Victorian
\nShadow Minister for Health, to the podium. Mr Jennings welcomed the Summit to Melbourne
\nand praised its contribution to local civic life and the wider health debate. He stressed the
\nimportance of remembering and respecting the original inhabitants of the land in terms of
\nhealth and other issues. Culture is an important underlying factor in the social determinants of
\nhealth, alongside economic and social participation.
\nThe city of Melbourne, the State of Victoria and the nation of Australia are blessed with
\nadvantages not enjoyed by all communities around the world. Climate change may exacerbate
\nH20 SUMMIT REPORT OF PROCEEDINGS PAGE 19
\nHEALTHY PEOPLE
\nSUCCESSFUL ECONOMY
\nthese disadvantages, and Mr Jennings praised the progress of climate negotiations in the
\nNorthern Hemisphere and hoped similar policies would be re-embraced closer to home.
\nMeeting the challenges of global warming and adverse weather events is already a factor in
\npublic health planning.
\nMelbourne and Victoria enjoy comfortable standards of living, relative economic equality and
\nhigh workforce participation. Victorians have access to universal health care, although
\nchallenges remain even within such an urbanised and geographically constrained community.
\nVictoria\u2019s medical professionals and researchers maintain exemplary standards of
\nperformance, and Mr Jennings praised their willingness to collaborate in the cause of public
\nhealth.
\nResearch must lead to innovation and improvement in pharmaceuticals, technology and
\nclinical practice. Translating the world-class work of Victoria\u2019s medical research institutes into
\nclinical and hospital care offers exciting opportunities, given the concentration of medical and
\nscience education in the State\u2019s universities and their burgeoning connections with hospitals
\nand community health practices.
\nVictoria faces the \u2018first world challenges\u2019 of driving capability, improving connections and
\noffering universal access in a comprehensive and equitable fashion. The creation of the
\nVictorian Comprehensive Cancer Centre in the Parkville Precinct
\n2
\nin association with
\nMelbourne\u2019s hospitals and research institutes will create an internationally significant facility.
\nBroader issues arise from the interlocking funding responsibilities of state and federal
\ngovernment. Australia\u2019s states have traditionally run the nation\u2019s public hospitals, while the
\nfederal government has paid for primary health and pharmacy benefits. Although this has
\ngenerally served the community well, jarring disconnects can disrupt a seamless patient
\njourney from primary health to the hospital system. The clarity and navigability of the patient
\npathway must be improved to deliver better health outcomes. Mr Jennings favoured a focus
\non community support and home-based case as an intermediary between the primary and
\nhospital systems in the future.
\nGovernment health policy should be more predictable. Moves towards a national health
\nagreement to share the burden of growing health costs between Commonwealth and states
\nhave stalled, and certain policy settings have degraded significantly over the last four years.
\nThis has increased pressure on state governments to find the right balance of investment in
\npublic health, a problem compounded by the federal establishment of Primary Health
\nNetworks
\n3
\n\u2013 formally known as Medicare Locals. These were designed to provide clear,
\nconsistent, reliable and available patient pathways, but have not yet achieved that goal.
\nPAGE 20 H20 SUMMIT REPORT OF PROCEEDINGS
\nH20HEALTH SUMMIT
\nINTERNATIONAL
\n13 & 14 November 2014 \u2022 Melbourne
\nProposals to increase catchment sizes and change funding arrangements will offer economies
\nof scale, but may increase problems of coordination and administration, reduce connections
\nto the community and hospitals and make it harder to integrate and coordinate general
\npractitioners (GPs).
\nThe costs of chronic care must be managed while maintaining the highest standards of care.
\nThe politics and economics of health care do not always align with the key performance
\nindicators of hospitals and emergency management, but health outcomes must be seen as a
\nproduct of the entire health system. Political debate should not focus on spending in the acute
\nsector alone.
\nThe system must build confidence in patient pathways in Victoria and elsewhere. In
\ncomparison to the relative sophistication of much of Australia\u2019s health system, the flow of
\npatient information and use of personally controlled electronic health records (PCEHR)
\nremains poor. A huge database of patient data should be available for use in clinical trials, but
\nthis information has not been adequately captured, therefore improved patient records and
\nelectronic management remain a priority. Mr Jennings hoped health ministers and
\ndepartments would continue to support the introduction and use of health IT in Australia,
\ndespite the problems involved and a patch track record. Confidence and certainty regarding
\ncurrent platforms and future trends in the connections between primary, community and
\nhospital care must be improved, and Mr Jennings called for better integration of mental
\nhealth, alcohol and drug services, aged care and disability provision. Whilst there is a
\ncommon rhetorical commitment to holistic provision, it is not always reflected in resource
\nallocation or the delivery of services on the ground.
\nHe reminded attendees of the problems faced by Australia\u2019s Indigenous inhabitants and the
\ndeveloping world on the nation\u2019s doorstep. Better community approaches must improve
\nstandards in Indigenous communities and tackle chronic illness, hepatitis and other issues
\nwhich sap both individual health and the public purse.
\nVictoria\u2019s Hazelwood coal mine fire subjected the local population to stress and air pollution
\nfor 45 days, and the public health response was clearly inadequate. It was a reminder for even
\nthe most comfortable state to remember its vulnerabilities and not take any public health issue
\nfor granted. Mr Jennings called for continued vigilance and determination to respond to such
\nevents and wished the Summit well in its deliberations.
\nH20 SUMMIT REPORT OF PROCEEDINGS PAGE 21
\nHEALTHY PEOPLE
\nSUCCESSFUL ECONOMY
\nACKNOWLEDGMENT
\nAfter the presentation of a book commemorating the 50
\nth
\nanniversary of the Helsinki
\nDeclaration on the ethical use of medical experimentation, and the history of the Port Phillip
\nMedical Society, one of the world\u2019s oldest medical associations and precursor of AMA
\nVictoria, the Hon. David Davis MLC, Victorian Minister for Health and Minister for Ageing,
\nacknowledged Summit guests and noted Melbourne\u2019s high international ranking in health care,
\neducation, culture, environment, infrastructure and stability. It is one of only nine cities which
\nachieved an \u2018ideal score\u2019 in the recent Economist liveability survey4
\nfor both public and private
\nhealth care, a success the Minister attributed to the Victorian Government\u2019s record health
\ninvestment of more than $15 billion in 2014-15.
\nSuch surveys remind Victorians and Australians of their fortune in enjoying a world-class
\nhealth system which both drives and is supported by a prosperous economy. The health
\nservices which Victorians take for granted are often unknown in the developing world, and
\nMinister Davis hoped the H20 Summit would offer opportunities to create connections and
\nshare the benefits of medical research and new approaches around the world. Australia has
\njust 0.33% of world\u2019s population and produces less than 1% of its intellectual property, but its
\ncapability in health service research and delivery is recognised worldwide. Victoria generates
\nmuch of the nation\u2019s medical research and attracts a high percentage of the nation\u2019s skilled
\nimmigrants.
\nNot all incoming migrants are skilled or in good health, however, and so Victoria invested
\nheavily in refugee and asylum seeker health in 2013. The State receives a third of all refugees
\nand asylum seekers entering Australia, more than any other state. Immigrants often arrive
\nfrom countries with limited access to modern health care and may have endured years of
\nphysical and psychological trauma and deprivation. They may present with multiple and
\nchronic health conditions requiring comprehensive assessment and a range of medical
\ninterventions. Such issues can include vaccine preventable illnesses, dental decay,
\nmalnutrition, impaired vision and hearing, drug dependency, the effects of sexual abuse,
\nmental health problems and social isolation. Australia must reach out to them to ease their
\nintegration into a modern, multicultural society.
\nRefugees need support and guidance in their own languages on how to navigate Australia’s
\ncomplex health system, who to ask for support and how to make the right decisions
\nregarding their health needs. Published in June 2013, the Victorian refugee and asylum seeker
\nhealth action plan
\n5
\noutlines a long-term strategic vision to meet the needs of refugees as a
\nhumanitarian ideal and economic imperative.
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\nThe Victorian Government launched a $50 million international engagement strategy in 2012
\n6
\nto help Victorian businesses establish international connections, enter global markets and
\ncreate new jobs. Its success led to the Global Health Melbourne Plan
\n7
\nwhich helps Victorian
\norganisations take health and aged care products and services into markets opened in the last
\nthree years. This support will make the most of Victoria\u2019s competitive advantage in health
\nsystem and facility design, medical health training, biotechnology, health conferences, medical
\nresearch and clinical trials.
\nOnly London, Boston, New York and Melbourne have two or more of the world\u2019s top 50
\nmedical schools. Melbourne remains an international leader in medical research, and the city\u2019s
\nwide range of globally respected research institutions enjoy strong international links with
\nother researchers and facilities. The Burnet Institute
\n8
\ndeveloped point-of-care diagnostics for
\nliver disease, for example, and will begin to manufacture test kits in China for sale to the
\nglobal market.
\nVictoria\u2019s $18.8 million Medical Technology Strategy
\n9
\nwas launched in October 2014 to
\nprovide coordinated support for the sector. The strategy promotes the State\u2019s capacities to
\nlocal and international markets, facilitates access to funding and improves the regulatory
\nenvironment for companies. The State\u2019s clinical trials research initiative
\n10
\nhas streamlined the
\nethical review process for trials at multiple sites to encourage global companies to conduct
\nwork in the State, boosting investment and speeding the release of new medications
\nworldwide.
\nThe Victorian Infectious Diseases Reference Laboratory
\n11
\nhas tested Australians for Ebola in
\nthe wake of the West Africa outbreak and is part of the World Health Organization (WHO)
\ninfluenza surveillance and response system, routinely analysing the influenza viruses
\ncirculating in Asia.
\nVictoria has a strong record of health promotion and preventative action. With support from
\nthe Commonwealth, the State Government launched Healthy Together Victoria12
\nin 2011, a
\nmulti-agency initiative to improve the health and wellbeing of Victorians and their
\ncommunities. It \u2018improves people’s health where they live, learn, work and play\u2019 by addressing
\nthe underlying causes of poor health in children’s settings, workplaces and communities
\nthough encouraging healthy eating and physical activity and reducing smoking and harmful
\nalcohol use.
\nH20 SUMMIT REPORT OF PROCEEDINGS PAGE 23
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\nThe Victorian Government supports creative solutions in the health sector and is diversifying
\nthe revenue base of Victoria\u2019s health organisations and strengthening their capacity to improve
\noutcomes for all. The system\u2019s sustainability, efficiency and productivity must be improved to
\nmaximise outcomes and take patients to the right care at the right time. The collection and
\nanalysis of health data will produce new insights into the social determinants of health and
\nnew governance structures will reward quality and encourage innovation. Victoria is proud
\nof its health system and the lifestyle enabled by it, and Minister Davis encouraged attendees to
\nenjoy their stay.
\nVIDEO ADDRESS
\nA video address by the Hon. Tony Abbott PM, Prime Minister of Australia, was broadcast to
\ndelegates. He welcomed the H20 Summit in the context of Australia\u2019s G20 programme and
\nstressed the importance of its themes. He emphasised the commitment of his government to
\nimprove domestic and international healthcare.
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\nDAY ONE LUNCH SESSION \u2013 HEALTH AS A WISE INVESTMENT
\nMs Anne Trimmer, Secretary General of the AMA, welcomed Dr Mukesh Haikerwal AO to
\nchair the session. Dr Haikerwal reiterated the event\u2019s theme of healthy economies requiring
\nhealthy people to sustain them. The WMA works with many nations at varying stages of health
\ndevelopment, and he found the problems they face, and their solutions, to be broadly the same.
\nOVERVIEW
\nHealth Data: Comparing Australia and International Health Spending
\nMr David Kalisch, CEO of the Australian Institute of Health and Welfare, reiterated the
\ndependency between economics and health. Health systems vary in scope and sophistication
\nacross the G20, with governments playing varying roles in funding, subsidy and regulation,
\nbut most developed nation systems are large and complex. Australia separates the costs of
\npublic hospitals and primary care between state and Commonwealth, with similar sums spent
\non each, while a \u2018maze\u2019 of public and private services and institutions is funded by
\ncontributions from Australian, State and Territory governments and private fees.
\nMany OECD nations restrained growth in health spending after the GFC, and ageing
\npopulations and technological developments will increase budget pressure around the world.
\nMost OECD countries spent between 9% and 12% of their gross domestic product (GDP) on
\nhealth in 2012 (although the USA spent 17%). Despite the GFC, these figures have increased
\nover the last decade, with an average of 8.2% a decade ago rising to 9.2% today. Health
\nspending peaked at 9.6% in 2009, before the GFC.
\nAlthough it remains the most cited statistic, the proportion of a nation\u2019s GDP spent on health
\ncan be \u2018crude and ambiguous\u2019, as the US experience shows that more spending is no
\nguarantee of better care. While it reflects an economy\u2019s ability to fund health and offers clues
\ntowards political intentions and public living standards, it offers little information on efficiency
\nand health outcomes. Life expectancy at birth has little correlation with relative spending in
\ndeveloped nations, with the USA suffering poorer outcomes than most while spending more.
\nHowever, developing countries show a positive correlation between levels of spending and
\nhealth outcomes, with some countries finding smart ways to use their health dollars free
\nThe proportion of a nation\u2019s GDP spent on health offers little information on efficiency and
\nhealth outcomes. The US experience shows that more spending is no guarantee of better care.
\nH20 SUMMIT REPORT OF PROCEEDINGS PAGE 25
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\nfrom the ossified structures of the developed world. Developed economies must increase
\nthe quality and effectiveness of their health spend, rather than merely its aggregate, to
\nimprove health outcomes, and attend to the social determinants of health, not least in
\nIndigenous communities in Australia.
\nThe Value Proposition for Research: Achievements Today, More Gains Tomorrow
\nProf Sharon Lewin, Director of the Peter Doherty Institute for Infection and Immunity at the
\nUniversity of Melbourne, spoke of her passion for health research and its return of $2.17 for
\nevery dollar invested
\n13
\n.
\nResearch has produced major gains in global health, and Prof Lewin outlined the progress made
\nin fighting AIDS and reducing infections from human immunodeficiency virus (HIV). Apocalyptic
\npredictions of its impact were made in its early days, when infection was a virtual death
\nNHMRC Discussion paper: Health and Medical Research in NHMRC 75th year
\nThe Health Benefits of Research
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\nsentence, but over the last 30 years effective treatments have been developed and newly infected
\npeople who receive anti-retroviral therapy retain a normal life expectancy. All Australian states
\nhave pledged to eradicate new HIV infections by 2020. While treatment in the mid-1990s
\nrequired more than 20 tablets a day and incurred a range of damaging side effects, the single,
\nrelatively low cost tablet of today generates minimal side effects and drug resistance if taken
\nproperly. Such treatment can reduce a patient\u2019s infectiousness by 96%
\n14
\nand so the more people
\nare treated, the less the disease will spread.
\nPatients receiving Anti-Retroviral Therapies 2002 \u2013 2010
\n13 million people now receive anti-retroviral drugs in lower-income countries, 40% of infected
\npeople, when in the early 2000s such treatments in these countries were virtually unknown.
\nTreatment has gradually reduced the number of global HIV infections from its mid-1990s
\npeak, and 25 countries in sub-Saharan Africa reported a 50% decline in new HIV infections in
\n2013. The end of AIDS can now be contemplated if infected people can be identified and
\ntreated to reduce the rate of transmission.
\nResearch aggregates a range of basic, clinical, social and operational approaches. While basic
\nresearch into retrovirology in the 1970s laid the foundations for anti-AIDS drugs, public health
\nsurveillance to identify and notify infected people and informed, effective public health
\ncampaigns also played important roles in stemming the disease. However, behavioural
\ninterventions alone cannot halt the spread of HIV. Clinical research is vital for any new drug, but
\nthe rapid establishment of multi-site, global networks involving low-income countries were
\nUNAIDS 2011
\nH20 SUMMIT REPORT OF PROCEEDINGS PAGE 27
\nHEALTHY PEOPLE
\nSUCCESSFUL ECONOMY
\nunique in the development of anti-retroviral medications. Such networks now extend across
\nAfrica and Asia, and a generation of investigators have now been trained to lead studies and
\nroll out treatments around the world. Social and operation research continues to inform the
\nresponse to the epidemic and highlight where best to invest in care.
\nPartnerships, community engagement and energetic advocacy were also instrumental in
\nmaking early progress in the fight against AIDS. Consumers in high-income countries pushed
\nfor accelerated drug development, clinical trials and drugs to come to market through
\ncohesive, articulate community groups and then urged global agreements on pricing to reduce
\ntheir costs. Doctors and scientists alone could not have achieved the cultural and political
\nimpact such groups enjoyed. There are countless examples of inspiring leadership from
\naround the world, from local action to major donations by the Gates Foundation, while
\nPresident George W. Bush drove the roll out of anti-retroviral therapy in Africa through the
\nPresident’s Emergency Plan for AIDS Relief in 2008.
\nThe battle is not yet won. There are still 2.5 million new infections every year and 35 million
\npeople living with HIV. Discrimination against high-risk groups persists and the need to
\ndiagnose and treat people early remains, with perhaps a fifth of Australian cases remaining
\nundiagnosed. A vaccine against HIV remains elusive, and there is still no cure for the
\ndisease, meaning treatment must be maintained for life at considerable cost to the health
\nsystem.
\nEbola has emerged as a new infectious threat in West Africa, and lessons from HIV should
\ninform the response of the international community. Ebola was first identified in the mid-
\n1970s, but the current epidemic is the largest to date. Earlier outbreaks were short lived and
\nisolated, affecting 200 – 400 people, but the 2014 outbreak has caused 13,000 infections
\nalready.
\nThe epidemic currently affects countries without the resources, health infrastructure and
\ncultural knowledge required to contain it. There are few health professionals in Guinea,
\nLiberia and Sierra Leone, for example, with only one or two doctors per hundred thousand
\npeople. These countries have a turbulent history of regional conflict, mistrust in government
\nand porous borders, and the current outbreak is now affecting densely populated urban areas,
\nrather than isolated rural villages. Traditional burial practices have increased exposure to the
\nvirus and fuelled transmission rates, although Ebola\u2019s death toll remains a small fraction of the
\nnumbers dying from AIDS in the region.
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\nSeveral strategies for combatting Ebola have been proposed in recent years, including
\nvaccines, man-made antibodies, blood transfusions and antiviral drugs, but none have been
\ncommercialised due to a lack of profit incentive. Although the current epidemic will
\nencourage the development of treatment strategies, Prof Lewin agreed with Tony Fauci, head
\nof the National Institute of Allergy and Infectious Diseases, that Ebola will be defeated by
\nsound public health practices, engagement with affected communities and international
\nassistance, rather than any miracle cure
\n15
\n.
\nWHO, UN, The Economist
\nEbola outbreaks to 12 October 2014
\nH20 SUMMIT REPORT OF PROCEEDINGS PAGE 29
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\nHow Investments in Health are Tracking Across the Global Market
\nMr Andrew Goodsall, Head of Healthcare Research at UBS Wealth Management Australia,
\ndiscussed the role of equity markets in the health sector. The stock market is a key source of
\ncapital for private health care companies, and access to private capital is crucial to their
\nsuccess. Private equity markets have funded medical research around the world, and Mr
\nGoodsall argued that government and other purchasers can extract greater efficiency
\nalongside a strong private sector system.
\nAustralian health firms on the Australian Stock Exchange (ASX) 200 have a market
\ncapitalisation of $64 billion, while the global pharmaceutical industry is worth over $4 billion.
\nThe health sector attracts investors who perceive it as non-discretionary, non-cyclical,
\nrelatively defensive and less risky than other parts of the market.
\nThe Australian economy declined in relative terms last year, due to a fall in commodity prices;
\nhowever, Australia\u2019s health care index performed well, exhibiting robust and consistent
\ngrowth. The Standard & Poor’s (S&P) 500 has also grown strongly in comparison to the
\noverall US economy.
\nThe Asian health market is developing quickly in the light of increasing individual prosperity
\nand ageing populations. Singapore\u2019s over-65s are increasing at 5.2% per annum, compared to
\nAustralia\u2019s 2.6%, while Japan has the oldest population in the region and high health spending
\nas a result. Market investment will tend to follow these opportunities, given the wealth held by
\nolder people, but this may misalign resources from the areas of greatest need, as in the case
\nof Ebola. Governments in India and China face significant challenges due to their massive
\npopulations, but increasingly affluent individuals in these countries are allocating more of their
\nincome to their own health care. Singapore also encourages individual financial responsibility
\nfor medical services.
\nMajor pharmaceutical companies are enjoying the benefits of a research and development
\n(R&D) \u2018surge\u2019 as part of the decade-long cycle which brings new products to market. Several
\noncology drugs have emerged recently, although their affordability and efficacy in extending
\nlife is disputed. The mapping of the human genome a decade ago prompted companies to
\ntrawl through their R&D portfolio to find drugs which were abandoned as ineffective for the
\ngeneral population, but can help genetically identifiable individuals.
\nMost governments have tried to control growth in health spending in recent years to place it in
\nline with growth with GDP or as a result of the GFC. Many economies are approaching a
\n\u2018tipping point\u2019 where their capacity to finance future growth may be overwhelmed by growing
\ndemand from an ageing population. Health care consumption can increase two or three times
\nwith age, and Australia\u2019s post-war baby boomers are reaching retirement age.
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\n49% of Australians have private health insurance, but while over 65s represent 16.5% of the
\ninsured population, they incur 49% of the benefits paid to private hospitals. Developments in
\ndrugs and technology and increasing demand from older people will intensify cost pressures
\nacross the OECD. Australia\u2019s health expenditure has increased towards the OECD average over
\nthe last decade. Spending by private health insurers and consumers has also increased, in
\ncontrast to the government pullback, and personal spending on health tends to increase with
\npersonal wealth. It is easier to align public health spending and economic growth if
\nindividuals are given price signals in public health care.
\nCollaboration in Policy Development and Interventions: Ensuring Wise Investment
\nAssoc. Prof Brian Owler, President of the AMA, called for collaboration in policy development.
\nHe maintained the argument that health spending should be viewed as an investment and
\nrejected any assertion that current health expenditure is unsustainable, given the current
\nbudget deficit. Political discussion of health and education centre on reducing their cost,
\nwhen it should focus on improving their outcomes.
\nAlthough it faces future challenges, Australia enjoys one of the most efficient and productive
\nhealth systems in the world and it is worth protecting. Life expectancy for Australians
\ncontinues to increase, and boys and girls born in 2012 can expect to live to 79.9 and 83.3
\nyears respectively, ranking Australia 6
\nth
\nand 7th
\namong the 34 OECD countries.
\nIt is easy to take Australia\u2019s health system and the benefits it brings for granted, but the AMA
\nis committed to defending it and the interests of patients. The AMA supports universal access
\nto affordable health care, with equity particularly important in general practice and
\nprimary care. The independence of the doctor-patient relationship is also under threat, but
\nGPs must be free to exercise their clinical judgement and refer patients without interference
\nfrom a third party or payer. The AMA supports the community rating system for private health
\ninsurance, although Prof Owler accepted that waiting periods may be involved.
\nImprovements must always be sought, however, and Prof Owler called for policy makers to
\nharness the \u2018creative dissatisfaction\u2019 of clinicians through genuine consultation. Australia has
\nseen a raft of health reform in recent years, particularly in public hospitals, but there has been
\nlittle engagement with primary care and GPs feel ignored as a result. Wise investment in health
\nWise investment in health requires collaboration and consultation with general
\npractice, and fiscally driven policies developed in isolation and thrust upon the
\ncommunity will not work, as exemplified by the $7 co-payment proposal.
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\nrequires collaboration and consultation with general practice, and fiscally driven policies
\ndeveloped in isolation and thrust upon the community will not work, as exemplified by the $7
\nco-payment proposal. Prof Owler was puzzled by moves to raise barriers in primary care when it
\nshould be bolstered to treat Australia\u2019s epidemic of non-communicable diseases.
\nAll stakeholders agree on a reorientation towards primary care, but successive governments
\nhave failed to deliver on this aspiration. The previous Labor administration introduced
\nMedicare Locals and GP Super Clinics, but got the formula \u2018horribly wrong\u2019. General practice
\nis the cornerstone of primary care, providing high-quality, comprehensive and cost efficient
\nservice. The most recent National Primary Health Care Strategic Framework
\n16
\nalso highlighted
\nthe importance of the \u2018medical home\u2019 – something many Australians already enjoy through
\ntheir relationship with their GP or medical practice.
\nThe management of chronic and complex disease comprises more than a third of GP activity.
\nSuch disorders include hypertension, depression and anxiety, diabetes, cholesterol-related
\ndisorders, chronic arthritis, oesophageal disease and asthma. Many patients suffer from two or
\nmore chronic complaints, complicating diagnosis and management. The OECD reports that
\nAustralia\u2019s GPs are doing an excellent job in managing diabetes in the community, and the
\ncountry\u2019s hospital admission rates of 6.9 per 100,000 for uncontrolled diabetes are the best in
\nthe OECD – significantly better than Canada\u2019s 15.8, the UK\u2019s 22.8 and Germany\u2019s 55.8.
\nGPs are increasingly working with practice nurses and other health professionals in structured
\nteam care supported by Medicare, but more needs to be done. The AMA supports the
\nadoption of a broad programme, similar to the Department of Veteran Affairs\u2019 coordinated care
\nscheme
\n17
\n, to fund GP provision of comprehensive, planned and coordinated care and so
\nreduce avoidable hospital admissions. Private health insurers could adapt such programmes
\nfor their members, and the AMA has discussed a more prominent role for general practice in
\nprivate insurance arrangements with a number of companies. Most private insurers already
\noffer customers with chronic problems telephone coaching, exercise and diet advice and
\nphysiotherapy, but these services are employed in isolation from the GP who best understand
\ntheir patient\u2019s needs. Cooperation could be explored through wellness programmes, electronic
\nhealth records and Hospital in the Home and GP-directed hospital avoidance schemes. These
\nshould be carefully negotiated to maximise patient outcomes without compromising the
\nindependence of the doctor\/patient relationship.
\nAll stakeholders agree on a reorientation towards primary care, but successive
\nAustralian governments have failed to deliver on this aspiration.
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\nInvestment to improve Indigenous health remains a priority, and the AMA is committed to
\nclosing the current \u2018health gap\u2019. Health expectancy is 10.6 years less for Indigenous men and
\n9.5 years less for Indigenous women, although it has improved by 1.6 and 0.6 years
\nrespectively in the last five years. The child death rate fell by 30% between 2001 and 2012,
\nalthough it remains too high.
\nThe Prime Minister has pledged to improve Indigenous health by bolstering school attendance
\nand adult employment rates, while the Assistant Minister for Health is working on
\nimplementing a health plan in consultation with Indigenous leaders and health experts. The
\nAMA\u2019s 2013 Aboriginal and Torres Strait Islander Health Report Card
\n18
\nstressed the
\nimportance of the early years and ensuring a good start to life. Gains have been made in the
\nPitjantjatjara Lands of South Australia’s far north-west, for example, where 75% of all
\npregnant women see a medical practitioner in the first trimester, a higher rate than many
\nmetropolitan centres. The proportion of children under three with significant growth failure in
\nthat area has fallen from 25% in the 1990s to less than 3% today, and its immunisation rates
\napproach 100%. These outcomes have not been easy to achieve, but will greatly benefit these
\nremote communities. The AMA\u2019s Indigenous Health Taskforce highlights the organisation\u2019s
\ncommitment to working in partnership with Indigenous Australians to find solutions and
\nhighlight success.
\nFor all the challenges facing the system, most citizens are able to access exceptional care.
\nThe same cannot be said for many parts of the world and so global investment should be
\nconsidered alongside domestic spending. As a first world nation with a temporary seat on the
\nUN Security Council, Australia\u2019s contribution to global health furthers its own interests, as well
\nas humanitarian ideals. Lifting the health and living standards of poorer nations will benefit the
\nglobal economy as those nations trade more and contribute to the global economy. Australia
\nplays a key role in its region and supports the health systems of Pacific nations, such as
\nPapua New Guinea and the Solomon Islands.
\nWest Africa may seem a long way from Melbourne, but the Ebola outbreak demonstrates why
\nAustralia and other developed nations cannot retreat into isolationism. Although the AMA
\ncriticised the Australian Government\u2019s initial response, it welcomes Canberra\u2019s donation of
\n$42 million to train and support health care volunteers in afflicted nations. Fears of Ebola\u2019s
\nspread to developed nations have provoked discussions of border protection and quarantine,
\nbut, while sensible domestic precautions are important, the outbreak must be contained at
\nsource. Australia\u2019s funding of human and logistic resources abroad therefore delivers security
\nand economic benefits to this country.
\nAs a first world nation with a temporary seat on the UN Security Council, Australia\u2019s
\ncontribution to global health furthers its own interests, as well as humanitarian ideals.
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\nIf the most pessimistic WHO predictions of 1.4 million infections by early 2015 come to pass,
\nthe impact on travel, trade and the global economy would be disastrous. The International
\nMonetary Fund (IMF) encourages West African nation to borrow more funds to tackle these
\nproblems, but the developed world must make a significant contribution. Australia encourages
\nimmunisation programmes in Cambodia and Laos, for example, and a strategic approach is
\nrequired to maximise value for money.
\nDreaming or Reality: Investing in Health, Successful Research-Based Innovation
\nDr Haikerwal quoted President John F. Kennedy\u2019s 1962 pledge to go to the moon \u2018not
\nbecause it is easy, but because it is hard\u2019
\n19
\nin advocating vision and ambition in medical
\nresearch, before introducing Assoc. Prof Nick Barnes, Senior Principal Researcher of the
\nComputer Vision Research group at National ICT Australia (NICTA).
\nProf Barnes traced the development of the bionic eye as an example of successful health
\nresearch and innovation. Artificial heart augmentation was science fiction 60 years ago, but
\nmillions of people around the world now rely on pacemakers, just as cochlear implants help
\nmillions to hear, and visual prosthetics will offer a new frontier in implantable devices.
\nA 2010 Lancet survey of the global burden of disease
\n20
\nfound that over 32 million people were
\nblind around the world, often as a result of age-related macular degeneration. A consortium of
\nresearchers and clinicians from leading Australian research organisations are now developing
\na retinal implant to restore vision to people with Retinitis pigmentosa and age-related macular
\ndegeneration
\n21
\n. The University of Melbourne is developing a high-acuity device made from
\nsynthetic diamond, while the University of New South Wales is working on a wide-view
\ncamera to facilitate patient mobility. The National ICT Australia (NICTA), the Centre for Eye
\nResearch Australia and the Bionics Institute worked closely on a 24 electrode prototype which
\nunderwent patient trials from 2012 to 2014, and NICTA will participate in another clinical trial
\nin 2015.
\nThe bionic eye involves a head-mounted camera and a wearable processor which convert its
\nimages into \u2018patterns of stimulation\u2019 for an implant close to the retina. The prosthetic
\nassembles the information in ways which relate to reality, allowing the wearer to interpret the
\nworld around them and so live more independently.
\nThe NICTA vision-processing team works on ways to select the most important information
\nfrom the camera\u2019s images relevant to the task in hand. Prof Barnes showed a video of a
\npatient who has been blind for 25 years, walking between randomly placed obstacles using the
\ncamera, its backpack mounted processor and a depth sensor. The trials showed that
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\naugmented subjects performed at chance in a standard low-vision test, but passed when using
\nthe retinal implant with minimal image processing. More intensive processing enhances depth
\nand contrast to help patients perceive objects and obstacles more clearly.
\nThis work has attracted both domestic and international attention and shows the value of
\ncooperation between leading research institutions, health practitioners and clinicians \u2013
\nnone of whom could have achieved these results alone.
\nValue-Based Health Care – Improving Outcomes that Matter to Patients
\nDr Neil Soderlund, Senior Adviser at the Boston Consulting Group and Head of Healthcare
\nPractice in Australia and New Zealand, spoke on value-based health care and improving
\noutcomes which matter to patients. He argued that measuring the outcomes which patients
\nexperience offers a powerful tool for physicians to direct care and produce better value for
\nmoney.
\nHe acknowledged that health spending has outstripped economic growth in many countries,
\nbut argued this was not a problem if people chose to spend money in this way. Spending on
\nsmartphones, for example, has increased by even more because users gain utility from their
\ndevices in ways unimaginable a decade ago. Additional health spending has been criticised as
\noutcomes have plateaued over recent years for every extra dollar spent, but a sharper focus on
\noutcomes in policy, research and clinical practice could maximise its value.
\nCare originates with patient need and then flows through a range of processes and activities
\nwhich in turn generate clinical indicators and patient outcomes. A great deal of time is usually
\nspent on managing the process by people who are administrators, rather than clinicians. They
\ntherefore try to standardise processes to reduce costs under the guise of \u2018clinical guidelines\u2019
\nand \u2018evidence-based medicine\u2019, but, although such measures can be useful, they are limited by
\nthe reluctance of frontline clinicians to be managed at that level of detail. The value-based
\nhealth care proposition offers a more workable alternative by focusing on patient need and
\nhealth outcomes. Process is left to administrators, policy makers, health payers and insurers
\nto ensure patient needs are met appropriately.
\nMedicine employed this mode of operation through much of its history \u2013 with barber surgeons
\nonly paid if their patients survived their operation. Modern IT should disseminate research to
\ninform every day clinical management, rather than moulder in journals. Valuable clinical data
\nremains underused, but is the most important part of the value-based health care
\nendeavour. Collecting and feeding back best practice to clinicians is useful, as is the evidence
\nbase it generates for long-term planning, but presenting doctors with the outcomes they
\nwere responsible for drives immediate and significant change and improvement.
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\nIndividual, institutional and national data can only be compared across borders if it is
\nstandardised, and the International Consortium for Health Outcomes Measurement
\n22
\nencourages standardised measurement to enable this international comparison of data.
\nThe digitisation of health information allows the efficient gathering, storing and sharing of data.
\nWithout much fanfare, virtually every GP now maintains a full electronic record of their patients\u2019
\nhealth experience and status, something which would have been hailed as an impressive
\nachievement 15 years ago. After a slow start, digital record keeping is also spreading in the
\nspecialist realm, and most clinical specialists under the age of 45 maintain electronic records
\nwhich will create a valuable store of information in the near future.
\nExperience in Sweden shows the value of collecting and feeding back individual outcome data
\nto clinicians. The development of clinical outcomes registries over the last 20 years by Swedish
\nclinical craft groups, at first on paper, but now by electronic means, has enabled outcomes to be
\ndiscussed with doctors on a one-to-one basis to improve results. 30-day mortality rates after a
\nheart attack are now a third better in Sweden than the UK
\n23
\n, for example, after starting from a
\nsimilar base, with variation between the best and worst hospitals narrowing considerably. Both
\ncountries have assiduously collected acute myocardial infarction (AMI) mortality data, but in
\nBritain the information is published in aggregated league tables, while Swedish doctors discuss
\ntheir personal results with a senior clinician or cardiologist familiar to them. This individual
\nattention has driven the change in practice required to improve results. It requires no heroic
\nmeasures as improvements are based on the prescription of standard, low-cost and long-
\nestablished post-heart-attack drugs such as beta blockers, aspirin and calcium channel blockers,
\nrather than any expensive cure. Their administration should be a matter of routine, but recording
\nand confronting Swedish physicians with their results has ensured it becomes reality. If the
\nSwedish improvements had been replicated in the UK over the seven year study period, 11,263
\nlives would have been saved. If a new drug generated similar benefits, it would be approved
\nquickly and used universally, regardless of cost.
\nThe measurement of the most meaningful outcomes is as important as the notion of measurement
\nitself. While mortality is an obvious indicator in heart attacks, the most important outcomes for
\nprostate cancer operations, for example, are less clear cut. The Martini Clinic
\n24
\nin Germany
\nperforms more radical prostatectomies than any other institution and attracts many patients from
\nabroad. Its popularity stems not from its five-year survival rate (95% compared to the average of
\n94%), but because it achieves a lower rate of the two most common complications \u2013 severe
\nerectile dysfunction and incontinence. The Clinic has rigorously recorded its outcomes from its
\ninception and employs 15 specialist neurological surgeons who do nothing but radical
\nIndividual, institutional and national health data can only be compared across
\nborders if it is standardised.
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\nprostatectomies. They are debriefed on their individual outcomes every month, and effective
\ninnovations, no matter how minor, are identified and shared.
\nThere is interest in these strategies from both provider and payer communities around the world,
\nbut they are particularly powerful when driven from the grassroots by clinicians. Dr Soderlund
\nencouraged Summit delegates to investigate similar approaches in their own institutions.
\nQUESTION & ANSWER
\nQuestions were then taken from the floor. Dr Xavier Yu, a radiology trainee at St Vincent\u2019s
\nHospital, asked whether \u2018medical tourism\u2019 – patients travelling to other countries for treatment –
\nwould remain a niche activity or become a booming market which Australia could take
\nadvantage of.
\nDr Neil Soderlund saw two distinct types of travelling consumers, with people seeking plastic
\nsurgery or IVF treatment in lower-wage economies or, in a less publicised aspect, seeking
\nbetter quality of care. Singapore\u2019s high reputation has created a major export, with foreign
\npatients spending US$3 billion in its hospitals, for example. This has allowed the Singaporean
\nhealth system to drive still higher quality from volume it could not achieve from just its local
\npopulation. Major opportunities exist for Australian entrepreneurs to offer high-quality
\nservices to foreign patients.
\nDr Frank Jones of the Royal Australian College of General Practitioners (RACGP) thanked Prof
\nOwler for emphasising the importance of primary care. Primary health research is poorly
\nfunded, with a recent inquiry showing it accounts for just 3% of the total. Most research is
\nhospital-based, and Dr Jones called for reflection on redressing the balance.
\nProf Owler said Americans are accustomed to travelling around their country to receive the
\nbest treatment, while Australians are rather reluctant travellers. However, he thought this
\nwould change over time as facilities differentiate themselves by provision or performance. He
\ndid not see doctors as the obstacle to performance tracking, saying he had lobbied for 14
\nyears to create a registry for shunts \u2013 the highest value device on the market. Such registries
\nexist all over the world, but the Australian Government has been reluctant to fund one, despite
\nits cost effectiveness and clinical support. Private health insurers would also benefit from such
\ndata gathering, but doctors must lead the lobbying for the resources required to do it.
\nMr Graham Brown, a retired public and global health practitioner, noted the USA\u2019s failure to
\nimprove life expectancy in line with other OECD nations, despite its much higher spending on
\nhealth. He called for the reasons to be analysed and hoped Australia would not follow its
\nH20 SUMMIT REPORT OF PROCEEDINGS PAGE 37
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\ndirection. While investment in a privatised health system might increase profits for companies
\nand investors, he called for evidence to prove that turning health into a commodity created
\nbetter patient outcomes.
\nDr Robert Wah said the USA had remained an outlier in OECD statistics for several reasons.
\nThe USA has a very heterogeneous society and, given the importance of social determinants
\nof health, faces more challenges than other countries, with additional issues including gun and
\ndrug use. Such factors reduce life expectancy independently of the quality of care delivered by
\nphysicians, although Dr Wah acknowledged that some major expenditures in the USA fail to
\nproduce immediate gains. However, the USA does undertake much of the world\u2019s health
\nresearch and development and pays for it through higher medication, procedure and
\nequipment costs, inflating its health spending figures. The rest of the world criticises its health
\nrecord while enjoying the benefits of its research without contributing to the cost.
\nDr Mzukisi Grootboom said South Africa may be a middle-income country, but has a similar
\nprofile to America when compared to its peers. It invests 8.5% of its GDP in health, but its
\noutcomes are poor – no better than lower-income countries in the rest of sub-Saharan Africa.
\nEvidence shows that public health interventions aimed at low-income groups are effective as
\nsuch people have the most to gain. The privatisation of health care can reduce its availability
\nto poorer communities and they suffer disproportionately from its results. Private health care
\nhas swollen from 40% to 60% of the total in South Africa over the last twenty years without
\ndelivering any benefits.
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\nDAY ONE AFTERNOON SESSION \u2013 GLOBAL HEALTH AND INVESTMENT
\nOPENING ADDRESS
\nHealth and Development: From \u201cPatient of Asia\u201d to \u201cGiant of East\u201d (1949-2030)
\nAfter a break, Ms Anne Trimmer opened the session on global health and investment. Dr
\nHaikerwal offered thoughts arising from the morning\u2019s discussion and introduced Prof
\nAngang Hu, a Professor and Dean at Tsinghua University, who discussed China\u2019s five-year
\nhealth plans.
\nHealth is an important national development goal for China\u2019s 1.36 billion people. Its 11
\nth
\nfive-
\nyear plan, covering 2006 to 2010, included core health indicators, such as life expectancy, for
\nthe first time. The new rural cooperative medical care system increased coverage from 23.5%
\nin 2005 to over 80% in 2010 and now reaches 96% of rural inhabitants. By 2010, over 90% of
\nthe population were inoculated, while infant mortality declined to 13 per 1,000 births and life
\nexpectancy reached 76. The 17
\nth
\nCongress of the Chinese Communist Party pledged further
\nmedical reform in both rural and urban areas.
\nA billion Chinese lacked medical insurance a decade ago, but coverage increased to 42%
\nduring the 11
\nth
\nfive year plan and reached 93% in 2012. The Government increased spending
\nto cover a third of the cost, and while other countries cut health expenditure in the wake of the
\nGFC, the Chinese increased spending 24.2% over their growth in GDP.
\nThe 13
\nth
\nfive-year plan will aim to increase life expectancy to 77.5, close to that enjoyed in
\nmore developed countries. China is catching up to the USA in terms of GDP, life expectancy
\nand other indicators from a low base. The country is undergoing rapid modernisation and
\nurbanisation and now has 200 million people aged 60 or more, a fifth of the world\u2019s total.
\nReducing health poverty and smoking are public health priorities, and China aims to become
\nthe best performing developing country by 2015. By 2020, it plans to equal the median level of
\ndeveloped countries and by 2030 rank with the best, including Australia. China is keen to learn
\nfrom the Australian health care system as it improves.
\n16 years ago, China was the \u2018patient of East Asia\u2019, but is now the \u2018giant of the eastern world\u2019.
\nImproving the nation\u2019s health provision has greatly increased its economic capacity and the
\nwelfare of its citizens, and Prof Hu agreed that investment in health is \u2018the best investment\u2019 as
\nit lays a firm foundation for wider development.
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\nPANEL DISCUSSION
\nImportance of Global Health and Investment
\nDr Haikerwal then led a panel discussion on the importance of global health and investment
\nwith Prof Heather Yeatman, President of the Public Health Association of Australia, Mr Roger
\nKilham, Director of Kilham Consulting and Dr Mark Peterson, Chair of the New Zealand
\nMedical Association.
\nProf Yeatman said disparate organisations should cooperate to advocate greater investment
\nin health. She offered several topics for consideration, including prioritising \u2018the health
\nperspective\u2019, taking a holistic approach to the health of the planet as well as its population,
\nunderstanding the social determinants of health, strengthening prevention and primary health
\nand finding new areas for investment.
\nIn common with other speakers, Mr Kilham rejected the idea that the current Australian
\nsystem is unaffordable. All public and private spending decisions are choices, and more is
\nspent on legal and illegal gambling than hospitals in Australia. About 19% of total national
\nhealth spending is met out of pocket by households, but they spend as much on the alcohol
\nand tobacco which damage their health. Indeed, more is spent on caring for pets in Australia
\nthan goes to GPs.
\nMr Kilham discussed The Price of Inequality, a book by Prof Joseph Stiglitz which offers a
\ncritique of the economic status quo and argues that increasing inequality in wealth and income
\nleads to poor economic performance. As money moves from the bottom and middle of
\nsociety to the wealthiest elite, human assets are underutilised, growth is curtailed, GDP is
\nreduced, economic instability is exacerbated and democracy, fairness and justice degrade.
\nAlthough the book focuses on the USA, Mr Kilham believed much of it applies to Australia.
\nIndigenous health remains poor despite attempts to \u2018close the gap\u2019, and the Australian
\nGovernment is still to \u2018connect the dots\u2019 between the social determinants of health and health
\nprovision. Health and work are interconnected, for example, as sick people are less able to
\nwork and unemployment is associated with illness. Mr Kilham underlined the importance of
\nmeasuring outcomes as many public policies are considered only in terms of costs or
\npotential savings to the budget, instead of their benefits to health. Roads would never be built
\nif only their costs were examined, for example, rather than their wider benefits. Costs are
\nknown and factual, while benefits are more difficult to define and articulate, and more effort
\nmust be made to create a proper framework for decision making.
\nDr Peterson agreed that health spending should be viewed as a wise investment, rather than
\nan increasingly unaffordable expense, and with the health benefits of employment. Studies
\n25
\nby Dame Carol Black in the UK indicate that employment is beneficial for individual health and
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\nthat healthy people are more likely to be in work. New Zealand\u2019s health service aims to be \u2018best
\nfor patient, best for population health status and best for cost effective interventions\u2019, and its
\nprogrammes and targets are assessed against these three criteria. Such targets have made a
\nhuge difference in China, and Dr Peterson found it interesting that their merit is still debated in
\na developed country such as New Zealand. New Zealand\u2019s Integrated Performance Incentive
\nFramework
\n26
\nsets cross sectional health targets across individual general practices, primary
\nhealth organisations (PHOs) \u2013 networks of general practice teams \u2013 and District Health
\nBoards.
\nHealth disparities and inequities remain an issue in New Zealand. Maori males live eight years
\nless than average, even after statistical correction for socio-economic status. New Zealand is
\nlooking to expand the use of primary care, although it levies a co-payment – a topical issue in
\nboth the UK and Australia. However, these co-payments are subsidised, with support targeted
\nat those in need. Children from 0 to 6 incur no fees, and from July 2015 there will be fully
\nsubsidised primary care for all 6 to 13 year olds. New Zealand has near universal enrolment in
\ngeneral practice, and most GPs in the country would agree the registration process empowers
\nits population health programmes.
\nDr Haikerwal invited questions from the floor. The first speaker noted the need for efficiency,
\ngiven decreasing funds and increasing demands, and called for proper accounting to identify
\nand control the sums spent on administration, figures which currently remain opaque.
\nAssoc. Prof Mark Yates observed that a value can be put on estimated carbon dioxide
\nemissions when building infrastructure, and wondered if the health effects of the build
\nenvironment could also be valued and quantified.
\nProf Heather Yeatman said a serious attempt to improve public health outcomes must involve
\ninvestment in education, public transport and other infrastructure to improve the social
\ndeterminants of health, rather than \u2018micro-shuffling\u2019 of the health system. She called for
\nresearch into the health impacts of new infrastructure, including pollution and exercise, and
\nstressed the need for more holistic planning.
\nMr Kilham said he had tried and failed to calculate how much is spent on health
\nadministration as the existing data is completely impenetrable. Administration costs are
\nfactored into everything, from surgical services to electricity, and while input\/output tables can
\nbe produced, their calculations owe more to imagination than reality. He sought a more
\nconstructive framework and differentiated between cost effectiveness – the cheapest way of
\nachieving a goal among alternatives \u2013 and cost\/benefit analysis which weighs the value of
\noutcomes against their cost. Both methods can be employed, but the public sector tends to
\nlook only at cost effectiveness, rather than cost\/benefits. Lobby groups are left to point to the
\nbenefits of improved quality of life and lower future health costs, and more work must be done
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\nto make more sensible public policy decisions. Australia is prone to \u2018political
\nmonumentalism\u2019, with politicians favouring large infrastructure projects, while processes
\nwhich may generate more value for society are more difficult to explain and so receive less
\nattention and investment.
\nMr Peterson called for a health perspective in town planning as building a motorway which
\nreduces traffic accidents, or building a cycleway to encourage exercise, have clear effects on
\nhealth. He reminded clinicians that public health schemes and better housing and sanitation
\nhave improved public health more than doctors treating disease.
\nKEYNOTE
\nInternational Effort in Health Systems, Development and Sustainability
\nMs Trimmer introduced Mr Ewen McDonald, Deputy Secretary of the DFAT, to deliver the
\nkeynote speech on the development and sustainability of international health systems.
\nMr McDonald outlined new directions in Australia\u2019s overseas aid programme and the nation\u2019s
\ncommitment to strengthening health systems and outcomes in the region. The programme
\npromotes prosperity, reduces poverty and lifts living standards.
\nHe acknowledged the medical, economic and social problems provoked by the Ebola outbreak
\nand detailed Australia\u2019s contribution to the global effort to help its victims and limit its spread.
\nAustralia has offered $42 million in aid, including the Prime Minister\u2019s commitment of over $20
\nmillion over the next eight months towards a treatment facility in Sierra Leone as part of the
\nUK-led effort in that country. This builds on earlier donations of $10 million to the UN Trust
\nFund, $3.5 million to the WHO, $2.5 million to Australian NGOs and $2 million to support the
\nUK in the delivery of frontline services. Australia supports the UN\u2019s efforts to encourage contact
\ntracing, safe burials and community education and will hone the Pacific region\u2019s readiness to
\ntackle any imported cases. The Ebola crisis has crystallised core development challenges
\nwhich require sustained attention and assistance over the long term. It reminds the world of
\nits interconnections and the need for ongoing global collaboration to maintain robust and
\nresilient health systems that deliver proper health care for all.
\nThe context of aid has changed in recent years. Notwithstanding the current Ebola crisis, the
\nfacts show that global health is improving. Deaths from AIDS, tuberculosis (TB) and malaria
\nhave fallen by around 40% since 2000, while maternal mortality in the Asia-Pacific region has
\nmore than halved in the last twenty years. However, global and regional averages can mask
\nmajor disparities, and many countries in this region still have underfunded health systems and
\noutstanding health issues. Despite progress towards meeting the Millennium Development
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\nGoals
\n27
\n, the rise in non-communicable complaints and emerging infectious diseases are
\nputting pressure on health systems which may be unable to cope.
\nThe methods by which aid is provided have also evolved, with new players promoting
\ndevelopment. The establishment and growth of the Global Fund and philanthropic
\norganisations such as the Clinton Foundation and the Bill and Melinda Gates Foundation have
\nadded fresh focus and impetus. The provision of intergovernmental aid and the role of UN
\nagencies and development banks remain important, but ongoing economic progress in the
\ndeveloping world means that Australia\u2019s bilateral partners are able to devote greater domestic
\nresources to expand their own health sector.
\nGlobal aid funds are dwarfed by alternative sources of capital for developing nations. OECD
\nfigures from April 2014 show official development assistance amounted to US$134 billion,
\nwhile remittances were US$400 billion and private capital flows topped US$190 billion,
\ndwarfing philanthropic aid of US$70 billion. Aid funding will never replace a country\u2019s own
\nefforts in safeguarding the health of its citizens. While there are some variations, international
\nhealth development assistance accounts for less than 1% of health expenditure in
\ndeveloping counties. International support must therefore help such countries maximise the
\neffectiveness of their own health resources, encourage political reform and drive systemic
\nimprovements.
\nThe private sector has an increasingly significant role to play and now provides 60 -70% of
\nhealth services in larger Asian countries, covering poorer people as well as the rich. It is an
\nimportant financer of health services and innovator of medical products and technology. Mr
\nMcDonald reinforced the importance of partnerships with private sector firms and praised
\nAustralia\u2019s expertise in this sphere.
\nAsia has enjoyed rapid economic growth in the last decade, and Mr McDonald praised China\u2019s
\nhealth goals and aspirations. South Korea is now an aid donor, and Indonesia is becoming a
\nmiddle-income economy. Many Asian countries will therefore lose eligibility for aid in the near
\nfuture, after relying on international contributions to combat HIV, TB and malaria and support
\nchildhood immunisation. However, large numbers of poorer people are at risk of being left
\nbehind. The World Bank estimates that 600 million people live on less than $2 a day in East
\nAsia and the Pacific, many of them in middle-income countries.
\nThe Australian Government has integrated aid, trade and foreign policy into a single
\ndepartment. In June 2014, the Minister for Foreign Affairs announced its new development
\npolicy with the promise it would promote prosperity, reduce poverty and enhance regional
\nstability.
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\nMr McDonald concurred with other speakers that health is essential to strong economic
\ngrowth. Healthier adults are more able to earn an income, and only well-nourished, healthy
\nchildren are able to learn the skills they need at school to break out of poverty. Healthier
\npeople are less susceptible to \u2018health shocks\u2019 which can plunge their household into poverty
\nthrough loss of income and the cost of medicine, consultations and hospital stays.
\nOutbreaks of infectious disease can have serious national and regional consequences and,
\nbefore Ebola, the economic and social impact of severe acute respiratory syndrome (SARS)
\nand avian influenza was considerable. The links between health, poverty and growth are
\nreflected in DFATs investment to support healthy, productive and resilient Pacific populations
\nand build a healthy, stable and secure region. Australia\u2019s overseas health spending increased
\nfrom $765 million in 2012 to $785 million in 2014.
\nFlexible, responsive and sustainable health systems have the people, supplies and
\ninfrastructure they require to deliver timely and appropriate services to people in need. Weak
\nhealth systems are exposed by the emergence of communicable trans-boundary threats such
\nas Ebola. New strains of avian influenza, a resurgence of polio, drug-resistant TB and malaria
\nare regional threats which expose the failings in routine services which leave people dying
\nfrom lack of basic health care and threaten other nations.
\nAustralia therefore concentrates on the \u2018unromantic, unremitting task\u2019 of sustaining all parts of
\na recipient\u2019s health system, from logistics to laboratories, with partners including NGOs,
\nacademia, the private sector and philanthropic organisations as well as national governments.
\nNGOs, including faith-based organisations, have contributed to earlier detection and better
\ntreatment of TB and HIV, improved sanitation and ensured better health for mothers and
\nnewborns in many countries in the region. Australia\u2019s support for regional health systems will
\nbe complemented by investments which address the environmental and social factors
\naffecting health and how people access health services. In addition to better nutrition, water
\nand sanitation, empowering women and girls is a central objective of the overall aid
\nprogramme, and particular attention will be given to women\u2019s health needs, including sexual
\nand reproductive health.
\nThe regional focus recognises the reality of Australia\u2019s geography and self-interest. Aid is an
\ninvestment in the future of the region, rather than charity. Australia encourages the
\nSolomon Islands to invest in its frontline health services and reform its procurement, for
\nexample, as better health outcomes will promote prosperity and reduce the risk of trans-
\nboundary health issues.
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\nIt is in everyone\u2019s interest to build better health systems in the Indo-Pacific. Leaders from 18
\ncountries in the region are considering an Australian-Vietnamese proposal to commit to the
\nambitious goal of a malaria-free Asia-Pacific by 2030, for example. Australia has addressed
\ndrug-resistant malaria in the region in recent years, demonstrating regional ownership of the
\nproblem and laying the foundation for further international collaboration to address regional
\nand global health security.
\nResearch continues to improve the impact of aid investments. The Minister for Foreign Affairs
\nhas announced that up to $30 million will be invested every year to assess the impact of
\nbilateral aid and build the lessons learned into future programmes.
\nProduct development partnerships can address the gaps in medicines and vaccines for
\ndiseases afflicting poor people in developing countries. New TB and malaria treatments are
\nurgently required to stay ahead of the resistance emerging to existing medicines. The
\navailability of powerful new treatments must be matched by the capability of health
\nsystems to deliver them to those in greatest need on an adequate scale, and Australia is
\nproviding start-up funding for innovative ways to break the bottlenecks in regional health
\nsystems.
\nIn conclusion, Mr McDonald shared the commitment of attendees to improve global health,
\npraised their work and advocacy efforts to this end and expressed confidence that Australian
\naid will reduce poverty and lift health and living standards in the region and beyond.
\nACKNOWLEDGMENT
\nDr Otmar Kloiber, Secretary General of the WMA, stressed the importance of Australia
\nremaining active in the international community. He praised the effectiveness of Australia\u2019s
\naid efforts and their emphasis on the social determinants of health and building resilient,
\nsustainable care systems. If its social determinants are not improved, a nation\u2019s health will
\nnot change, regardless of other efforts.
\nPhysicians support international cooperation and trade to support peace and equity. However,
\nthere is concern at trade negotiations \u2018behind closed doors\u2019, and Dr Kloiber hoped
\ngovernments would negotiate \u2018with their people\u2019. He then presented Mr McDonald a book
\ncommemorating the 50
\nth
\nanniversary of the Helsinki Agreement.
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\nPANEL DISCUSSION
\nReflection on Health Investment in Our Nations
\nMs Anne Trimmer invited Dr Haikerwal to chair a panel discussion on international efforts to
\nsecure sustainable health systems. Ms Melissa Tims, a Senior Policy Advisor at National
\nAustralia Bank (NAB), praised the Australian health system\u2019s provision of free attention and
\ntreatment at any public hospital, albeit with waiting periods on occasion, but questioned its
\nsustainability. The Australian Government has a AU$5 billion funding gap, and faces major
\ninfrastructure outlays to support Australia\u2019s ageing population.
\nMs Tims said the mindset of health consumers would have to change as a result and outlined
\nthe role organisations such as NAB can play, not least in keeping people in the workforce
\nlonger. More flexible arrangements can support older or disabled people in the workplace, and
\ntechnological innovation may see a quarter of care delivered virtually by 2020. She called for a
\ndisciplined, holistic approach with cross-sector participation across public and private realms
\nto deliver the reforms required. Victoria has seen successful public-private partnerships, and
\nshe noted the emergence of social impact investing in Australia.
\n50 to 69 year olds hold 40% of the nation\u2019s wealth and will spend more on health as their
\nneeds increase. Senator Mitch Fifield, Assistant Minister for Social Services in the Victorian
\nGovernment, is considering an online \u2018trip advisor\u2019 for aged care, showing a willingness to
\nlisten to consumer concerns and for funding to follow the consumer in a more deregulated
\nmarket. A blueprint
\n28
\nproduced by NAB with National Seniors Australia and the Per Capita
\nthink tank reports that Australia\u2019s ageing population will create significant business
\nopportunities for private firms to attend to its needs.
\nDr Ozdemir Aktan, General Surgeon and President of the Turkish Medical Association, said
\nthat Turkey has seen major changes in health delivery and pointed to the specific issues facing
\nhis country. Turkey spends the least amount on health per capita – US$900 \u2013 in the OECD and
\nover the last decade its system has been increasingly privatised, despite the opposition of the
\nTurkish Medical Association. About half the workforce is unregistered and does not pay
\ninsurance premiums and so are not eligible for medical help. Encouraged by the IMF and the
\nWorld Bank, privatisation is being implemented in many middle-income countries, but \u2018one
\nsystem will not fit all\u2019 and poorer people may lose access and incur higher out-of-pocket
\nexpenses as a result.
\nTurkey has received 1.5 million refugees from the war in Syria and Iraq and faces many
\nissues. Only 200,000 are housed in camps, with the rest dispersed elsewhere in the country.
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\nThe refugees need food, health care and work, but many are being used as a cheap workforce
\nand face greater occupational hazards, diseases and accidents as a result. The best
\ninvestment in health in Turkey would be regional peace, allowing a concentration on other
\npriorities.
\nDr Mzukisi Grootboom, Orthopaedic Surgeon and Chair of Council at the South African
\nMedical Association, underlined Mr McDonald\u2019s points about the social determinants of
\nhealth. He stressed the importance of collaboration between government departments as
\nsynergies from transport, housing, water, electricity and education are as important as the
\nhealth system itself in improving public health outcomes. He agreed with Dr Aktan that
\npeace and stability are also vital. The Ebola outbreak has been fuelled by the fragility of sub-
\nSaharan health systems, and lessons should be learned from the international collaboration
\nwhich tackles AIDS and malaria. National interventions require harmonised approaches and
\nthe involvement of local communities. Former President Mbeki\u2019s rejection of medical
\nconsensus and the use of anti-viral AIDS drugs in South Africa was costly
\n29
\nand was only
\noverturned by the community\u2019s use of the courts.
\nAlthough South Africa has invested heavily in health care, it \u2018has little to show for it\u2019 and every
\nministry is now being held accountable for its results to ensure effective action. The Department
\nof Health has signed a performance agreement to guarantee measureable progress within five
\nyears, including increased life expectancy and interventions against AIDS. South Africa now has
\nthe world\u2019s largest rollout of anti-AIDS drugs and a programme encouraging male circumcision.
\nHealth issues faced by South Africa during the apartheid era persist today, with the middle class
\nenjoying more access to health care than poorer echelons of society. Dr Grootboom criticised
\npoor governance and a lack of accountability in the public health system, but was also
\nconcerned by the growth of the private sector and its attraction of doctors, trained at public
\nexpense, away from the public sphere.
\nHealth, education and the empowerment of women and girls are key pillars of the new South
\nAfrica. There is a strong focus on primary care and it has adopted the Brazilian system of ward-
\nbased community health workers who visit poorer families in their homes and trace contacts for
\nTB and AIDS more effectively.
\nAlthough the international community has scaled back its aid efforts, there remains a strong
\ncommitment to improve global health and the economies of poorer countries to encourage their
\ninvestment in domestic health care.
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\nQUESTION & ANSWER
\nDr Haikerwal invited comments from the floor. Ms Tania Tanner criticised current policy
\nmaking for its focus on instant gratification at the cost of sustainability and asked how the
\nbalance could be shifted from the pursuit of immediate economic benefits towards ensuring
\nlong-term environmental and social stability.
\nProf Michael Moore of the Public Health Association noted the Australian Institute of Health and
\nWelfare\u2019s calculation that only 1.8% of Australia\u2019s health budget is spent on prevention, while
\ninternational aid accounts for just 1% of Australia\u2019s budget overall. He called for the proportion
\nspent on prevention and primary health care to be increased.
\nDr Grootboom said a national development plan, drawn up by stakeholders and experts from a
\nrange of sectors and presented for broad community consultation, aimed to remedy 50% of
\nSouth Africa\u2019s identified deficiencies by 2030 through inter-sectorial collaboration.
\nDr Aktan noted agreement on the importance of primary health care and also supported
\ninvestment in prevention rather than treatment. He agreed that war was a major cause of ill
\nhealth, observing that polio was virtually eradicated before it reappeared in Afghanistan after
\njihadists murdered vaccinators and began to spread it themselves around the world.
\nSustainability must be built on primary health care run by governments to ensure universal
\ncoverage for their populations.
\nMs Tims said Australia was fortunate to have private health insurers which are increasingly
\ninterested in primary health care to keep people out of hospitals.
\nAnother delegate stressed that domestic health spending had to be both effective and
\nsustainable.
\nDr Grootboom said the cost of administration was an important issue in South Africa as the
\nproportion of frontline health workers in the public service has slumped from 60% to 30% in
\nrecent years. The cost of the bureaucracy is hidden from the government struggling to control
\nit, and the growing ranks of administrators mask the lack of qualified clinicians in the public
\nsphere. He argued that no more than 5% of health system workers should be administrators.
\nAnother attendee was pleased at the mention of Brazil\u2019s primary health strategy to engage the
\ncommunity in health policy and decision making.
\nMs Tims said the Australian obsession with property encouraged banks and investors to
\nfavour infrastructure investments which generate a cash flow and return.
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\nDr Robin Coupland, of the International Committee of the Red Cross, admitted he courted
\nunpopularity by raising the fact that many of the hospitals he had visited in the developing
\nworld were riven with corruption, with doormen having to be bribed to gain admittance,
\npharmacies selling counterfeit drugs and medical staff demanding payments to administer
\nthem. He called for ethics to be included in talk of budgets, accountability and governance.
\nDr Grootboom agreed that greater investment in prevention and primary health is the cheapest
\nand most effective way to improve health outcomes in poor communities. As banks will not
\ninvest in such provision, it must remain a government responsibility. He called for out-of-
\npocket costs to be reduced and the pooling of resources to share risks and rewards in
\nguaranteeing health care for all.
\nCONCLUSION DAY ONE
\nMs Anne Trimmer then invited Prof Philip Davies, Deputy Director-General of Health
\nCommissioning Queensland Division at Queensland Health, Dr Haikerwal and Dr Deau to
\nsummarise the day\u2019s discussions.
\nProf Davies drew three messages from the session, the first being attendee\u2019s challenge to the
\nperceived wisdom that Australia\u2019s current health system and ongoing spending growth is
\nunsustainable. He did note, however, that the Government does not pay for two thirds of the
\nnation\u2019s smartphones, while it does pay for two thirds of health care. Nevertheless, health care
\nis a service which richer individuals and nations choose to spend more on and, in a
\ndemocracy, a nation will allocate its budgets as its population decrees. More attention should
\nbe paid to the quality of health spending, rather than its quantity, and a more informed
\ndialogue should begin with consumers about priorities, given the tension between preventative
\nand primary health and the acute sector raised by several speakers.
\nHis second issue was a lack of clarity surrounding the objectives of the Australian health
\nsystem. High life expectancy is not proof that health care is responsible if the country enjoys a
\nstrong economy, benign climate, few natural disasters and strict gun control. A health system
\nmust have a wider range of indicators, and while disability-adjusted life year offers a more
\nrational benchmark, the health system can also aim for equity, choice, autonomy,
\nconfidentiality and the local provision of services. Health systems should be managed to
\ndeliver outcomes and achieve defined objectives. The Queensland Government funds results,
\nnot activities, and pays the NGOs and private firms it partners with accordingly.
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\nProf Davies traced the success of the crowdsourced taxi company Uber to prioritising pre-
\ndefined outcomes over processes and realising that the journey matters more than the method
\nemployed to achieve it. Uber has used the modern mobile technology which almost everybody
\nalready owns and carries at all times to overcome information asymmetry between drivers and
\npassengers and break the monopoly of the traditional taxi industry. A health system which
\nfocused on outcomes, rather than process, and patient outcomes rather than demarcation and
\nprotection of producer interests, would be equally exciting and challenging.
\nThe world is facing the challenges of chronic disease and new threats such as Ebola, but
\nimprovements in health care will require systemic change as well as additional funding. A
\nfast-developing China now confronts the same issue of an ageing population as Australia, and
\ncountries such as Singapore now have a significantly higher per capita GDP. Advances such
\nas the bionic eye and retroviral drugs are changing health care alongside social and economic
\npressures, but while health has led technological and pharmaceutical change, it has
\nlagged behind other sectors in organisational reform.
\nStrong and effective government is a vital intermediary in the interaction of health and
\nthe economy. Managers and administrators are never popular, but just as health
\nspending can be productive or wasteful, so there is efficient or obstructive bureaucracy.
\nThe World Health Report of 2006
\n30
\nshowed that one in three health service workers are
\nmanagers or support staff, with two thirds delivering treatment. In Africa as a whole, only
\n17% of employees are not frontline health workers, indeed some of the failings in that
\ncontinent may stem from a lack of efficient administration and governance. Prof Davis
\nbelieved that sound and transparent government is the \u2018silver bullet\u2019 which will improve
\nhealth care in developing countries in the region and around the world.
\nDr Deau called for clinicians and their associations to lobby for better health systems to
\nincrease human capital, improve productivity and promote wellbeing, before Dr
\nHaikerwal thanked the Summit\u2019s organisers, speakers and attendees and drew the day to
\na close.
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\nDAY TWO MORNING SESSION \u2013 NON-COMMUNICABLE DISEASES (NCDs) &
\nTHE SOCIAL DETERMINANTS OF HEALTH ACROSS THE COMMUNITY
\nINTRODUCTION
\nMs Frances Mirabelli welcomed attendees and introduced the day\u2019s topics of non-
\ncommunicable and chronic disease, the social determinants of health and the threat of climate
\nchange.
\nDr Otmar Kloiber said the previous day\u2019s discussion had offered fresh perspectives on the
\ninterrelationships of economics and health, and criticised politicians for marginalising the
\nimportance of health by portraying it as an expense, rather than the largest sector in service-
\noriented OECD economies. Huge sums were found to bail out spendthrift banks and insurance
\ncompanies after they mismanaged their affairs, while tax payers benefit personally from
\ngovernment spending on health and support its prioritisation.
\nResearch-driven innovations such as the bionic eye can generate significant commercial
\nreturns, but social benefits can also be secured without greater spending or developing new
\ntechnology. Australia\u2019s introduction of plain packaging for cigarettes was a simple measure to
\nreduce consumption at no cost to the taxpayer and succeeded despite inevitable and strident
\nindustry opposition. Health professionals must engage in debate about social determinants
\nand climate change, and the WHO should pay more attention to NCDs and mental health
\nissues.
\nMs Anne Trimmer emphasised the corrosive effect of corruption in both health provision and
\ngovernment around the world. Transparency International estimated that more than 5% of the
\n$3 trillion spent on health in 2006 was lost to corruption. Ms Trimmer called for leaders in the
\nhealth sector to acknowledge the problem and ensure that every health dollar is well spent.
\nKEYNOTE
\nDiscovering the Future of Health Care: Reflections from Adjacent Sectors
\nDr Pradeep Philip, Secretary to the Victorian Department of Health, reflected on the future of
\nhealth care through perspectives drawn from other sectors.
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\nHealth systems must evolve to meet the challenges of an ever more complex and changing
\nworld. As previously noted by several speakers, demand for health services is growing as
\npopulations age and chronic disease and co-morbidity increase. Other issues include
\nincreasing treatment costs, more intensive use of services, technological advances and
\nchanging patterns of disease and care. A general rise in incomes and wealth tends to increase
\nhealth service consumption by every age group, and patient expectations are \u2018sky rocketing\u2019,
\nfuelled in part by the accessibility of information on the internet. The rise of NCDs will change
\ntraditional understanding of who delivers health care and when and where it is delivered.
\nNCDs demand a different approach from the infectious challenges of the past, with a new
\nfocus on lifestyles and the social influences upon them. Their multiple and cumulative
\ncausation will require a radical re-imagination of the system in response.
\nThe G20 Leaders\u2019 Summit in Brisbane will bolster international economic resilience by
\nimplementing new financial regulations, modernising international taxation, strengthening
\ntrade, reforming global institutions and addressing the perennial problem of corruption.
\nThese structural and macro-economic reforms aim to increase G20 economic growth by at
\nleast 2% over trend in the next five years. However, significant supply-side challenges remain
\nas economies recover from the GFC of 2008 and world trade reorients towards new growth
\ncentres, including China, India and Brazil.
\nGiven economic instability and poor growth in recent years, the ever growing demand for
\nhealth services calls for \u2018dynamic system change and adaptation\u2019. Transformational change in
\nhealth care must leverage the technological and organisational innovations in other sectors to
\ndeliver better health outcomes at lower cost.
\nDr Philip offered four economic and social trends which may shape the future of health care.
\nNew ways of looking at the world are emerging, replacing the historical focus on isolated
\ncomponents with a broader view of interconnections, networks and relationships.
\nConsideration of horizontal connections can offer insights inaccessible by drilling down into a
\nnarrow, vertical \u2018slice\u2019 of reality. Health must therefore go beyond the treatment of individuals
\nto place people in their broader context. Studies which map the social environment of health
\ninform both the health sector and the community about the causes and drivers of illness and
\ninfirmity. Population health and personalised medicine should be acknowledged as symbiotic,
\nrather than mutually exclusive domains.
\nHealth must go beyond the treatment of individuals to place people in their broader
\ncontext. Population health and personalised medicine should be acknowledged as
\nsymbiotic, rather than mutually exclusive domains.
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\nA focus on the \u2018business of illness\u2019, characterised by individual episodes of care delivered in
\nacute settings, should give way to more holistic approaches, with a continuum of care offered
\nby a number of multidisciplinary providers, often in the community or patient\u2019s own home.
\nPatient choice and independence should be a key outcome in optimising their experience.
\nWealthier and more sophisticated consumers are rejecting mass-produced products in favour
\nof bespoke goods produced on demand and tailored to their individual requirements.
\nProducers are adding value by turning commodity goods into personalised services which
\ndeliver complex yet seamless multi-faceted experiences. This \u2018experiential economy\u2019 is
\nchanging the commercial world, and health care will not remain immune. The transformations
\nwrought in the financial sector, manufacturing and retail have changed the focus of whole
\nsectors towards the consumer experience. The private sector is innovating and competing by
\nintroducing customised platforms which interact with the consumer and adapt in response.
\nCustomised goods and personalised services are the keys to success in a hyper-connected
\nworld of communication, choice and competition, and health care must begin to exhibit
\nsimilar sensitivity to customer preferences and experiences.
\nThe traditional dynamic of expert clinicians lecturing and administering to passive patients is
\nchanging as people independently seek information on their own terms. The internet has
\ndemocratised expertise, which is no longer seen to vest in a single authoritative source,
\ntransforming the asymmetry of knowledge which the health sector has traditionally embodied.
\nThe health sphere, along with every other sector, must find new ways to respond to consumer
\ndemands for personalised experience and expanded choice amid shattered information
\nasymmetries.
\nThis shift in production is empowered by the gathering and analysis of Big Data by companies
\nto mine the behaviour and characteristics of their customers and personalise advertising,
\nproducts and services in response. Just as retailers and supermarket exploit the data they
\ncollect on customer spending patterns to target products more efficiently, Big Data will help
\nhealth providers identify their riskiest patients and cohorts, triangulate social, educational and
\nemployment data and integrate case notes from clinicians, pathology and imaging results.
\nThe future of Big Data in the health sector lies not in static data linkage, but the use of real-
\ntime feedback to inform decision making and health management.
\nPatient choice and independence should be a key outcome in optimising their
\nexperience.
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\nThe customisation of care will spawn a new industry of data-based technology in pursuit of
\n\u2018the quantified self\u2019
\n31
\n. A patient\u2019s interactions with the health system will increasingly involve a
\nwide range of mobile and wearable devices, innovative apps and social networking.
\nSmartphone-linked and cloud-enabled devices and apps, glucose sensors, blood pressure
\nreaders, implantable devices, smart drug infusion pumps, pill-based cameras and portable
\nultrasound will inform health consumers and help clinicians monitor their status and treat
\nthem in real time. The implications for the health workforce and the settings of care of such
\nadvances may be profound.
\nThe \u2018quantified self\u2019 is not a pipe dream. It will shape the near future and is grounded in the
\ntechnology of today. Health consumers will increasingly expect the health system to stay in
\nstep with the state-of-the-art technology they use as a matter of course elsewhere in life.
\nPatients will expect communication to occur in everyday language and treatment to deliver the
\noutcomes they care most about. Patient persuasion, as well as mere engagement, will
\nbecome ever more important in a consumer-centric world. As the system incorporates this
\nnew methodology, the state of practice within it will start to radically change.
\nAn expanded community of mutual learning and peer relations is developing through the ever
\ncloser interconnections between geographies, communities and individuals driven by
\nglobalisation. Health system leaders are forging and benefiting from networks of peers around
\nthe world, sharing benchmarks for best practice and new ideas for progress. These horizontal
\npeer connections help planners and providers understand their own performance and
\npotential. Just as globalisation has changed the rest of our social and economic landscape, it
\nis changing the sociology of health in radical ways and offers continuous opportunities for
\ninnovation, improvement and new modes of understanding. Practitioners in all domains must
\ncapitalise on these developments, and the H20 Summit itself is testament to this trend.
\nHealth care will be reconceptualised as the supply-driven systems of today – focused on
\nprocedures, hospitalisations and clinicians – evolve into platforms organised around the
\npatient experience. These will prioritise outcomes rather than activities, drive down costs and
\nimprove quality and safety. Learning and partnerships across the globe will help transform
\ntraditional domains to meet the challenges of the future.
\nThe future of Big Data in the health sector lies not in static data linkage, but the use of
\nreal-time feedback to inform decision making and health management.
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\nIn the face of uncertainty, constraint and change, physicians must ponder their purpose more
\nthan ever before. Such analysis must be grounded in the human experience to deliver what
\npeople need and demand. Today\u2019s understanding of processes, systems, analysis and
\nspreadsheets must become springboards for progress tomorrow. Seemingly intractable
\nproblems cannot be solved by mere tinkering with the existing system, and every stakeholder
\nhas a part to play in its transformation.
\nACKNOWLEDGEMENT
\nDr Kloiber agreed that physicians must face the challenge of a health system changed by
\ninformation technology. The WMA considered IT issues in its first policy document, released
\n41 years ago, on the networking of computers containing patient information, and is still
\nexploring its fast-developing opportunities.
\nDr Kloiber stressed the need to maintain the integrity and rigour of medical standards and
\nopposed the trend for governments and standards bodies to adopt self-regulation or
\nstandards produced by self-selected groups, in which the companies which pays the most
\ngets the rules they desire. He called for a \u2018professional and open process\u2019 which serves the
\nneeds of patients and a nation\u2019s population, rather than the commercial interest of competitors
\nin the market place.
\nIn introducing the next speaker, Dr Kloiber noted the growing number of attacks on facilities
\nand health professionals around the world. Efforts to encourage the WHO to assess or draw
\nattention to the issue have made little progress, as some of the governments which control it
\nare part of the problem, rather than the solution. The WMA and Red Cross are promoting the
\nimportance of medical neutrality and respecting those who help the sick and wounded, a role
\nthe Red Cross has played since 1863.
\nKEYNOTE
\nGlobal Health and Health Care: The View of the International Committee of the Red Cross
\nDr Robin Coupland, Chief Surgeon and Medical Adviser to the International Committee of the
\nRed Cross, explained the ICRC\u2019s mandate to provide assistance and protection to victims of
\narmed conflict around the world. It works in 79 countries, many of which have catastrophic
\nhealth systems, and understands the profound link between ill health and armed conflict.
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\nThe ICRC offers first aid and surgical care in conflict areas, visits places of detention to
\nmonitor conditions and care for detainees and offers physical rehabilitation services.
\n8.2 million people were treated by the Red Cross in 2013, 750,000 detainees were visited
\nand 6.7 million people received food.
\nDr Coupland treated up to 5,000 wounded people in seven years of field surgery and related
\nhis experiences in Africa, Asia and the borders of Afghanistan. He highlighted recent outbreaks
\nof violence in the Central African Republic, South Sudan, Gaza, Ukraine and elsewhere as a
\nworrying resurgence of armed conflict and the health issues it creates. Developing problems
\nof ageing populations and rising patient expectations are also complicating the work of the
\nRed Cross, with more informed patients expecting higher standards of service. The difficult
\ntask of adapting traditional provisions to new demands can create serious security risks to the
\nagency, but it can no longer adapt its standards to their context as once it did and provide care
\nwhich is merely \u2018ok for Africa\u2019.
\nThe ICRC\u2019s Health Care in Danger project32
\nhas explored new perspectives on medical ethics
\nin areas of armed conflict. Ethical debate once centred on detainees and methods of
\ninterrogation, but a broader spectrum of issues must now take centre stage. Health
\nprofessionals and their families naturally flee insecure and conflict-ridden areas, reducing
\nservice capacity just as the need for care increases.
\nThe Red Cross is determined to \u2018do more and better\u2019 in the face of these growing challenges.
\nIt has set itself five objectives, the first of which is to build on its three core competences and
\ngenerate standards for them. It must also widen its scope to embrace NCDs, the ever more
\nreported incidence of sexual violence and assure a continuum of care. Instead of merely
\nassisting a local hospital with surgical material and staff to treat a surge of war wounded, it
\nmust also support its routine surgery, pre-acute and primary care. It will focus more
\nresources on vaccination, reproductive health, mental health and psycho-social support for
\nthe families of missing people, unaccompanied children and the victims of mistreatment and
\nsexual assault.
\nIntegrated health assistance is a priority – it is hard to support surgery in a community
\nwithout clean water or give paediatric care to children who do not have enough to eat. The
\nICRC must also assure quality and accountability to its patients, host governments and donors
\nto retain their support. The ICRC should also consider the social determinants of health, a
\nprovision added to its five strategies at the behest of Dr Coupland himself, given that \u2018health is
\na state of complete physical, mental and social wellbeing and not merely the absence of
\ndisease\u2019
\n33
\n.
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\nThe ICRC needs more and better staff, but suffers a recruitment problem. It needs more
\ngeneral surgeons at a time when almost all students are trained in specialities, meaning senior
\nsurgeons must remain in the field to receive new surgeons and train them. The ICRC must
\nbuild and maintain a reservoir of institutional expertise and work on applying its standards to
\ndifferent contexts where it can.
\nThe Red Cross also lacks a consistent decision making process to balance health and political
\nconsiderations in deciding the allocation of scare resources and, just as importantly, when
\nthose resources are withdrawn. Such decisions are still made on an ad-hoc basis. The ICRC
\nmust also strengthen partnerships with Ministries of Health, other NGOs and its national
\nsocieties.
\nThe ICRC has ambitious plans, but Dr Coupland was pessimistic about its ability to achieve
\nthem, given the spiralling violence, intimidation and looting it faces in the field. The Health
\nCare in Danger project is examining ways to protect staff and facilities as without adequate
\nsecurity nothing else can be achieved. An ICRC study analysing 655 violent incidents around
\nthe world recorded attacks on hospitals and ambulances and the commonplace assault and
\nintimidation of staff around the world. Incidents at check points are also common, and can
\nreduce access to urgently needed care in ways which are seldom reported by the media. The
\nentry of armed forces or police into hospitals in search of terrorists or criminals can bring
\nhealth provision to a halt for the duration. If whole towns are insecure, medical staff cannot
\ntravel to work, meaning hospitals \u2018grind to a halt\u2019 in their absence. Dr Coupland recalled a
\nterrorist attack on a graduation ceremony for medical students in Mogadishu
\n34
\nwhich not only
\nkilled doctors and students, but denied care to the thousands of people they would have
\ntreated in their careers. The Red Cross therefore views the threads to health professionals
\nand their work in war zones and unstable areas as the major global health issue.
\nSome countries have developed national laws to safeguard health care workers, and the Red
\nCross has offered guidelines to protect ambulances and hospitals and regulate searches,
\ncheckpoints and targeting in urban areas. A series of workshops have also been held with
\nnon-state armed groups about respecting the security of humanitarian operations. The ICRC
\nsupports investment in global health, but this must be allied to investment in its protection.
\nThe solution to this issue lies in the hands of governments, militaries and armed groups as
\nwell as the health community.
\nIn regard to Ebola, Dr Coupland hoped it would not take hold in a country undergoing conflict
\nas this would greatly exacerbate its local impact and global threat.
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\nOVERVIEW
\nThe Global Challenge of Non-Communicable Disease
\nDr Tony Bartone introduced Emeritus Prof Stephen Leeder, Chair of the Western Sydney
\nLocal Health District Board and Editor-in-Chief of the Medical Journal Australia (MJA), to
\ndiscuss the global challenge of non-communicable disease. Prof Leeder praised the holding of
\nthe H20 Summit to coincide with the G20 meeting.
\nNCDs kill 40-50 million people in the world every year, dwarfing the 2 million who die from
\nAIDS. NCDs affect younger people as well as the old, and heart disease and stroke remain
\nsignificant health issues alongside other growing global threats to health. 780 million people
\nlack access to clean water, for example, and a shift to meat rather than traditional vegetable-
\nbased diets in the developing world may exacerbate water shortages. A kilogram of rice
\nrequires 3,500 litres of water, but 1 kg of beef uses 15,000, as well as contributing to methane
\nemissions and deforestation. Rising sea levels will also threaten coastal cities and reduce the
\navailability of potable water.
\nSeveral \u201820\u2019 conferences were held alongside the G20 meeting, including events on civil
\nsociety, labour, youth and business, but all these issues are relevant to reducing NCDs. Social
\nand community factors influence their incidence, but social determinants are not responsible
\nalone. The ways in which health care is delivered can also make a profound difference to their
\nprevalence.
\nIn 2001, WHO Commission on Macroeconomics and Health
\n35
\nexamined the interplay of health
\nand economics in relation to HIV, perinatal conditions, malaria and TB, but largely ignored
\nNCDs. A subsequent report \u2013 A Race against Time \u2013 raised awareness of the NCD pandemic,
\nand its second edition was released in 2014. Awareness of the importance of NCDs and their
\ncomplex interplay with social factors has grown over the last fifteen years. In 2011, a UN
\nmeeting
\n36
\nsaw 123 nations pledge action to reduce their risk and improve their treatment
\naround the world. Former Australian health minister Nicola Roxon spoke at that meeting about
\nAustralia\u2019s proposals for the plain packaging of cigarettes.
\nCardiovascular disease costs Russia, China, Brazil, India and South Africa 20 million years of
\nproductive life each year. NCDs account for half the disability in developing economies and
\n20% of total health care costs. The economic case for action must be made to secure the
\nsupport of treasuries as well as health departments for investment in change.
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\nWhile Australia has reduced its mortality from heart disease by over 70% and eliminated it as
\na major cause of death in under-65s, a third of coronary deaths in the developing world are
\npeople under 65. The developing world stands where the developed world did in the 1960s,
\nand heart disease still robs low-income nations of productive workers and disrupts their
\nfamilies. Coronary disease is also a major, if underappreciated, factor in women\u2019s health and
\nkills five times as many women of child bearing age as perinatal problems and HIV.
\nCardiovascular disease generates 30% of the world\u2019s disease burden, while mental illness
\naccounts for 7%. The Lancet NCD Action Group has produced a series of reports on the
\nissue
\n37
\nand identifies five areas for intervention – smoking, salt, alcohol and the use of proven
\ndrugs – to cut it by a quarter by 2025.
\nExpanding these aims, the medical profession should lobby for the prevention and better
\ntreatment of chronic disease in Australia and around the world. Integrated care is often
\nadvocated, although it is poorly understood, and should place the patient at the centre of a
\nhealth care team. Clinicians should support state, national and international prevention
\nprogrammes because, while Australia has a strong track record in this regard, it needs to do
\nmore. Professionals should look for preventative opportunities in the clinical setting, and Prof
\nLeeder expressed alarm at the previous day\u2019s apparent separation of clinical care and
\nprevention. Many cases of type 2 diabetes and heart problems could be prevented through
\nattention by GPs and other health staff. Type 1 diabetes remains a global issue, as 500,000
\nchildren are born with it every year, but 100,000 will never receive insulin.
\nIn the words of St Francis, Prof Leeder reminded attendees that if they first do what is
\nnecessary, then do what is possible, they will soon find themselves doing the impossible. He
\nurged clinicians who emphasise prevention in patient interactions to move on to committee
\nwork and call for change on a national and international level.
\nInternational Action Addressing Mental Health: The \u201cFundaMental SDG\u201d Initiative
\n38
\nProf Dinesh Bhugra, President of the World Psychiatric Association (WPA) and Professor of
\nPsychiatry at Kings College in London, discussed the importance of international action on
\nmental health as \u2018there is no health without mental health\u2019 and mental health is \u2018everyone\u2019s
\nbusiness\u2019.
\nMental health is associated with higher educational attainment
\n39
\n, better productivity
\n40
\n,
\nimproved physical health and cognition
\n41
\n, reduced mortality42
\n, greater social interaction43
\n,
\nless criminal behaviour, lower rates of smoking
\n44
\nand increased resilience to adversity.
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\nHowever, mental health is seldom mentioned as part of general health, a state Prof Bhurga
\nblamed in part on Rene Descartes\u2019 notion of dualism between mind and body. In reality,
\nmental and physical health are inextricably intertwined. Mentally ill people suffer higher
\nlevels of physical illness, while the physically ill tend to have lower levels of mental health.
\nDepression is double the average in diabetics, for example, and three times more in those with
\nrenal failure. The mental health aspect of the Ebola crisis has also been ignored, despite many
\nchildren losing their parents and widespread fear of the disease.
\nFigures from the WHO suggest that mental illness accounts for nearly a quarter the UK\u2019s total
\nburden of disease, compared to 15.9% for cancer and 16.2% for cardio-vascular disease
\n45
\n,
\nand yet funding for mental health services is far from proportional. One in four people will
\nexperience mental illness during their lives, and one in six adults suffer some form of mental
\nillness at any one time \u2013 with half of these episodes lasting more than a year. It is likely that
\nevery family in the land will know at least one person suffering mental illness.
\nIt affects individuals, families, communities and nations and drives risk-taking behaviour,
\nhealth inequalities and reduced life expectancy. Its trans-generational effects can lead to
\neducational failure in children and subsequent ill-health. Mental illness exacerbates social
\ninequalities as well as being, to some extent, a product of them.
\nMental illness costs the UK \u00a3110 billion \u2013 7.8% of GDP \u2013 including \u00a332 billion of lost
\nproductivity
\n46
\n. Many people lost their jobs and grew depressed after the GFC when they found
\nthemselves unable to find work again. It is the largest cause of disability and cost to the
\nNational Health System (NHS), absorbing 10.8% of its budget. Total service costs \u2013 including
\nNHS, social and informal care \u2013 were \u00a322.5 billion in England in 2007. The annual costs of
\ndepression in Britain are \u00a37.8 billion, while anxiety costs \u00a38.9 billion
\n47
\n, schizophrenia \u00a36.7
\nbillion
\n48
\n, medically unexplained symptoms \u00a318 billion49
\nand dementia \u00a317 billion50
\n. The total
\naverage costs per suicide are \u00a31.3 million in Scotland
\n51
\nand \u00a31.5 million in Northern Ireland52
\n.
\nAnnual costs of mental illness during childhood and adolescence vary between 13,000 and
\n65,000 Euros per child
\n53
\nin the UK. Childhood mental illness can affect the sufferers\u2019 future,
\nand the cost of crimes committed by those with early conduct problems is \u00a360 billion per year
\nin England and Wales
\n54
\n.
\nMental health issues are often ignored by politicians, but in June 2013, 22 members of the
\nBritish Parliament stood up in the House of Commons to discuss their personal experiences.
\nThese ranged from obsessive-compulsive disorder and alcohol problems to depression and
\npost-natal depression and dementia suffered by their parents.
\nOne in four people will experience mental illness during their lives, and one in six adults
\nsuffer some form of mental illness at any one time.
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\n50% of psychiatric disorders in adulthood start before the age of 15 and 75% before the age
\nof 24. Better prevention would reduce the economic, individual and social toll of poor mental
\nhealth. It would enable more cost-effective use of resources, improve social functioning and
\nboost social capital.
\nRisk factors for mental issues in childhood include parental behaviour such as child abuse,
\npre-natal alcohol consumption, smoking, cannabis, stress and violence as well as poor
\nphysical and mental health, single parent status and low incomes. Prof Bhurga noted that car
\ndrivers must undergo rigorous training, tests and certification \u2013 none of which are required to
\nhave a child. A family culture of unemployment, alcohol abuse and relationship problems can
\nresult in mental health problems tumbling down the generations. A range of groups facing
\nsocial inequalities, including people with learning disabilities, ethnic minorities, LGBT people
\nand prisoners, are also more exposed to high-risk factors. As noted elsewhere, such factors
\naffect physical wellbeing too. On average, people in the poorest neighbourhoods die seven
\nyears earlier than those in richer suburbs and have 17 fewer disability-free years of life. High-
\nincome inequality degrades trust and social capital and is associated with higher mortality,
\nviolence and racism.
\nThe WPA\u2019s agenda over the next three years will look at gender-based domestic violence, child
\nsexual, emotional and physical abuse, prisoner mental health care, the position of vulnerable
\nminority groups and mental health promotion. 63% of inmates in American gaols, for
\nexample, have a psychiatric disorder. Prof Bhurga termed these institutions \u2018asylums without
\ntreatment\u2019 and highlighted the impact on their children, families and society.
\nEvidence suggests that early interventions can save six times their cost and reduce criminal
\nbehaviour. Interventions can include early parenting skills, school-based prevention
\nprogrammes, treatment of childhood anxiety and phobias and help for psychosis and other
\nissues. Children who are taught how to manage bullying suffer fewer mental problems, and
\nprogrammes from Jamaica to Pakistan have helped children deal with issues in their
\ncommunities ranging from gun violence to untreated epilepsy.
\nA range of policies to build social strength and resilience are vital. Suicides can be reduced by
\nsafety protection on bridges, alcohol consumption can be cut by duty increases and
\neducation, work-based stress can be tackled through reduction and management courses, and
\nhealth promotion, such as Australia\u2019s plain packaging regulations, can cut smoking and
\nsupport health. Smoking cessation schemes should be introduced into medical and
\npsychiatric wards, where alcohol and substance misuse and sexual health issues should also
\n50% of psychiatric disorders in adulthood start before the age of 15 and 75%
\nbefore the age of 24.
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\nbe addressed . Many patients are obese, due in part to side effects of large amounts of
\nmedication, and should be helped to manage their diet and exercise more.
\nEmployment programmes, adult learning provision, debt interventions, housing
\nimprovements, better heating and insulation and green spaces in urban areas can also reduce
\nstress and social pressures. Social policy should build cohesive communities, increase social
\ncapital and encourage positive connections between citizens.
\nHealth professionals can help patients embrace meaning and purpose in life and learn new
\nskills to cope with stressful situations. Intangible factors such as mindfulness, spirituality,
\nlearning, leisure, creativity and sleep can be as important as medication in learning to live with
\nsymptoms without an immediate cure. As exemplified by the MPs mentioned above, patients
\ncan still hold down significant jobs.
\nThe profession must think of new ways to convey its message to the public and politicians.
\nProfessionals should go into schools and work with parents, teachers and educational
\npsychologists to educate young people and help individuals in need. Sustainable development
\ngoals should prioritise mental health and acknowledge and address the co-morbidity of
\nphysical and mental issues. The UN has been asked to adopt a number of mental health goals,
\nand Prof Bhurga urged nations to increase investment in mental health to at least 5% of
\ntheir total health budget by 2020 and 10% by 2030.
\nThe Value of Investing in Successful Ageing: Success in Health and Health Care
\nAssoc. Prof Mark Yates, a geriatrician and academic at the Deakin and Melbourne University
\nClinical School in Ballarat, discussed the need to invest in \u2018successful ageing\u2019, given that a
\nquarter of Australians will soon be over 65, with many over 85.
\nPeople\u2019s decisions and life styles in middle age can influence how well they age, just as the
\nearly years influence a person\u2019s life chances. Doctors may be divided on whether dementia is a
\nmental illness, but its burden is undeniably growing. However, assumptions that older people
\nnecessarily absorb more health resources can be mistaken. Issues of morbidity compression
\nand extension should be considered, but if better lifestyles and medicines help people avoid
\ndisability for longer, they will absorb less health expenditure (although if this involves ever
\nmore expensive treatments and technologies, that reduction in disability will have a higher
\nprice tag).Prof Yates called for a focus on the degree of disability that people live with and the
\nproductivity they can maintain, rather than the cost of achieving it. An ageing society would
\nmean a less productive one if employees continued to retire at 65, but if \u201950 is the new 30\u2019,
\npeople will be able to work into their 70s and investment in successful ageing will help
\nmaintain productivity.
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\nIt is often assumed that the rising number of older people will increase hospital costs;
\nhowever, older people do not always spend a lot of time in hospital – although those that do
\nare expensive. Indeed, the Productivity Commission suggests that the ongoing health costs of
\nthe elderly actually decrease, and people who die at 85 cost less in their last three years of life
\nthan those who die at 55. Accumulated data from the USA shows a person\u2019s Medicare and
\npharmaceutical costs do not incrementally increase after the age of 65 as might be expected.
\nIf people can age more successfully, their last few years of life should cost the health system
\nless than currently expected.
\nIt is the growing need for long-term residential care, rather than medical expenses, which cost
\nthe public purse. Successful ageing which reduces disability and the need for residential care
\nwould save money and reduce the need for extra residential care staff. However, if high
\nresidential costs and a shortage of care workers mean more people with dementia are cared
\nfor by relatives at home, the effect on the working population will be significant. 13% of
\ncurrent carers permanently reduce their paid work, 20% take leave of absence and 8%
\nhave left work entirely. The plight of dementia sufferers and those who care for them must
\nalways be considered together.
\nProf Yates saw the health system\u2019s treatment of dementia as a test of its overall effectiveness.
\nDementia sufferers are rapidly increasing in numbers, and it is the second largest cause of
\ndisability after depression for over-65s in Australia. It runs a predictable course, has major
\nimpacts beyond the patient themselves and is unlikely to find a cure in the foreseeable future.
\nHowever, there are opportunities for prevention, and work by Alzheimer\u2019s Australia shows that
\nreducing age-specific incidence rates by 5% or 10% would have a significant impact.
\nThe onset of Alzheimer\u2019s disease is affected by environmental and behavioural factors.
\nResearch suggests that 2% is caused by diabetes, 2% by midlife obesity, 5% by midlife
\nhypertension, 10% by depression, 13% by physical inactivity, 14% by smoking and 19% by
\ncognitive inactivity and poor education
\n55
\n. An improvement in health, education and other social
\ndeterminants could therefore reduce its incidence in the future. Exercise can improve the
\nphysical and cognitive performance of older people suffering symptoms, while dementia is
\ndeclining in people with cardiovascular problems, even allowing for differences in diagnoses in
\nthe past, from better management of hypertension and diabetes and more exercise in middle
\nage. However, the growth of midlife obesity, which is closely linked to hypertension, diabetes
\nand other risk factors for dementia, may wipe away the gains made in the recent past.
\nThe health system\u2019s treatment of dementia is a test of its overall effectiveness. The plight of
\ndementia sufferers and those who care for them must always be considered together.
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\nDementia cannot be cured, but its handicaps can be minimised. Ballarat\u2019s Dementia Care in
\nHospitals programme56
\nsought to change perceptions of the disease and its paradigm of care.
\nIt is assumed that people can understand and perform the role of passive, obedient patients when
\nthey enter hospital, but up to 30% of adult admissions may exhibit cognitive impairment, requiring
\nstaff to change their communication strategies and the hospital environment. Communities
\nthemselves can become more \u2018dementia friendly\u2019, a subject already studied in Britain
\n57
\n.
\nSuccessful ageing also demands understanding and successful management of \u2018medical
\nfutility\u2019. Despite improvements in care and technology, people must accept when and why
\nfurther medication becomes counterproductive. This is a debate which must involve all
\nstakeholders and take a wide scope of patient capability into account. Successful ageing
\nrequires research into dementia and related issues to intensify. Despite recent boosts from
\nGovernment, research resources dedicated to cancer and cardiovascular disorders is six to
\neight times greater than those devoted to dementia.
\nVIGNETTE
\nConsumers Advocating for their NCD Care
\nMr Frank Quinlan, Chief Executive Officer of the Australian Mental Health Council, discussed
\nconsumer advocacy for mental health and NCD care. Mental health has been the subject of a
\ngovernment review in 29 of the last 30 years, the latest of which reported to the Australian
\nGovernment in November 2014
\n58
\n. Such reviews tend to emphasise efficiencies, savings,
\nproductivity and rationalisation of services, but the concerns of clients and carers focus on
\nsymptoms, diagnoses, treatment and compliance. Studies show that clients and carers want
\nsecure housing, financial security, stronger relationships and opportunities to participate, and
\nthough resources should be used efficiently, policy should concentrate on the needs of their users.
\nMr Qiunlan offered a number of indicators and targets built around six core principles, as
\nadvocated by an expert policy group for the Council. People with mental health issues suffer
\nbelow-average physical health, and Mr Quinlan called for measures to encourage physical and
\nmental wellbeing across the whole community. People with mental illness need respect and the
\nopportunity to contribute in employment and society. Patients want a positive experience of
\ncare, and it is regrettable health service customers are not routinely surveyed about their
\nexperience. Steps should be taken to reduce avoidable harm and suicide, the use of seclusion
\nand restraint should be re-examined and action taken to reduce social stigma and discrimination.
\nMental Health Australia found that people with mental issues were almost as likely to face
\ndiscrimination by a staff member providing care as they were from the general public.
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\nThe public accepts the importance of mental health, and recent national and international
\ncampaigns have raised awareness. Mental Health Australia\u2019s Seven Point Plan for Mental
\nHealth59
\ncalls for agreement on the care systems, while funding responsibilities should be
\nclarified as mental health frequently falls in the gaps between state and federal provision.
\nThere should be more participation from consumers and carers in the governance, design and
\nevaluation of the system as all too often people are given services they do not want, while
\nothers fail to receive the services they need. Incentives must be properly aligned, as many
\nactivities are undertaken, but little funding is attached to the successful achievement of
\noutcomes. Early interventions should also be emphasised to minimise problems in later life.
\nProviders with an entrenched interest in the existing system must consider what they are
\nwilling to sacrifice to move forward.
\nVIGNETTE
\nTobacco Control: Divesting from Tobacco
\nDr Bronwyn King, a Radiation Oncologist at the Peter MacCallum Cancer Centre in Melbourne,
\ndiscussed her campaign to end tobacco share holdings by investment funds. She began the
\nTobacco-Free Investment Initiative in 2010 after discovering her unwitting investment in the
\ntobacco industry through her superannuation scheme, despite working at the largest cancer
\ncentre in the Southern Hemisphere since 2001.
\nTobacco has a devastating impact on individuals, their families and the community, but the
\nsavings of other health professionals and the Australian community as a whole are commonly
\ninvested in tobacco by super funds, despite Australia\u2019s leading role in public measures to
\nreduce its consumption. Most super funds buy into foreign indexes of major companies, and
\nunless their customers opt for a \u2018green\u2019 or \u2018ethical\u2019 option, these will usually include major
\ntobacco producers. In discussions with her super fund, Dr King found that BAT, the Imperial
\nTobacco Group, Philip Morris and the Swedish Match Company were four of her five largest
\nholdings. Tobacco accounts for a very small percentage of a super fund\u2019s total assets \u2013
\nbetween 0.1% and 1.28% – however, just 0.5% of the $1.7 trillion sector would mean $8.5
\nbillion is invested in tobacco, with most Australians remaining unaware of how their money is
\nbeing used.
\nDr King\u2019s discussions with her super fund, First State Super, made progress after a difficult
\nstart and she was invited to present her case to its board. A year later, after a merger with a
\nlarger Sydney-based fund, it banned tobacco from its portfolio and sold $200 million of
\ntobacco shares. Publicity around its decision and the support of its CEO provoked discussion
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\nin the industry, and 21 super funds to date have followed suit, shedding $1.3 billion in tobacco
\nshares. Funds have cited a variety of reasons for their actions, from ethical and health
\nconcerns to the impossibility of engaging with the tobacco industry itself, given the nature of
\ntheir business. Health-related funds were confident they would have the support of their
\nmembers for this action, while government funds were able to align their holdings with state
\nand federal anti-smoking policies. Other super funds moved before the introduction of
\ndisclosure legislation which will oblige them to declare their holdings, while others drew links
\nto child labour or the behaviour of tobacco firms abroad which would be illegal in Australia.
\nDr King is working with 35 more funds and aims to make a robust case study of Australia to
\ntake the campaign abroad. She is writing a publication for the WHO and will speak at a UN
\nyouth conference in 2015. She thanked health organisations for their support and offered to
\nhelp attendees advance the campaign in the future.
\nThe Role of Health Insurers in Supporting Chronic Disease Management
\nDr Andrew Wilson, Head of Provider Relations and Integrated Care at Medibank, discussed
\nthe role health insurers can play in supporting the management of chronic diseases in
\npartnership with primary health professionals.
\nMedibank was formed 38 years ago as a government insurer, but is now a commercial
\ncompany about to be listed on the stock exchange. Health costs are rising, and although
\nMedibank is \u2018comfortable\u2019 with paying for good quality health care for its members, it
\nsupports preventive measures to reduce expensive hospital admissions and treatment,
\nparticularly for chronic disease. It also wants activities which cost money but have no
\ndefinable benefit identified and addressed.
\nMedibank aims to enhance patient experience, improve health outcomes and facilitate
\naffordable and quality care. As most of its costs relate to hospital fees it is discussing
\noutcome-based, rather than activity-based, funding with institutions and professionals. High
\nfees are no guarantee of best outcomes, with Sydney\u2019s most expensive major hospital having
\nthe highest rate of preventable problems and 28-day readmissions.
\nThe savings of other health professionals and the Australian community as a whole are
\ncommonly invested in tobacco by super funds, despite Australia\u2019s leading role in public
\nmeasures to reduce its consumption.
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\n2.2% of Medibank’s 3.8 million members account for 35% of its expenditure in hospitals \u2013 a
\nsum of $1.1 billion. However, 70% of these people have underlying chronic complaints.
\nBetter primary care is required to keep them well and out of hospital, and although Medibank
\nhas no interest in directly funding primary care services, it does seek opportunities to support
\nprimary care practitioners. The less access people have to primary care, the more likely they
\nare to go to hospital \u2013 a far more expensive option, given Australia\u2019s geography.
\nA qualitative survey of frequent health care consumers found they suffered problems
\ncaused by poorly handwritten prescriptions, the substitution of drugs and a general lack of
\ncoordination of services with GPs. People with complex and chronic health needs often
\nexperience psycho-social issues which can drive their hospital admissions as much as their
\nphysical complaints. Support to help such people keep medical appointments \u2013 or pay their
\nelectricity bills – is as critical as medication, and the survey highlighted the enormous burden
\nfaced by their carers and families.
\nIn its efforts to coordinate primary care, improve health outcomes and so reduce hospital
\nadmissions, Medibank recently launched CarePoint60
\nin partnership with the Victorian
\nDepartment of Health in a trial due to run to 2017. It offers a new patient-centric integrated
\nmodel of care for 2,200 people with chronic conditions and complex needs which is
\nimplemented across services and supported by collective funders. It acknowledges the critical
\nrole of the GP and involves care assessment, planning and navigation, home monitoring and
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\nelectronic plans and patient records. Up to a quarter of all hospital admissions are avoidable,
\nand reducing these would save up to $400 million dollars a year, some of which could be
\nreinvested into other services.
\nCareFirst61
\n, a pilot launched by Medibank with Queensland GPs, will improve patient behaviour
\nand health literacy for the 10-20% of patients below the top 2% through additional support,
\nincluding health coaching, telephone advice or a dosette box to organise medication.
\nA recent literature review identified five key traits of successful disease management
\nprogrammes around the world. These include GP-initiated enrolment of patients, delivery of
\ncare by practice nurses, the development of care plans within clinical guidelines, disease-
\nspecific education sessions and regular review of medications. All were integrated in the
\nCareFirst scheme.
\nAlthough the extent to which private insurers should involve themselves in primary care
\nremains controversial, Dr Wilson called for medical professionals to welcome partners willing
\nto invest to help some of society\u2019s sickest members. He accepted that GPs should remain the
\narbiters of care, but called for earlier intervention to prevent expensive \u2018train wrecks\u2019 in the
\nfuture. He hoped Medibank would identify 100,000 more people who would benefit from
\npreventative programmes in the next two years, including phone support to help them keep
\nappointments and \u2018navigate\u2019 their care.
\nRising to the Challenges with Action Now: How We Can ALL Act!
\nAfter a break, Dr Bartone welcomed Dr Alessandro Demaio, Global Health Fellow in NCDs and
\nAssistant Professor at the Harvard Medical School and Copenhagen School of Global Health,
\nto speak on action against NCDs.
\nThe WHO defines NCDs as lung disease, mental illness, diabetes and heart disease and
\ncancers. Dr Demaio stressed the importance of the drivers and risk factors behind these
\ndiseases, including social determinants, smoking, physical inactivity, alcohol and poor diet.
\nHe underlined the seriousness of the ‘NCD epidemic’ and debunked several common myths
\nabout them.
\nFive key traits of successful disease management programmes around the world include
\nGP-initiated enrolment of patients, delivery of care by practice nurses, the development
\nof care plans within clinical guidelines, disease-specific education sessions, and regular
\nreview of medications.
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\nNCDs are not \u2018diseases of tomorrow\u2019, but the leading cause of global death today,
\naccounting for 36 million of the 56 million deaths every year. NCDs are not limited to the
\nrichest people or nations, they cause and perpetuate poverty and are a major barrier to social
\nand economic development around the world. NCDs threaten to reverse many of the gains
\nmade towards the Millennium Development Goals over the last 15 years.
\nNCDs are not a natural part of ageing as 50% of NCDs affect people under 70, while type 2
\ndiabetes is increasingly seen in adolescents and children. NCDs comprise the largest threat to
\nfemale health and development around the world. Helen Clarke of the UN Development
\nProgramme draws a close link between poverty, female health, maternal child health and
\nNCDs. NCDs are responsible for 65% of female mortality and create a huge burden of care as
\nwomen are forced from education or the workforce to look after family members.
\nDr Demaio argued that if two thirds of all Australians are overweight or obese, factors beyond
\nindividual overindulgence must be at play. NCDs are not the result of individual laziness, as is
\noften supposed, but the \u2018canary in the coal mine of a broken system\u2019. UN Secretary General
\nBan Ki Moon has said the issue of NCDs is \u2018neither technical nor financial\u2026not a medical or
\npublic health problem, but a political one\u2019
\n62
\n. 80% of global diabetes and heart disease and a
\nthird of all cancers can be prevented with the technology of today.
\nRather than equate health only with health care, Dr Demaio criticised growing Australian
\nincome inequality as the richest ten families own more than the poorest 1.73 million citizens.
\nAffordable housing is a major issue in Sydney and Melbourne, and the speaker stressed the
\nneed for green spaces and educational opportunities in an increasingly privatised system.
\nPatients should not be scolded for becoming unwell in cities built for cars rather than
\npeople, and the challenge of NCDs should be used to propel a broader social agenda. In
\ncommon with climate change, NCDs are a man-made problem with man-made solutions if we
\nconfront the problem, rather than ignore it, deny its existence or hope it goes away.
\nDr Demaio called for a \u2018zero tobacco future\u2019, reductions in sugar consumption, the
\nencouragement of exercise and praised people who become weekday vegetarians. Alcohol
\nintake should be reduced and society\u2019s \u2018fundamentally strange relationship\u2019 with this addictive
\ndrug should be questioned, alongside wider considerations of the social, economic,
\ncommercial and structural \u2018causes behind the causes\u2019 of NCDs around the world.
\nIf two thirds of all Australians are overweight or obese, factors beyond individual
\noverindulgence must be at play.
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\nHe urged health professionals to lobby on these issues for the sake of the poor and
\nmarginalised communities which are most affected by them and have the least resilience to
\ncope. Social structures should be reformed, and the human toll of NCDs should be
\nremembered amid the avalanche of statistics.
\nMedical students should also be taught humility, as most health improvements over the last 150
\nyears were a product of economic growth, engineering innovations and public infrastructure
\nsuch as clean water and sanitation, rather than the efforts of the medical profession. Many
\nfuture improvements will also result in large part from changes in public policy, meaning
\nphysicians can do the most good for their patients by advocating for systemic change.
\nHealth professionals must encourage urban planners to make the healthy choice the most
\nconvenient choice for the community. 40% of Copenhagen\u2019s workforce cycles to work, and its
\n12% obesity rate is half that of Australia. Dissuading car use through better public transport,
\nmore bike lanes and other measures should be designed into urban infrastructure. Health
\nprofessionals should also work with parent groups. Dr Demaio favoured a ban on advertising
\nfor alcohol, soft drinks and junk food, particularly to children, and the sale of soft drinks in
\nplain packaging similar to cigarettes.
\nSchools should teach children to have a healthy relationship with food, as a poor diet is the
\nmain risk factor for morbidity. Taxation should price unhealthy food out of people\u2019s shopping
\nbaskets, and doctors should work with scientists and psychologists \u2013 and not the food
\nindustry \u2013 to create packaging, labelling and retail environments which encourage healthy
\npurchasing decisions. Consumers should not be confused by a bombardment of impenetrable
\ninformation and then carry the blame for poor choices. The same psychology and behavioural
\nscience used by the food industry to entice people in the wrong direction should be used to
\nmake things better.
\nDoctors should help focus the health system on prevention and primary care, and tackle the
\nperception that general practice remains the \u2018poor cousin\u2019 of the medical profession. Dr
\nDemaio urged attendees to raise the profile of NCDs through social media and encourage
\ntransformative change, as was seen in the fight against HIV, in everything from education and
\nurban planning to the production of food. A groundswell of public support for change is
\nrequired to overcome the resistance of entrenched commercial vested interests in the status
\nquo. Medical professionals should work with other sectors; however, the responsibility of
\nlarge businesses remains to their shareholders rather than the public good, and an \u2018arm\u2019s
\nlength\u2019 relationship with big business should therefore be maintained. Health professionals
\nmust also engage the public in an inclusive dialogue.
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\nNCDFREE
\n63
\n, a social movement Dr Demaio cofounded which aims for a world free from
\npreventable NCDs, has raised $90,000 to make a series of short publicity films, organise boot
\ncamps for young leaders and run an international campaign which reached a million people.
\nIt aims to engage people born after 1980 and link the issue with poverty with a sense of global
\nurgency.
\nMaking IT Work: The Place of IT in Coordinating Care
\nMs Ann Larkins, Chief Knowledge and Information Officer at Barwon Health, outlined the
\nsuccessful implementation of health IT in Victoria\u2019s largest regional health service over the last
\ndecade. Barwon Health serves 350,000 people over 21 sites with 400 acute, 100 rehabilitation
\nand 400 aged care beds. Its range of services, including community and mental health, spread
\nof population, demographic range and partnerships with other stakeholders make it an ideal
\ntest bed to show how coordinated, end-to-end care can work to improve service efficiency and
\npatient outcomes.
\nBarwon began to plan for \u2018e-health maturity\u2019 in 2002, and the development of a data
\ndictionary, data warehouse, e-health records and mobile care delivery continues today. It has
\nproduced point-to-point discharge summaries for GPs since 2011, alongside notifications for
\nattendances and discharges, mental health care summaries and crisis and shared care plans,
\nparticularly for mental health.
\nClinicians should be able to access a range of applications to suit their particular needs,
\nconnecting to other health providers to deliver coordinated care. Over the next five years,
\nBarwon will take advantage of consumer developments in IT which prioritise data, rather
\nthan applications, to pursue its aims of \u2018convergence\u2019, \u2018conformance\u2019 and \u2018collaboration\u2019.
\nConvergence of clinical systems and technology will support mobile workflows, while the
\nconformity of data and systems to widely accepted standards will enable interoperable and
\nsecure messaging. Collaboration with clinicians in the design of IT will produce more
\nappropriate systems and encourage physicians to use them.
\nThe health region requires an infrastructure of \u2018fit for purpose\u2019 applications to support an
\nincreasingly mobile and distributed workforce across acute and community care and, just as
\nimportantly, support the use of patients\u2019 phones and mobile devices. Shared electronic patient
\nrecords and reliable and affordable 3G and 4G coverage will empower all its partnerships and
\nservices. Barwon introduced thin\/zero client solutions in 2012 to support remote care through
\na \u2018bring your own devices\u2019 progamme, and a mobile device management solution is planned
\nfor early 2015. The health system can use the ubiquity of patient-owned devices to deliver
\nbetter outcomes for everyone without unnecessary investment in proprietary technology.
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\nHealth offers a huge market, but vendors remain reluctant to build or support the clinical
\ninformation systems which health providers need. Barwon\u2019s new platform will treat data as its
\ncore resource, and present a user interface which is almost disposable in nature.
\nThe conformity of data and messaging to broadly accepted standards has been achieved by
\nembedding national identifiers throughout Barwon\u2019s clinical information systems, with the
\nsouth west region the last to be added in 2015.
\nPCEHR were integrated in October 2014 and offer benefits to women and children with their
\ntake up by maternity patients encouraged through Medicare Locals. Their use should be
\nencouraged by emergency departments.
\nCollaboration must be encouraged throughout Victoria\u2019s system of devolved government to
\nprevent local innovations creating a plethora of isolated information silos. Barwon partners
\nwith Deakin University, Medicare Locals and mental health and integrated cancer services and
\nis talking to private health insurers to encourage interoperability. Partnerships with people
\nregarding life choices and care are a priority, with \u2018information prescriptions\u2019 being
\nconsidered to help patients navigate the minefield of information available. Information
\nprescriptions offer personalised health and medical information about a patient\u2019s diagnosis,
\ntreatment and care plan and cover the key points of discussions held with their doctor.
\nPrevention and health promotion are emphasised by Barwon, and telehealth capabilities and
\nnew models of care are being developed. Data analysis by Deakin University produced a list of
\nhospital patients likely to relapse, for example, and a trial investigated the value of telehealth
\nsupport and remote monitoring against a control group in reducing remittance. Knowledge
\nmanagement is needed to treat NCDs, with information captured dynamically, managed in real
\ntime and shared generously in teams providing integrated care.
\nKnowledge management is needed to treat NCDs, with information captured
\ndynamically, managed in real time and shared generously in teams providing
\nintegrated care.
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\nVIGNETTE
\nJoining up the Dots: Secure Communications NOW!
\nMr Jason Trethowan, CEO of Barwon Medicare Local, discussed secure communications. He
\ntraced the advantages which more integrated connections could offer various patients \u2013 from
\nthose with chronic conditions to parents of children with changed behaviour – as well as the
\nneeds of health professionals, including remote GPs requesting second opinions. Patients
\nexpect, and the medical profession wants, a well-connected health system delivering the best
\nquality of care as close as possible to people\u2019s homes.
\nBarwon adopted its connected system in 2007, after consultations with GPs flagged the need
\nto replace cumbersome faxes with electronic results. This collaboration encouraged a greater
\ntake-up by physicians than systems imposed by the government. Rather than use the
\nstandard systems of the time, Barwon took what it learned from its health practitioners and
\nlooked for the most appropriate solution. It adopted \u2018Referral Net\u2019 from Global Health and
\nhas continued to develop the system to meet its users\u2019 needs.
\nBarwon also worked with practice managers and senior receptionists, as they are the
\ngatekeepers to the primary health care system. Sustainable and effective systems to support
\npatient interests now connected doctors, allied health professionals, specialists and hospitals
\nthroughout the region at reasonable cost with strong professional support. Secure messaging
\ncarries 18,000 pieces of patient correspondence every month, 95% of which would have been
\nposted or faxed seven years ago. Barwon understands the importance of working with
\nclinicians to gain their support for PCEHR and deliver value from them.
\nBarwon is now introducing HealthPathways
\n64
\nto translate evidence-based practice to the local
\nlevel through GPs and primary care. It discourages unnecessary referrals, while helping GPs
\nlink patients needing further attention to the specialists they need. HealthPathways is not a
\nclinical protocol to force GPs into cost-saving decisions, but empowers their decision making
\nand builds better relationships with their specialist colleagues.
\nVIGNETTE
\nDr Yes: Additional Strategies to Support Care
\nDr Rosanna Capolingua, a GP and former President of the AMA, chairs Healthway
\n65
\n, a West
\nAustralian health promotion foundation which she termed more \u2018aggressive and dynamic\u2019 than
\nVicHealth, its Victorian counterpart. It was created to buy out tobacco sponsorship of the arts
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\nand sport and now replaces alcohol and junk food advertising as well, despite fierce industry
\nopposition and a lack of political support.
\nDr Capolingua emphasised the role which doctors can play in public health advocacy, and
\noutlined the WA\u2019s \u2018Doctor Yes\u2019 programme, founded in 1996. Young people can feel
\ninvulnerable to health problems and engage in risky behaviour as a result. The programme
\ntrains young doctors to talk to young people about sex, drugs and other issues in the
\nlanguage they understand. There are now over 800 \u2018youth friendly\u2019 doctors in Western
\nAustralia, and hundreds of thousands of high-school students have been involved since its
\ninception. The issues facing adolescents continuously evolve, and the content of the scheme
\nis revised as a result, with fresh cohorts of young, energetic and connected medical students
\nfrom the University of Western Australia who can relate to young people and the problems
\nissues facing them. Sexting, cyberbullying and artificial cannabis did not exist in 2001 while
\nthe rate of self-harm and suicide in young people have trebled in the last two years. The
\nprogramme empowers young people to make healthy choices regarding diet, exercise,
\nrelationships and lifestyles. Messages are tailored to fit their target communities. \u2018Doctor Yes\u2019
\nis centred in Perth, for example, but reaches Aboriginal children in the far north west, and the
\nsex education delivered to the girls in Kalgoorlie at 13 is very different to that given to private
\nschool girls in Perth of the same age.
\nInternational views of the NCDs
\nDr Masami Ishi, a Japanese neurosurgeon and Vice-Chairman of Council at the WMA, said
\nJapan\u2019s universal health coverage was established in 1961. It recently launched a new check
\nsystem for NCDs backed by telehealth and supported by the Japanese Medical Association.
\nThe JMA supports investment in health, but while private stakeholders are increasingly
\ninvesting in the area, their returns go to shareholders, rather than patients. Investment must
\nbe supervised by physicians and professional groups, and Dr Ishi hoped that new movement
\nto encourage ethical investment and improve policy making would emerge.
\nQUESTION & ANSWER
\nDr Haikerwal encouraged attendees to ponder the different perspectives offered in these talks
\nand the emphasis on success, rather than intractable problems outlined.
\nProf Owler agreed on the \u2018fascinating range\u2019 of subjects discussed and that success could be
\nachieved in complex issues, just as with complex patients, by picking pathways to success,
\ntackling specific problems and making direct differences to outcomes. He thanked the
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\nSummit\u2019s international and local visitors for attending, Dr Haikerwal for his scrupulous
\nattention to detail and Dr Bartone and others for their efforts.
\nDr Haikerwal then invited Dr Nathan Pinskier, chair of the Royal Australian College of GPs\u2019
\nCommittee on Technology and Health, to comment on IT in Australian health. Australia had
\nsignificantly increased its e-health capability in the last five years, however, much remains to
\nbe done. National infrastructure, including the healthcare identifier service and digital
\ncredentials to ensure secure messaging and electronic transfer of prescriptions, have been
\ndeveloped, but the design of PCEHR has split between the needs of patients and
\nphysicians. Patients see their record as a way to access their own health information, but they
\nare still to be generally embedded into day-to-day clinical practice around Australia.
\nFurthermore, with the exception of some parts of general practice, health professionals have
\nnot embraced electronic point-to-point messaging.
\nPCEHR were envisioned as the end point of a ten-year process of establishing a health
\ncommunications network; however, their implementation was brought forward seven years,
\nmeaning the networks they rely upon do not exist or are not well established. Dr Pinskier
\ncalled for these foundation services to be built, delivered and made interoperable, given that
\nthere are a dozen secure messaging products in use which do not communicate with each
\nother, despite the technical ability to do so.
\nHe asked for electronic prescriptions to be given legal status to encourage their use, and for
\nthe political, cultural and commercial culture in health to catch up with today\u2019s technology.
\nOpen Note APIs in the USA give clinical information to patients after a consultation, and there
\nare many other examples of success around the world.
\nMs Jan Donovan of the Consumer Health Forum of Australia praised the morning\u2019s emphasis
\non NCDs and emphasised consumer concerns about obesity. She criticised a lack of public
\nhealth campaigns or price signals for alcohol and junk food, given the success of action
\nagainst tobacco. She advocated action against NCDs through preventative public health
\ncampaigns and agreed on the benefits of PCEHR. She had seen the success of electronic
\nrecords in remote Aboriginal communities on a recent visit to the Northern Territory and
\nwondered why they were not used across the country.
\nLinda Worrall-Carter, Professor of Cardiovascular Nursing at ACU and St Vincent’s Hospital
\nin Melbourne, said one in three women suffer a cardiovascular event and emphasised the
\nimportance of cardiovascular disease for women\u2019s health, alongside issues such as breast
\ncancer.
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\nDAY TWO LUNCH SESSION – THE SOCIAL DETERMINANTS OF HEALTH
\nVIDEO ADDRESS
\nChaired by Dr Tony Bartone, the discussion began with a video address by Sir Michael
\nMarmot, a Professor at University College London and Chair of the WHO Commission on the
\nSocial Determinants of Health
\n66
\n.
\nThe Social Determinants of Health Agenda in the UK: SDH – Front and Centre in Health
\nProf Vivienne Nathanson, Senior Director of Professional Activities at the British Medical
\nAssociation (BMA), argued that social determinants should be \u2018front and centre\u2019 in
\ndiscussions of health policy. She discussed their impact in the UK and the role medical
\nprofessionals can play by using evidence to advocate for improvement.
\nHealth inequalities exist within and between countries, and people in more privileged nations
\nshould work to reduce disparities between them as well as within them. Life expectancy at
\nbirth for boys in the UK can vary as much as 18 years in the same city, be it London or
\nGlasgow, due to social conditions rather than any difference in access to the NHS.
\nProf Nathanson wanted physicians to promote health in its broadest sense, rather than merely
\npractise health care. Middle-class people understand health education and make use of
\nservices which poorer people do not, and she called for health professionals to venture into
\nthe \u2018discomfort zone\u2019 of looking at social determinants and involving themselves in issues of
\nhousing and employment as well as health. People who live in poor housing with little
\nprotection from damp and cold will become ill as a result, and doctors must campaign for
\nbetter housing for all, rather than content themselves with helping individual cases.
\nDoctors must use medical evidence to present a compelling case for change and coordination
\nin government policy outside the narrow health sphere. Attempts to reduce pension costs by
\nincreasing the retirement age will founder, for example, if most people are too disabled to
\nwork beyond 65. This would merely shift the burden on the public purse from the old age
\npension to disability allowances.
\nDoctors must use medical evidence to present a compelling case for change and
\ncoordination in government policy outside the narrow health sphere.
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\nPeople from lower socio-economic groups are more likely to be disabled at an earlier age and
\nare already the most dependent on state benefits, while doctors, lawyers and teachers are less
\nlikely to be disabled, more likely to have private pensions and accumulated wealth and less
\nlikely to be a burden on the state. The Treasury must talk to Health and other departments
\nabout these issues to consider them holistically. Discussions of alcohol in the UK focus on
\nviolence and policing rather than its health implications, for example, and higher duties should
\nbe contemplated to reduce its consumption.
\nThe BMA supports placing the social determinants of health at the heart of policy formation
\nto promote a holistic and effective approach. Everyone would agree that a child should have
\nthe best start in life, and so framing policy proposals in terms of their benefits for children
\nmakes it harder for decision makers to dismiss their importance. The BMA frames its social
\npolicy goals around health and wellbeing, rather than health care, and is careful to avoid the
\nimpression that doctors want to medicalise every aspect of life in pursuit of better health
\noutcomes.
\nPeople from poorer areas will be more likely to attend appointments, stop smoking, reduce
\nalcohol consumption and participate in health promotion programmes if they feel they have a
\nstake in the future. Prof Nathanson urged other medical associations to place social
\ndeterminants at the centre of their policy discussions and partner with other organisations and
\nsectors in pursuit of change. Medical bodies should meet with teaching unions, for example,
\nto discuss health promotion in education. Prof Nathanson praised the \u2018Doctor Yes\u2019 campaign
\nand its equivalents in the UK and elsewhere for helping young people resist social pressure
\ntowards damaging behaviours. She told of the Liverpool Fire Brigade\u2019s willingness to help
\nlocal young people by sharing its fitness facilities and running community sports events and
\nvegetable gardens. She urged health professionals to be equally imaginative and proactive in
\nthe community, as well as using evidence in partnerships to lobby for wider social and
\npolitical change.
\nDeveloping New Patient Centred Care Initiatives and the Health Literacy Agenda
\nMr Roy Batterham, Senior Research Fellow at Deakin University, discussed his work with
\nThailand\u2019s Ministry of Health in developing grassroots, patient-centred care initiatives and
\nboosting health literacy. Thailand\u2019s health outcomes rank between the USA and Australia,
\ndespite spending just 4% of GDP on health. It has a well-developed system of community
\nnurses and health volunteers, and Mr Batterham was both inspired and humbled by their
\nintimate knowledge of the communities they worked in and their commitment to their patients.
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\nThe country has tremendous strengths in its community-oriented culture, but has much to do
\nto deal with industries promoting alcohol, tobacco and sugar. Per capita sugar consumption,
\nfor example, has increased 15-fold since the mid-1970s. Thailand\u2019s road traffic accident rates
\nare four times that of Australia, and over 2,500 children drown every year in a country with
\nmany bodies of water, but little tradition of teaching children to swim.
\nSocial inequalities in health can be addressed by strengthening the capacity of local
\ncommunities, agencies and service personnel to respond creatively to local needs. Health
\nliteracy can help achieve these goals, and its measurement offers a tool to inform local
\nplanning and give local communities and health providers a voice. The structure of health
\nservices can militate against the achievement or even the pursuit of equity within it and
\nhamper creative debate with local communities. Health literacy, by contrast, offers a
\nframework for sharing local wisdom and good practice and stimulates discussions among
\nfamilies and peer groups in meaningful and constructive ways.
\nHealth campaigns tend to target groups within easy reach, rather than those in greatest need.
\nPhrases such as \u2018readiness for change\u2019 and \u2018capacity to benefit\u2019 are designed to pursue
\neffectiveness and value for money, but can be used to justify a failure to act in creative and
\nflexible ways to pursue health equity. A strict focus on standardisation and averages in
\nresearch without understanding local variance can also be counterproductive. An emphasis
\non top-down management, uniformity and vast sets of performance indicators often inhibits
\nthe capacity of local agencies and services to respond flexibly and appropriately to the varying
\nneeds of their constituencies.
\nHealth literacy affects people\u2019s ability to access and use health care, to interact with health
\nservice providers, to care for their own health and the health of their families and the ability to
\nparticipate in health debates and discuss issues with others. These notions of functional,
\ninteractive and critical health literacy are well understood, but it should be seen as a problem
\nsolving tool, rather than a relationship between abstract constructs. A flexible range of
\nstrategies is required to help people with different needs make healthy decisions.
\nThere are any number of studies on \u2018parts of the elephant\u2019, but simplistic measurements rarely
\noffer insight into effective steps to improve things. A number of multidimensional tools can
\noffer more guidance and acknowledge the tendency of patients with stigmatising conditions
\nHealth literacy affects people\u2019s ability to access and use health care, interact with health service
\nproviders, care for their own health and the health of their families, participate in health debates
\nand discuss issues with others.
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\nsuch as back pain, obesity and HIV to lose trust in health professionals and avoid contact with
\nthem for fear of being judged and lectured. As an alternative, Mr Batterham conducts focused
\nsurveys and cluster analysis of patient groups to produce descriptive health profiles with
\nadditional input from qualitative data and interviews. Such surveys can reveal why certain
\ngroups underuse health provision or map the many influences on individual and collective
\nhealth decisions. Stress can be a useful marker in many Asian countries for mental health
\nissues, for example, as people are reluctant to discuss them openly. Workshops are then held
\nwith local health providers to pool existing solutions and brainstorm new ones, with trials
\nlaunched to test their efficacy. This work can progress across multiple sites in multiple
\ncountries to develop an online knowledge base to guide practitioners and service planners
\nwanting to respond more flexibility to client needs.
\nVIGNETTE
\n\u201cSons of the west\u201d
\nDr Vanda Fortunato, Chief Executive Officer of Macedon Ranges and North Western
\nMelbourne Medicare Local, introduced a video on the \u2018Sons of the West\u2019
\n67
\n, a men\u2019s health
\nprogramme launched by the Bulldogs AFL club. The Bulldogs had tried to partner with other
\nhealth organisations for 18 months without securing support, but the success of a Dads and
\nLads football programme in Liverpool in tackling smoking, obesity and poor attendance at
\ncancer screening programmes encouraged the Medicare Local to support it.
\n1,075 men registered with the Sons of the West and 831 completed its online health
\nquestionnaire. 95% reported improved health knowledge as a result and 20% said their health
\nhad improved. 13% saw an improvement in blood pressure and 75% continued to participate
\nin some form of physical activity after the programme\u2019s end. It will be expanded into a new
\n18-week scheme at the start of the next AFL season.
\nDr Bartone commended the scheme, noting the Bulldogs also began a prostate cancer
\nawareness foundation.
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\nVIGNETTE
\nHolistic Approaches to Health and Welfare from Alzheimer\u2019s Australia
\nMs Carol Bennett, incoming CEO of Alzheimer\u2019s Australia, discussed holistic approaches to
\nAlzheimer\u2019s care. She offered a case study of an elderly woman in a nursing home suffering
\nfrom end-stage dementia, and challenged the system to improve the experience of people in
\nher situation. Over 330,000 Australians have been diagnosed and live with dementia, a number
\nwhich may climb to 900,000 by 2050. 44 million people suffer from dementia around the
\nworld, a figure which could swell to 135 million by 2050. 1.2 million Australians care for
\ndementia sufferers, and there are over 100 million carers worldwide. The rate of dementia
\ndiagnoses is increasing rapidly, with another case logged every six minutes in Australia.
\nBy 2050, there will be one new case diagnosed every 95 seconds – over 7,400 new cases per
\nweek. The economic implications are considerable, dementia\u2019s global cost reached $600
\nbillion in 2010 alone, a sum which would make it the world\u2019s 18
\nth
\nlargest economy, and this
\nsum is rapidly increasing.
\nMs Bennett asked for better aged care and improved prevention and primary care across the
\nsystem. People with dementia and their carers must be supported and given choices about the
\nhelp they wish to receive. Clients are often expected to fit in with whatever services are on
\noffer, rather than those services being tailored to client need. A more responsive health
\nsystem should focus on the patient\u2019s experience of care, as well as its delivery by clinicians,
\nand engage more closely with its communities.
\nDementia degrades the ability to connect with others as well as the function of the brain, and
\nmore \u2018dementia friendly\u2019 communities and better public understanding could help change
\nthe experience for millions of suffers. Everyone can contribute in their own small ways to
\nimprove the lives of people with dementia. Research should continue to explore treatment
\noptions, and Ms Bennett praised the Australian Government\u2019s assignment of more resources
\nto this end.
\nShe emphasised that most people will not suffer dementia as they age and it should not be
\nseen as an inevitable part of ageing. In common with other chronic diseases, there is evidence
\nthat lifestyle factors can increase or decrease its risk and severity. Around half of Alzheimer\u2019s
\ncases are potentially attributable to amendable factors such as diabetes, hypertension, obesity,
\nsmoking, depression, and cognitive and physical inactivity. Early intervention and engagement
\nacross a broad range of domains could help slow the decline which sufferers experience from
\nforgetfulness to confusion to incapacity, and reduce the financial burden of hospital
\nadmissions and residential care.
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\nPANEL DISCUSSION
\nSocial Determinants of Health: Words into Action
\nA panel discussion on the social determinants of health featured Prof Frank Jones, President
\nof the RACGP and a representative of the World Organization of Family Doctors (WONCA),
\nProf Michael Moore, CEO of the Public Health Association of Australia and President Elect of
\nthe World Federation of Public Health Associations, and Mr Andrew McAuliffe, Senior Director
\nof Policy and Networks at the Australian Healthcare and Hospitals Association.
\nMr McAuliffe said that despite Australia\u2019s reputation as a healthy country, some groups within
\nit are significantly more at risk and experience a greater burden of disease. He had seen a
\n\u2018glimmer of hope\u2019 two years ago when an Australian Senate inquiry considered a national
\nresponse to the WHO\u2019s report on social determinants
\n68
\n; however, despite support from both
\nsides of politics and sensible recommendations on the integration of health into wider policy
\ndiscussions, the report was not acted upon.
\nMr McAuliffe recalled similar frustrations from his experience as a bureaucrat in the
\nQueensland Health Department writing cabinet submissions to the budget committee. The
\neconomic and trade implications for the State were considered for each funding submission,
\nas were its effects on employment and the environment, but health was not a factor.
\nPoliticians contest for votes with promises of hospitals and beds, rather than consider the
\nholistic integration of health and other policies.
\nProf Jones believed GPs understand the importance of social determinants and public health
\nprovision, but, working on the front line, they must deal with the patients in front of them,
\n70% of whom suffer from chronic disease. GPs work in teams and understand the importance
\nof integrated care. They are experts in diagnosis, therapeutics and the continuity of care which
\nimproves health outcomes and reduces hospital admissions. GPs deal with increasing
\nnumbers of complex presentations, rather than people with a single complaint, but nearly all
\nAustralian research is based in hospitals, with less than 3% dedicated to primary health.
\nAustralia has 64 medical sub-specialities, but this is not a record it should be proud of. More
\nattention should be given to the health service as a whole and general practice.
\nGPs are conscious of the social and personal contexts behind their patients\u2019 presentations,
\nwith issues of alcohol, unemployment or difficult relationships underlying many visits to the
\ndoctor. GPs should sell their message more effectively to politicians, journalists should be
\neducated to write in more informed ways, and primary care should be expanded to reduce the
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\nproblems of chronic disease. Prof Jones read a brief statement from the President of the
\nWorld Organisation of General Practitioners which argued for global investment in primary
\ncare and family medicine, particularly in low- and middle-income nations.
\nProf Moore said despite the oft-cited Economist survey which regards Melbourne as the
\nworld\u2019s most liveable city, the OECD holds Canberra as the best place in the world for citizen
\nwellbeing. Melbourne is \u2018liveable\u2019 because it is prosperous, and politicians from comfortable
\nbackgrounds on both sides of politics fail to understand the social barriers faced by less
\nfortunate Australians. As chair of the Social Determinants of Health Alliance, he emphasised
\nthe social context of health and urged medical professionals to use their knowledge and the
\nrespect in which they are held to influence the government and advocate for change.
\nProfessor Yates said that people suffering from dementia can wait three years to be
\ndiagnosed and urged GPs to use specialists in complex cases. However, Australia lacks a large
\nenough network of specialists to provide proper support, and a clearer pathway of diagnosis
\nmust extend beyond primary care.
\nProf Jones said incentives in the health system encouraged a quick throughput of patients and
\n\u2018lazy medicine\u2019 by which GPs refer patients straight away. He agreed that referral pathways are
\n\u2018problematic\u2019 and called for more use of information technology to help GPs hold video
\nconsultations with specialists. Rural doctors are particularly isolated, and IT should empower
\ntheir practice and referrals.
\nDr Kieren Le Plastrier of HealthDirect said half the Commonwealth\u2019s $10-billion spend on
\nmental illness is paid out as Disability Support. He asked what could be done to convince
\npoliticians to address social determinants and invest in services outside the major hospitals.
\nProf Moore considered $10 billion to be an underestimate, taking into account the prisons
\nwhich incarcerate many people with mental health issues.
\nMr McAuliffe said responsibility was being devolved through the health system, but managers
\nare still pressured to produce \u2018year-to-year deliverables\u2019 rather than plan \u2018the big picture\u2019. A
\nGP criticised the government for planning to \u2018slash and burn\u2019 rebates for GPs, pathology and
\nradiology, while Prof Moore criticised its apparent antipathy to action on social determinants
\nand the proposed $7 co-payment for GP consultations. Mr McAuliffe said the Government\u2019s
\npolicies were founded on misinformation and dismissed its figures regarding GPs\u2019 utilisation.
\nHe criticised any reductions of primary care and called for the removal of ineffective drugs and
\ntreatments to save resources, rather than increasing out-of-pocket expenses for people least
\nable to pay. Prof Jones said the medical community should take responsibility for not getting
\nits message across to the politicians while Prof Moore called for a reappraisal of fiscal
\nreforms which reduce tax for mining, and big business, but may increase recessive taxes on
\nthe public such as GST.
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\nDAY TWO AFTERNOON SESSION – CLIMATE AND HEALTH
\nOVERVIEW
\nClimate Change and Health: Can We Safely Reach the Future?
\nAssoc. Prof Mark Yates, a board member of AMA Victoria, introduced Prof Lynne Madden,
\nAssoc. Dean of Learning and Teaching at the University of Notre Dame, who urged health
\nprofessionals and students to take action on climate change. She dedicated her address to
\nthe late Tony McMichael, Professor of Climate Change and Health at the University of
\nCopenhagen, and praised his work on the Intergovernmental Panel on Climate Change (IPCC)
\nand his conviction that preservation of the planet\u2019s biosphere is essential to human health.
\nA recent UN meeting, attended by 124 heads of state, increased political momentum
\ntowards the Paris talks which will agree coordinated, transformative action to meet
\nmeaningful targets to address climate change. World leaders have agreed to limit
\ntemperature rises to less than 2\u00b0C above pre-industrial levels, but without significant
\nemission cuts from all parties, that window of opportunity will soon close. Demonstrations
\naround the world before the UN meeting saw over a million people take to the streets, with
\nover 300,000 at a march in New York.
\nClimate stability since the last age has allowed human civilisation to flourish, but the
\nburning of fossil fuels and wholesale deforestation has increased carbon dioxide in the
\natmosphere by 40%, trapping more of the sun\u2019s energy and increasing global temperatures
\nin the infamous \u2018greenhouse effect\u2019.
\nAtmospheric temperature has increased by almost 1\u00b0C in recent decades and will rise between
\n4 \u00b0C to 7 \u00b0C by 2100 at current rates of emission. Limiting the increase to less than 2 \u00b0C
\nrequires the rapid decarbonisation of economies over the next 10 to 15 years.
\n\u2018\u2026..we\u2019ve started to disrupt the world\u2019s climate system and very many other of
\nthe great natural systems that are this planet\u2019s life support system, we are
\nactually beginning to change the conditions of life on earth. And that\u2019s a big
\ndeal…There will be a whole range of adverse health effects.\u2019 –
\nProf A.J. McMichael in a podcast for the NHMRC in 2009
\nH20 SUMMIT REPORT OF PROCEEDINGS PAGE 83
\nHEALTHY PEOPLE
\nSUCCESSFUL ECONOMY
\nClimate change will affect health in a variety of ways, from the direct health consequences of
\nextreme climate events such as storms and heatwaves to its effects on ecosystems, infectious
\ndiseases, food supplies and fresh water and the social disruption engendered by climate
\nrefugees and resource wars. Air pollution from fossil fuels already kills a million people a year,
\nbut a rise of 4 \u00b0C to 7 \u00b0C could cause billions of deaths as areas are rendered uninhabitable
\nand the ecosystems on which we depend collapse.
\nClimate change is therefore the biggest global health threat of the 21
\nst
\ncentury, and while mankind
\ncan adapt to some degree, the elimination of its source is urgently required. Health professionals
\nmust find their voice and use their credibility with the public to call for urgent action.
\nThe health system can reduce its carbon footprint and rethink its delivery of care and sources
\nof energy. The investments of its substantial pension funds should also be ethically appraised
\nand redirected where appropriate. The Sustainable Development Unit
\n69
\nof Britain\u2019s NHS has
\ndriven evidence-based reform, for example, and Oxford University\u2019s Centre of Sustainable
\nHealth care
\n70
\nworks on further strategies for change. Medical colleges should integrate the
\nhealth effects of climate change into their curricula, and institutions active on the issue,
\nincluding the AMA and BMA, should be supported by professionals.
\nIntersectional cooperation should reinforce the work of others and emphasise the health
\nbenefits to their actions to reduce emissions. As outlined in the recent New Climate Economy
\nReport
\n71
\n, cities must be redesigned, low-carbon energy sourced and the wholesale destruction
\nof forests and bio-diversity arrested. Citizens must bring pressure to bear on politicians,
\nbusiness and institutions, and Prof Madden encouraged attendees to write to politicians and
\nnewspapers about the Paris talks and support climate charities and advocacy organisations.
\nPathways to Deep Decarbonisation in 2050: Climate Action is Good For You!
\nThe Hon. John Thwaites, Professorial Fellow at the Monash Sustainability Institute and Chair
\nof ClimateWorks Australia, offered pathways to \u2018deep decarbonisation\u2019 by 2050. He was
\ninterested in the extent of discussions at the G20 in Brisbane on the issue, given the recent
\nand historic emissions agreement between the USA and China.
\nClimate change is the biggest global health threat of the 21st
\ncentury. Health professionals
\nmust find their voice and use their credibility with the public to call for urgent action.
\nPAGE 84 H20 SUMMIT REPORT OF PROCEEDINGS
\nH20HEALTH SUMMIT
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\n13 & 14 November 2014 \u2022 Melbourne
\nThe IPCC report presents the world with a stark choice between cataclysmic temperature
\nincreases in the 21
\nst
\ncentury, or limiting change to a more manageable 2 \u00b0C.
\nThe primary impacts on health of heat waves, rising sea levels and extraordinary weather
\nevents, indirect impacts of drought, mosquito-borne diseases and malnutrition, and the
\ntertiary risks posed by economic disruption will vary according to the vulnerability of
\nindividuals, communities and nations, with Africa and southern Asia worst affected.
\nAlthough every major country has agreed to limit the damage to 2 \u00b0C, no country has
\nidentified how they will achieve it. Australia can slash its carbon emissions while maintaining
\ngrowth of 2.4%, a similar rate to the past five years
\n72
\n.
\nThe Deep Decarbonisation Project
\n73
\ninvolves the 15 major emitting countries and outlines
\nways to limit global warming to 2 \u00b0C. Produced by the Sustainable Development Solutions
\nNetwork, the project was launched by the UN Secretary General at the recent UN climate
\nsummit.
\nH20 SUMMIT REPORT OF PROCEEDINGS PAGE 85
\nHEALTHY PEOPLE
\nSUCCESSFUL ECONOMY
\nAustralia\u2019s Pathway to Deep Decarbonisation
\n35 billion tonnes of carbon is released around the world every year, and to achieve even a
\n50% chance of limiting global warming to 2 \u00b0C, this must be reduced to 15 billion by 2050,
\ndespite a projected higher global population of 9 billion. This means reducing emissions from
\n5 to 1.6 tonnes per head, a particular challenge for Australians who are responsible for 17
\ntonnes per head due to land clearing and the nation\u2019s reliance on coal for electricity
\ngeneration.
\nProf Thwaites outlined a four-pronged strategy to achieve this goal. Energy efficiency must
\nreduce the energy required to produce every dollar of GDP by 2030 through replacing halogen
\nlights with LEDs, more efficient heating, ventilation and cooling systems and modernised
\ntransport. Coal-fired power stations can be replaced by renewable energy, notably solar
\npower, with Australia opting to use 100% renewables, or 70% with the balance made up by
\nnuclear power or carbon capture and storage. Electric cars should supersede petrol and diesel
\nand mining trucks could be replaced by conveyer belts. There are also significant
\nopportunities for Australia to capture carbon through reforesting land cleared for pasture.
\nPAGE 86 H20 SUMMIT REPORT OF PROCEEDINGS
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\nINTERNATIONAL
\n13 & 14 November 2014 \u2022 Melbourne
\nCutting carbon emissions will reduce the threat of bushfires, droughts and heatwaves and
\nease pressure on food supplies. Energy efficiency will create healthier buildings, with
\ninsulation reducing heating costs, heat stress and impacts from cold spells. The replacement
\nof coal and transport fuels with solar generated electricity will cut air pollution, and more
\nwalking, cycling and use of public transport will cut obesity and diabetes.
\nProf Thwaites noted potential downsides to the response to climate change \u2013 nuclear power is
\ncontroversial and has its dangers, although far fewer people have died in nuclear accidents
\nthan in coal mines. Biofuels can also reduce food production, particularly in developing
\ncountries. He urged attendees to use a \u2018health lens\u2019 to view potential action on climate
\nmitigation.
\nAlthough the \u2018Black Saturday\u2019 bushfires killed dozens of people in a day, 374 people died from
\nheat stress elsewhere in Victoria. Research on excess deaths from higher temperatures
\nreveals a threshold of around 28 \u00b0C for Melbourne, after which there is a jump of 17% in
\nmortality. Given the nonlinear relationship between temperature and excess deaths, even a
\nslight reduction in temperature rise above that threshold will save a significant number of
\nlives. Planting trees in the urban environment can reduce the impact of very hot days by up to
\n15 \u00b0C by providing shade, and the provision of water features, woodland, green roofs and
\ngardens can all reduce the risk of morbidity and mortality through heat stress.
\nClimate action: Our Planet our future- Students\u2019 leading community Action!
\nMs Grace Davies, the National Student Representative for Doctors for the Environment in
\nAustralia, and Ms Alice McGushin of the Australian Medical Students Association (AMSA)
\ndiscussed action by medical students on climate change.
\nHuman health relies on a healthy environment and so to undermine the environment is to
\nundermine health. Clinicians, medical students and associations therefore have a
\nresponsibility to take action at this crossroads in human history. Medical students have been
\nengaging and educating their peers, liaising with teaching institutions to add climate change to
\nthe curriculum and running \u2018code green\u2019 events to engage people in solutions, from bike riding
\nand tree planting to carbon neutral parties.
\nThe AMSA have held a series of discussion and educational events, while medical students
\nhave also engaged the medical profession through the annual \u2018Doctors for the Environment\u2019
\nconference and events run by other professional organisations. Students also have raised
\nawareness with the public, politicians and media and framed ongoing energy discussions as
\nurgent health concerns.
\nH20 SUMMIT REPORT OF PROCEEDINGS PAGE 87
\nHEALTHY PEOPLE
\nSUCCESSFUL ECONOMY
\nStudents have called for divestment from fossil fuels by banks, universities and
\nsuperannuation funds, but ongoing subsidies for fossil fuels in Australia and around the world
\npresent a $7.7 billion a year barrier to progress.
\nThe Paris Conference of December 2015 will see countries agree to firm carbon reductions,
\nand ambitious targets should be set to secure better health and a safer world. Engagement by
\nhealth professionals and their organisations should advocate meaningful targets and strong
\nnational policies to achieve them. The climate crisis can be turned into a health opportunity,
\nand medical networks and influence must be mobilised to take it.
\nPANEL DISCUSSION
\nClimate and Health
\nDr Stephen Parnis, Vice Chairman of the AMA, chaired a panel discussion on climate change
\nand health which featured Prof Vivienne Nathanson, Dr Robert Wah, WMA President, Mr
\nJonathon Kruger of the Australian & New Zealand College of Anaesthetists and Dr Tim
\nMalloy, President, Royal New Zealand College of General Practitioners.
\nProf Nathanson said medical professionals and the health system as a whole should set a
\ngood example and reduce carbon footprints where possible. Physically active transport and
\ndisinvestment in fossil fuels should be pursued, although legal stipulations to maximise
\nreturns for members may complicate the actions of pension funds. As doctors face difficult
\ndecisions every day and understand both resource limitations and the difficulties of securing
\nbehavioural change, Dr Parnis believed they would make excellent advocates on climate
\nissues.
\nDr Wah emphasised the economic importance of doctors in the economy and stressed this
\nfinancial clout could be used to secure political support for social, health and climate issues.
\nThe American Medical Association estimates that doctors created $1.6 trillion of economic
\nactivity in 2012 in the USA alone and sustained 10 million jobs. The average American
\nphysician generates $2.2 million of economic output every year and supports almost 14 jobs,
\npumping $1.1 million in wages into their local economy.
\nThe American Medical Association is teaming with the YMCA to prevent 60 year olds
\ntransitioning from pre-diabetes to diabetes in a programme which works in 70% of cases.
\n30 million patients in the USA still have uncontrolled hypertension, a figure the Association
\nPAGE 88 H20 SUMMIT REPORT OF PROCEEDINGS
\nH20HEALTH SUMMIT
\nINTERNATIONAL
\n13 & 14 November 2014 \u2022 Melbourne
\naims to reduce by 10 million by 2017. Doctors can have a major impact if they join in
\npartnerships to tackle issues in their communities as well as with individual patients.
\nDr Parnis said that doctors translate complex questions of pathology and treatment into
\neveryday language for their patients and could play a similar role for complex issues in the
\npublic domain. Mr Kruger said strong professional associations were required to drive
\nchange, but such efforts could have as much impact as clinical treatment. He called for
\ncooperation between groups and sectors and for the necessary media and communication
\nskills to be emphasised and developed. Medical groups should engage with education and the
\njustice system, for example, as well as health departments.
\nDr Parnis agreed that leadership and advocacy was as important as research or administration
\nand encouraged attendees to participate and encourage colleagues to play similar roles. Dr
\nMalloy emphasised the threat faced by Pacific Islands from rising sea levels and called for
\nclinicians to take the lead in their own locality. While running a general practice in rural New
\nZealand, he has also planted woodland, produced fuel from forestry waste and created a
\nvegetable garden to encourage healthy eating in his community. Doctors should use their
\nspheres of local influence to make a tangible difference, as well as advocate for national and
\ninternational action. Dr Parnis reiterated his point that understanding and persuasion
\npresented in everyday language were needed rather than lectures from above. The Australian
\nmedical profession is aware of the issues of climate change and is determined to act.
\nCLOSING REMARKS
\nThe H20 Summit was closed by Ms Tana Wuliji, lead of the Health Workforce Development
\nUnit at USAID. Although the Summit was subtitled Healthy People \u2013 Successful Economies, a
\nsuccessful economy does not necessarily generate better health for its population. Health
\nprofessionals are the mediator between a strong economy and better health. The world\u2019s
\nenvironmental, economic and social systems are more interconnected that ever before, which
\ncreates both opportunities and vulnerabilities, as a weakness anywhere can affect people
\neverywhere. The rate of change is accelerating and, despite areas of progress, health impacts
\nfrom environmental damage, social inequities, geopolitical conflict and demographics
\nremain. 80% of population growth, for example, will be in Africa by the end of the century
\nwhile developed nations age. Resilience is the focus of the G20, but it can only be enabled by
\nstrong public health. Policies and systems should pursue sustainable development and be
\ncontinuously recalibrated to meet changing needs.
\nH20 SUMMIT REPORT OF PROCEEDINGS PAGE 89
\nHEALTHY PEOPLE
\nSUCCESSFUL ECONOMY
\nThe G20 should be encouraged to improve health investment to foster growth and stability,
\nwhile social inequality can be addressed through reforms in health, trade, climate, education,
\ninfrastructure, justice and security. Private investments aim for profit, but their effect on the
\nenvironment, society and sustainability present additional challenges. Sustainable growth and
\nresilience cannot be secured, if short-term profit is achieved at their expense.
\nHealth professionals must engage with the investments, policies and actions of others which
\naffect health, and Ms Wuliji applauded the WMA and doctors worldwide for taking up these
\nissues. The interdependence of the modern world has been exposed by Ebola, whose
\neconomic fallout cannot be quarantined. Global networks should be used in positive ways to
\nexamine other perspectives, share innovations and lend collective weight to sustainable
\nprogress. Ms Wuliji challenged attendees to assess what outcomes they valued and whether
\nthey were vested with processes or results. If the health profession truly values its patients\u2019
\nwelfare over its own entrenched interests, it will reduce barriers and embrace fresh solutions.
\nShe praised the \u2018ripples\u2019 created by the H20 Summit and hoped the WMA would help turn
\nthem into \u2018waves\u2019 around the world.
\nDr Haikerwal asked for support for a short statement, based on the Summit\u2019s discussions and
\nprevious research, to be sent from the WMA to the G20. He hoped the event would lead to
\nfurther functions and thanked its organisers and members of the AMA, WMA, BMA and other
\nspeakers and attendees for their contributions, passion and support.
\nDr Pradeep Philip thanked Dr Haikerwal for his unstinting efforts and urged for attendees to
\nuse their considerable influence to encourage change. Health should be repositioned in the
\npublic debate as an economic driver, with spending seen as an investment not a cost. Health
\naffects everyone and remains an intensely personal experience despite all the advanced
\ntechnology around it. Health is instrumental to productive lives, strong societies and human
\nflourishing. Dr Philip asked attendees to consider what they could contribute to these issues,
\nhoped they had enjoyed their time in Melbourne and said their presence demonstrated their
\ncommitment to helping people across the world. The real work will begin once the event is
\nover as attendees absorb its lessons and implement them in people\u2019s lives. He thanked the
\nSummit\u2019s organisers, sponsors and contributors, hoped the G20 would listen to their message
\nand drew the event to a close.
\nPAGE 90 H20 SUMMIT REPORT OF PROCEEDINGS
\nH20HEALTH SUMMIT
\nINTERNATIONAL
\n13 & 14 November 2014 \u2022 Melbourne
\nNOTES AND REFERENCES
\n1
\nWorld Medical Association
\n2
\nhttp:\/\/www.vcccproject.vic.gov.au\/ThePrecinct
\n3
\nwww.health.gov.au\/internet\/main\/publishing.nsf\/content\/primary_health_networks
\n4
\nhttp:\/\/www.eiu.com\/public\/topical_report.aspx?campaignid=liveability2014
\n5
\nhttp:\/\/docs.health.vic.gov.au\/docs\/doc\/Victorian-refugee-and-asylum-seeker-health-action-plan-2014-2018
\n6
\nhttp:\/\/www.budget.vic.gov.au\/domino\/web_notes\/budgets\/
\nbudget12.nsf\/d6e571e551bef80eca2572bb002bcea7\/19be194180bbfe57ca2579f100149aa1!OpenDocument
\n7
\nhttp:\/\/dsdbi.vic.gov.au\/what-we-do\/promote-trade-and-industry\/global-health-melbourne
\n8
\nhttp:\/\/www.burnet.edu.au\/
\n9
\nhttp:\/\/dsdbi.vic.gov.au\/our-department\/strategies-and-initiatives\/victorias-medical-technology-strategy
\n10
\nhttp:\/\/health.vic.gov.au\/clinicaltrials\/
\n11<\/p>\n

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