Policy Roundtable on People-centred Integrated Health Services, Singapore, 26-27 September 2016 : meeting report

Meeting Report

POLICY ROUNDTABLE ON PEOPLE-CENTRED INTEGRATED HEALTH SERVICES

26–27 September 2016 Singapore

Policy Roundtable on People-Centred Integrated Health Services 26–27 September 2016 Singapore

WPR/DHS/ISD(03)/2016 RS/2016/GE/41(SGP)

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC English only

MEETING REPORT

POLICY ROUNDTABLE ON PEOPLE-CENTRED INTEGRATED HEALTH SERVICES

Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

Singapore 26–27 September 2016

Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines

March 2017

NOTE

The views expressed in this report are those of the participants of the Policy Roundtable on Peoplecentred Integrated Health Services and do not necessarily reflect the policies of the conveners.

This report has been prepared by the World Health Organization Regional Office for the Western Pacific for Member States in the Region and for those who participated in the Policy Roundtable on People-centred Integrated Health Services in Singapore from 26 to 27 September 2016.

SUMMARY Achieving people-centred and integrated health services can generate significant benefits in all countries, whether low-, middle- or high-income. Populations are living longer and noncommunicable diseases (NCDs) are on the rise. Higher levels of education, increased availability of information, and greater access to goods and services have raised people's expectations of health care services. Acknowledging these demographic trends and the collective challenges facing health systems, WHO calls for a fundamental shift in the way health services are organized, managed and delivered. This approach makes the perspectives of individuals, families and communities central to the organization of health services and systems. The Policy Roundtable on People-centred Integrated Health Services was held in Singapore and included twenty-six policy-makers and experts from ten countries or territories, which included Australia, Cambodia, China, Hong Kong SAR (China), the Lao People's Democratic Republic, Malaysia, Mongolia, the Philippines, Singapore and Viet Nam. The objectives of the policy roundtable were: 1) to learn from country examples of successful models of service delivery that are peoplecentred and integrated; 2) to review good practices and lessons learnt on patient engagement, strengthening governance and accountability, and coordinating services around the needs of people; and 3) to identify priority actions for advancing people-centred integrated health services and moving towards universal health coverage. The policy roundtable was organized around the dates of the International Forum on Quality and Safety in Healthcare: Asia organized jointly by the British Medical Journal and the Institute for Healthcare Improvement, which provided additional opportunities for learning and sharing. The roundtable investigated several important aspects of service quality and patient safety, namely engaging people and putting them at the centre of health service delivery, re-designing services around peoples’ needs and preferences, and transforming governance and establishing the appropriate system enablers to support people-centred care. Several challenges and lessons in implementing people-centred integrated health services were identified. While a few of the challenges are country specific, most are shared, including: 1) transforming the provider-centric design of health systems; 2) changing the traditional model of health professional education towards a multidisciplinary team model; 3) decreasing the fragmentation of care by breaking down silos; 4) adapting health systems to be needs and value-based to better support changes in population demographics, health-care needs and community expectations; 5) enhancing care coordination to reduce the misuse and overuse of health services; 6) removing barriers to timely communication and information sharing between health-care providers; 7) improving regulatory oversight to reduce the impact of commercialization and commoditization of health-care services;

8) strengthening health information systems and developing metrics (both quantitative and qualitative); and 9) reporting approaches for patient experience. During the roundtable, several strategies were highlighted to deal with the challenges identified. For instance, in New Zealand and Hong Kong SAR (China) it is a requirement to include patient representatives on their District Health Boards and Hospital Boards, respectively. In Singapore, health-care providers regularly conduct focus group discussions to understand the needs and expectations of patients and their families. Other strategies include: 1) strengthening links between health and social sectors at all levels to better address the codependency between health and social services for the population (as, for example, in Japan); 2) investing in preventive care, primary care and community care particularly for the management and control of NCDs and age-related health issues to act as gatekeepers to the system; and 3) aligning policy directions and incentives to generate the desired behaviour in health-care providers and encourage better communication and teamwork and facilitate information sharing. It was concluded that developing a trustful relationship between providers, patients and the community is key for the provision of people-centred health services. In this regard, advances in information technology have the potential to enhance coordination and continuity of health services, especially in geographically remote areas. Also, addressing the needs of vulnerable groups in the population requires special attention, particularly in removing the barriers to their accessing health services. Communities often have difficulty in navigating health systems, in such cases the role of care coordinators becomes important to ensure coordinated and timely access to services. It was agreed that “if it [the health service] is not people-centred it is not sustainable”. Further, improving health cannot be driven by the health sector alone, and it is essential to develop a shared governance framework that partners with other sectors.

CONTENTS 1. INTRODUCTION .............................................................................................................................. 1 1.1 Meeting organization .................................................................................................................... 1 1.2 Meeting objectives ........................................................................................................................ 2 2. PROCEEDINGS ................................................................................................................................. 2 2.1 Opening session ............................................................................................................................ 2 2.2 Technical sessions ......................................................................................................................... 2 Session 1: Setting the scene: lessons on overcoming challenges in implementing people-centred integrated health services ....................................................................................... 2 Session 2: Engaging and placing individuals, families and communities at the centre of health service delivery ..................................................................................................... 4 Session 3: Re-designing health services around the needs of people: how to get the supply side right? ................................................................................................................ 5 Session 4: Transforming governance for people-centred service delivery ..................................... 6 2.3 Country-specific sessions.............................................................................................................. 7 3. CONCLUSIONS AND RECOMMENDATIONS ............................................................................. 8 3.1 Conclusions ................................................................................................................................... 8 3.2 Recommendations ......................................................................................................................... 9 3.2.1 Recommendations for Member States ................................................................................... 9 3.2.2 Recommendations for WHO Secretariat................................................................................ 9 ANNEXES ............................................................................................................................................ 12 Annex 1. List of participants ............................................................................................................. 12 Annex 2. Programme of activities..................................................................................................... 16 Annex 3. Regional Director’s speech ............................................................................................... 19 Annex 4. Summary of discussions with country participants ........................................................... 21 Keywords: Delivery of health care, Integrated/Health Services

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1. INTRODUCTION 1.1 Meeting organization Current epidemiological and demographic trends have highlighted the fact that traditional models of providing health care are neither effective nor sustainable. Thereby, business as usual is no longer an option and these trends call for more a comprehensive approach across the continuum of care, better coordination of care, and multidisciplinary teams. More importantly, engaging communities, patients and families has been recognized as an essential component of this approach. Many countries have undertaken efforts to reorient their health system to provide more equitable, accessible and sustainable health services that seek to better coordinate care around people’s needs. In Member States across the Western Pacific Region effective coverage by people centred and integrated health services is still not a reality for large portions of the population. As early as 2005, the WHO Regional Office for the Western Pacific (WPRO) had worked closely with Member States and its partners to promote people-centred health care and provide practical guidance on how services may be better organized to achieve better quality of care, better health outcomes and improved well-being. Since then WPRO has initiated and supported a number of people-centred initiatives, such as a movement for Patient for Patient Safety (PFPS). In October 2015, the Regional Committee for WPRO endorsed the Western Pacific regional action framework on universal health coverage, emphasizing that improving the quality of health services requires the delivery of well-coordinated services, organized around the needs and expectations of individuals, families and communities. In September 2016, a policy roundtable was held in Singapore to identify the critical dimensions in improving people-centred integrated health services. The consultation was held over two days, and included a policy roundtable and country-specific follow-up discussions with representatives of all the participating countries and territories, which included Australia, Cambodia, China, Hong Kong SAR (China), the Lao People's Democratic Republic, Malaysia, Mongolia, the Philippines, Singapore and Viet Nam. The policy roundtable was organized around the dates of the International Forum on Quality and Safety in Healthcare: Asia held jointly by the British Medical Journal and the Institute for Healthcare Improvement, which provided additional opportunities for learning and sharing. The roundtable in Singapore builds on the success of a roundtable in 2015 in Hong Kong SAR (China) on quality in health services. While the 2015 roundtable focused on adverse event reporting, the role of clinical guidelines and standards, financing and incentive mechanisms, this year’s event investigated other important aspects of service quality and patient safety, namely engaging people and putting them at the centre of health service delivery, re-designing services around peoples’ needs and preferences, and transforming governance and establishing the appropriate system enablers to support people-centred care. The list of participants is available in Annex 1. The programme of activities is available in Annex 2.

-21.2 Meeting objectives The objectives of the Policy Roundtable on People-centred Integrated Health Services were: 1) to learn from country examples of successful models of service delivery that are peoplecentred and integrated; 2) to review good practices and lessons learnt on patient engagement, strengthening governance and accountability, and coordinating services around the needs of people; and 3) to identify priority actions for advancing people-centred integrated health services and moving towards universal health coverage.

2. PROCEEDINGS 2.1 Opening session Dr Vivian Lin, Director, Division of Health Systems, WHO Regional Office for the Western Pacific, delivered the opening address on behalf of Dr Shin Young-soo, WHO Regional Director for the Western Pacific. Dr Sin Young-soo’s opening address is available in Annex 3. Dr Lin emphasized the remarkable opportunity offered by the post-2015 agenda to accelerate progress in health. The sustainable development goals (SDGs) underline the importance of a more integrated and holistic approach to good health, with universal health coverage (UHC) as the foundation for achieving all health-related SDGs and the development of strong resilient health systems. Accordingly, countries will need to make considerable efforts to improve health system performance through innovative approaches that strengthen core health system functions while appropriately responding to growing community expectations. The issues related to quality, safety and the patient’s journey through the health system have become paramount. In many Member States, efforts are under way to improve patient experience and satisfaction with health services. There is growing realization that people-centred integrated services is the most comprehensive, effective and sustainable approach to achieving UHC. It was emphasized that the policy roundtable represents the commitment to continue the conversation and engagement with both policy-makers and practitioners to foster mutual learning and share best practices across countries to improve people-centred integrated health services. 2.2 Technical sessions Session 1: Setting the scene: lessons on overcoming challenges in implementing people-centred integrated health services In many countries, health services continue to be fragmented as a result of a growing number of disease-specific programmes and interventions. In most of these countries, health system inefficiencies have been fostered by an overly biomedical oriented, disease focused, technology driven and doctor dominated approach to health service delivery. Consequently, communities, patients and their families remain dissatisfied and often uninformed about their rights or entitlements. Dr Baghirov introduced this session, raising some important issues related to the challenges in implementing people-centred integrated health services. This was followed by group work that aimed to answer the following key policy questions: (i) why are health services not designed and delivered in a people-centred way? (ii) how can we overcome these challenges in implementing people-centred

-3integrated health services? and (iii) how can people-centredness contribute to improving quality in health services? The session identified some important challenges associated with the implementation of people-centred integrated health services. While a few of the challenges were country specific, most were common across countries. 1) In most countries, health systems are designed on traditional models of providing health care and of measuring health system performance with limited attention paid to community aspirations and needs. 2) Education for health professionals has primarily focused on clinical knowledge and skills with limited emphasis on multidisciplinary approaches to health-care provision. 3) The focus on the biomedical model of health has facilitated a hospital-centric approach to service delivery that permeates fragmented health-care delivery. 4) On-going changes in population demographics, health-care needs and community expectations mandates reorientation of the health system to evolve and adapt, to be more needs- and value-based. 5) In many instances, health services and social services are not well-integrated, contributing to poor outcomes and resource optimization. 6) Lack of timely communication and information sharing between community and health-care providers as well as among health-care providers adversely affects the patients’ experience. 7) In certain locations, the lack of regulatory oversight has resulted in commercialization and commoditization of health-care services. 8) Health system performance indices often focus on disease-specific processes and outputs with limited attention paid to measuring experience and satisfaction of patients and their families with the health services. The session also highlighted a few strategies that have been implemented in countries to address some of these challenges. These are summarized below. 1) Patients, families and communities are recognized as key stakeholders in health and their active engagement is desired. To enable this, New Zealand and Hong Kong SAR (China) require patient representatives to be members of the District Health Board and Hospital Boards, respectively. In Singapore, health-care providers regularly conduct focus group discussions to understand the needs and expectations of patients and their families, which are taken into consideration during policy-making. 2) It is important to strengthen the links between health and social sectors at all levels to better address the co-dependency between social and health issues for the population. It is not enough to link health and social issues at the provider level; they have to be linked at the policy-maker and grassroots level too. For persons with complex health and social needs, health-care providers and social services providers have to work together to address the behavioural and social issues leading to poor health. 3) Investment in preventive care, primary care and community care is critical. Hospital care is expensive and more suited to acute medical conditions. NCDs and age-related health issues are better managed with effective preventive and regular primary care. Primary care needs to be of good quality and accessible, to provide first-line care and treatment and to serve as a gatekeeper to specialized health-care services. For patients with complex health and social

-4needs, community care that is team-based is better placed to help the patient recover and stay engaged with the local community. 4) The alignment of policy directions and incentives is pivotal to generate the desired behaviours in both health-care providers and users. 5) Health service delivery should promote communication and teamwork between providers, including the creation of platforms to facilitate information sharing. 6) The health system should collect data on aspects of health care that are meaningful to patients, families and communities, and shift the focus of the key performance indicators to be more value-based. Session 2: Engaging and placing individuals, families and communities at the centre of health service delivery Reorientation of the health services towards a people-centred health system requires action at all levels. It also involves the support for communities to be actively engaged in their health and its determinants, to participate in health policy decisions, to exert their health rights and responsibilities, and to be empowered to choose options that suit their needs. These are particularly important to address inequalities in health. Dr Lin introduced this session and highlighted some important aspects relating to individual, family and community engagement in health service delivery. This was followed by a panel discussion that responded to the following key policy questions: (i) how do providers learn about what patients and families want and expect? (ii) how can health-care providers, patients and families, especially from underserved groups, engage with each other to clarify expectations? and (iii) how can providers know they have made a difference in improving the quality of health services as well as overall health outcomes through improved patient, family and community engagement? The panel consisted of Dr Liu Siu Fai, Dr Mary Ann Tsao and Professor Hiroto Ito. The summary points from the discussion are highlighted below. 1) The changing demography and rising prevalence of NCDs implies that health service delivery has to be more people-centred and integrated, to better meet the needs of the patients and their families. 2) Health systems have to adapt to the needs and expectations of patients and their families. In order to achieve this in a systematic and responsive way, health systems should explore structural changes (such as having appropriate representation on hospital boards, establishing patient advisory committees, etc.) or changes in the process (such as developing a platform for understanding the perspective of the people and communities). The latter can take the form of patient forums and conventions, engagement with patient groups and community leaders, scheduled focus group sessions, etc. 3) For health services to be more people centred, the culture and environment within which health care is delivered needs to change. Health-care providers, policy-makers and administrators should be able to support patients in being engaged in the management of their conditions and risk factors. For instance, health-care providers should co-develop care plans with the patient and their family. For patients with complex conditions and needs, providers may have to probe deeper to understand their aspirations and it may be necessary to educate and negotiate a care plan that is realistic, agreeable and appropriate. Policy-makers and administrators need to design structures and create platforms for them to engage with patient groups and representatives, and receive their feedback and ideas. 4) Vulnerable groups in the population may require special attention, as their needs might be different and they may face barriers to accessing health services. This may include rural

-5populations, the elderly, geographically remote and difficult to access regions, areas with poor access to telecommunications, etc. 5) To prioritize the importance of being people centred, health-care institutions and organizations should include principles of people-centred services into their governance structure or related accreditation system for institutions or programmes. 6) The key to the provision of people-centred health services is trust between providers, patients and the community.

Session 3: Re-designing health services around the needs of people: how to get the supply side right? People-centredness is a core aim of the health system, yet care often fails to meet this aim. In most countries, people-centred care is still not the norm, and navigating the health-care system remains a challenge for patients and their families. With increases in the complexity of the system, engagement of individuals, families and communities takes on increased importance as a means of ensuring that appropriate care is provided as per individual needs, preferences and circumstances. Centring care on people’s needs and preferences requires health-care organizations and institutions to prioritize coordination and cooperation among various elements of their health services. Dr Juan Tello, Programme Manager, Health Systems and Public Health, WHO Regional Office for Europe, provided an overview underlining some of these elements related to supply-side preparedness for people-centred integrated health services. The session also tried to address some key policy questions including: (i) what are the key drivers for better coordination of health services around the needs of people, including underserved population groups? and (ii) how working in teams (multidisciplinary and interprofessional) can improve health outcomes and patient experiences? The key discussion points from the session are summarized below. 1) Health care should be coordinated around the needs of people at all levels of service planning and delivery. In this regard, a strategic overview of the role of various health-care and socialservice providers at different levels of the health system is critical to understanding and clarifying the interrelationships and system dependencies between providers. With this overview, systematic review and design of guidelines and protocols may provide an opportunity for more integrated services, with appropriately incentives. 2) Information technology has the potential to be a game changer for the coordination of health services, especially in geographically remote areas. These technologies can provide a network of health and social-service providers available for patients based on locality, create platforms for secure and timely information sharing between providers, and improve quality and patient safety through incorporating guidelines, protocols or clinical pathways into the providers’ practice. 3) In places where health systems have become increasingly difficult to navigate, care coordinator roles may be created to help people receive the services they need in a timely and coordinated manner. As the health needs of patients and their families have increased and become more complex, health service delivery has also grown in complexity. In many countries, care coordinators have proven useful in helping patients and their families navigate the health systems. In the future, as health systems mature to be more connected and integrated and communities become more health-literate and empowered, individuals may become more confident and independent in accessing health services to meet their needs.

-64) Providing training to health-care professionals on working in teams and leading multidisciplinary teams is important. Unfortunately, health professionals are often not trained to work in teams during their undergraduate curriculum and vocational training. Most learn on the job and attain a level of sufficiency but only a few are able to lead high performing teams. With health-care services becoming more complex, team-based care has become normative hence interdisciplinary training of health professionals has become essential. 5) Well-designed clinical pathways that inform providers of their roles and responsibilities can help to facilitate better teamwork. These pathways should be co-designed by stakeholders and regularly reviewed when new evidence and feedback is available. Pathways help providers understand their role in the overall patient journey, define their scope of responsibilities and authority, and help outline their interactions with other stakeholders. Overall these help build better teamwork for health service delivery. Session 4: Transforming governance for people-centred service delivery Health services continue to be fragmented due to poor coordination of structures and integration of processes between health and social care services. While there are many reasons for this poor coordination, one important factor is weak health systems governance and service delivery arrangements. Patient-centred integrated health services can only be achieved in a collaborative environment where patients, families, providers and health and social institutions work together. This requires effective stewardship and governance of the health system, a conducive policy environment and aligned financial incentives. Dr Lin introduced this session and highlighted some important aspects relating to governance for people-centred service delivery. This was followed by a panel discussion that responded to the following key policy questions: (i) how have governments and institutions used regulation, governance, incentives, information systems and public–private partnerships to make health services more integrated and people-centred? and (ii) what are the country experiences in promoting the active involvement of all stakeholders (civil society, private sector, health professionals, academics, etc.) in policy dialogues to influence the way services are resourced, planned and delivered? The panel consisted of Associate Professor Kenneth Mak, Dr Glendon Farrow and Ms Stella Ward. The key points from the discussion are summarized below. 1) Transforming governance for people-centred service delivery requires an understanding of the drivers of this transformation. This includes changing population demographics (such as ageing), the push towards sustainable health systems, and changing expectations of the population towards health. 2) It requires the establishment of networks and alliances, within and outside of the health sector. 3) To change and improve overall population health, the health sector must work closely with other sectors, like education, social and trade to promote healthy behaviours, habits and cultures. Central governments and area-based health authorities must engage with nongovernmental organizations (NGOs) and the private sector to improve the health of the population, in a way that is meaningful for them. The traditional facility-based governance structure must be transformed to one that is network-based. 4) Adoption of a team-based approach to creating health, with the involvement of patients, families and communities will remain critical. People journey through the health-care system differently based on their life stage and health needs. Individuals with chronic medical conditions requiring services from different health-care providers often have to suffer from poorly coordinated care and difficult transitions across different care settings. Bringing

-7providers together, through various forms of communication and platforms, to address the patient’s needs collectively in a team-based approach is the first step. The next step requires them to develop one care plan for the patient, and understand each team member’s role s and responsibilities. For such teams, it is useful to have a lifelong family medicine practitioner (or equivalent) to anchor the patient’s care coordination and team communications. Empowering individuals, families and communities to better understand their health needs, effectively navigate the health-care system, and pro-actively partner with providers to codevelop their care plan is important. To enable individuals and families to actively participate in their health plan, they must be given ownership of their health information, and have the means to access that information. In addition, resources informing populations how to develop healthy lifestyle habits and correctly access health services must be made easily available and accessible. Acknowledging the need for data safeguards, patient’s health information needs to be available to health- and social-care providers who are caring for the patient. At the system level, anonymized aggregated data should also be made available to local health authorities, planners, companies and researchers, for them to analyse and decide on population health needs, and better address these needs. Health-care providers must engage with patients and their families to understand their social circumstances, care needs and aspirations, to co-develop a care plan that is personalized and appropriate. Health system governance and financing and the outcome framework should be designed using a people-centred lens. Improving health cannot be driven by the health sector alone, and it is essential to develop a shared governance framework that partners with other sectors like social, education and trade to deliberately discuss and address these issues. Health financing policies need to support a people-centred approach to health care. As funding drives behaviour, new financing models have tried to move away from paying for episodic care, shifting the focus from the disease to the individual. Further, as health-care systems become more complex there is a need to adopt an outcomes-based framework that is guided by values that are people-centric rather than provider-centric.

5)

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2.3 Country-specific sessions Recognizing that each country is at a different stage in reorienting their health system to adopt a people-centred approach, a one-size-fits-all design is impractical. Day 2 of the policy roundtable comprised of in-depth discussions with participants from seven Member States that participated in the policy roundtable: Cambodia, Hong Kong SAR (China), the Lao People's Democratic Republic, Malaysia, Mongolia, the Philippines and Viet Nam. There was WHO Country Office participation from China. A summary of the in-depth discussions is provided in Annex 4. WHO Secretariat and WHO country offices will work together on the highlighted challenges and issues with Member States to provide country support, and assist in implementing people-centred integrated health services. It was recognized that WHO can support by encouraging and facilitating regional collaboration to strengthen the capacity of health systems in Member States.

-83. CONCLUSIONS AND RECOMMENDATIONS 3.1 Conclusions The roundtable identified challenges and lessons in implementing people-centred integrated health services. Some challenges are country specific, but most of them are shared, including: 1) transforming the provider-centric design of health systems; 2) changing the traditional model of health professional education towards a multidisciplinary team model; 3) decreasing the fragmentation of care by breaking down silos; 4) adapting health systems to be needs and value-based to better support changes in population demographics, health-care needs and community expectations; 5) enhancing care coordination to reduce the misuse and overuse of health services; 6) removing barriers to timely communication and information sharing among health-care providers; 7) improving regulatory oversight to reduce the impact of commercialization and commoditization of health-care services; and 8) strengthening health information systems and developing metrics (both quantitative and qualitative) and reporting approaches for patient experience. Several strategies were highlighted by both participants and advisers, which can successfully deal with these challenges. For instance, New Zealand and Hong Kong SAR (China) require patient representatives to be included on their District Health Boards and Hospital Boards, respectively. Singapore’s health-care providers regularly conduct focus group discussions to understand the needs and expectations of patients and their families. This helps recognition of patients, families and communities as key partners and stakeholders in health, and their engagement thereafter. Other highlighted strategies include: 1) strengthening links between health and social sectors at all levels to better address the codependency between health and social services for the population (as, for example, in Japan); 2) investing in preventive care, primary care and community care particularly for management and control of NCDs and age-related health issues to act as gatekeepers to the system; and 3) aligning policy directions and incentives to generate the desired behaviours in health-care providers and encourage better communication and teamwork and facilitate information sharing. Other important conclusions of the roundtable, as highlighted by the participants themselves at the final session of the meeting, include: 1) To develop and provide health services that are people-centred, having a trust relationship between providers, patients and the community is key. 2) Information technologies and information systems have the potential to be a game changer for coordination and continuity of health services, especially in geographically remote areas. 3) Vulnerable groups in the population require special attention, as their needs may be different, for example, barriers to accessing health services.

-94) In places where health systems have become increasingly difficult to navigate, roles of care coordinators may be established to ensure people access services in a timely and coordinated manner. 5) Clinical care pathways should be co-designed by stakeholders, including community representatives, and regularly reviewed when new evidence and feedback is available. 6) Improving health cannot be driven by the health sector alone, and it is essential to develop a shared governance framework that partners other sectors. 7) If it is not people-centred it is not sustainable. Equally, resilient and sustainable health systems require community centredness. 3.2 Recommendations 3.2.1 Recommendations for Member States 1) Assess the current service delivery arrangements through the lens of people-centred care, identify service delivery bottlenecks and develop strategies to address them within the context of national UHC roadmaps. 2) Initiate or continue policy dialogues at the national level, with the support of expertise available in the region on how to engage individuals, families and communities in the design and delivery of health services. 3) Review and, as necessary, redesign governance mechanisms that support a coherent and integrated approach in health-care policy and planning. 3.2.2 Recommendations for WHO Secretariat 1) Support countries in the development and implementation of people-centred integrated health strategies in congruence with the country-specific UHC roadmaps. 2) Review elements of health systems through a people-centred lens, and update People-centred health care: A policy framework published by the Western Pacific Regional Office in 2007, based on new evidence and experience in countries, in full alignment with Universal health coverage: Moving towards better health – Action framework for the Western Pacific Region. 3) Share the outcomes of the meeting with the WHO country offices and engage them and other stakeholders, such as collaborating centres, in the people-centred policy work in countries that promote quality and safety of health services, working towards UHC. 4) Communicate the outcomes of the roundtable at different forums, including the UHC Technical Advisory Group meeting in December 2016, and mobilize support and expertise in moving the people-centred and integrated health services agenda forward. Country-specific support Cambodia Share knowledge from different countries to create a common understanding of peoplecentred models of care (highlighting district health systems, primary health care, hospitals, NGO involvement); support engagement with, and regulation of, the private sector to establish baseline quality and safety that is considered acceptable; leverage the Quality Assessment Level 2 tool to support integrated care and institutionalizing quality of care.

- 10 Hong Kong SAR (China) Host a workshop to support a common understanding of people-centred health care and definitions to be applied; support the establishment of information sharing and reporting requirements, through health-care law; build on existing public–private partnerships and encourage interoperability between health information systems to support continuity of care, and information sharing; help evaluate pilots, and scale-up those that conform to system-wide approaches, reaching out to those left behind. The Lao People's Democratic Republic Foster effective leadership and partnership by hosting a national policy roundtable (including minister, departments, provincial and hospital levels), giving priority to people-centred health care; support the monitoring and evaluation (both quantitative and qualitative) of people-centred policies and actions, designed to achieve integrated health care and a continuous flow of information feedback into the system; develop a flowchart and protocol to ensure that the roles and responsibilities of every individual, group and organization participating in the people-centred planning process is clearly understood and agreed by them and adequately supported. Malaysia Support efforts to build on existing community clinics and mobile health teams and integrated health screening programmes, intended for the holistic care of outpatients; realign existing workforce capacities to support primary health-care delivery, such as maternal and child health to noncommunicable diseases; explore the introduction of financial incentives and bundled payments to ensure care is delivered in an integrated people-centred way, for example, clinical care pathways (diabetes screening); address gaps in the measurement of people-centred health care at all levels, including individuals, families and communities, health professionals, health providers and health systems. Mongolia Support engagement with civil society, advocacy groups and patient rights’ groups to foster transformational change and co-design; identify change champions that can mobilize and create a demand for people-centred care; support country exchange with Malaysia, particularly on the PFPS programme and explore links with WHO collaborating centres; meet with health minister early in 2017 to discuss the integration and implementation of people-centred health care at all levels of the health system and across all sectors and societies. Philippines Support a credible, transparent and comprehensive accreditation system for health professionals and health facilities; implementation and regulation of requirements for all professionals; convene meetings with all concerned stakeholders, including providers to mobilize continuous quality improvements; help define roles and responsibilities within service delivery networks. Viet Nam Promote quality and safety in health services and people-centred health care by supporting a national conference; support the development of Cho Ray Hospital as a model for people-centred health care through patient identification, clinical care pathways, and applying a multidisciplinary approach (requires government clearance); the learnings from this hospital can then be shared with

- 11 other hospitals in the country, and support on-the-job training and problem-solving to redesign service delivery processes.

- 12 ANNEXES

Annex 1. List of participants LIST OF PARTICIPANTS, TEMPORARY ADVISERS, OBSERVERS and SECRETARIAT

1. PARTICIPANTS AUSTRALIA Ms Janet Quigley, Assistant Secretary, Primary Health Care Reform and Implementation, Department of Health, Canberra, Australia, Telephone: (612) 62895372, Email: janet.quigley@health.gov.au Dr Veasnakiry Lo, Director of Department of Planning and Health Information, Ministry of Health, Phnom Penh, Cambodia, Telephone: (855) 23 426 372, Email: veasnakiry@gmail.com.kh Dr Sok Srun, Director, Department of Hospital Services, Phnom Penh, Cambodia, Telephone: (855) 12 912122, Email: soksrun@online.com.kh CHINA Dr Kun Zhao , Director, Division of Policy Evaluation and Technology Assessment, China National Health Development Research Center, Beijing, People's Republic of China, Telephone: (86) 13901398208, Email: zk317@yahoo.com Dr CHUNG Kin-lai, Hospital Chief Executive, North District Hospital, Hospital Authority, Hong Kong, Hong Kong SAR (China), Telephone: (852) 2683 7880, Email: chungkl@ha.org.hk Dr Bounnack Saysanasongkham, Deputy General Director, Department of Health Care, Ministry of Health, Vientiane, the Lao People's Democratic Republic, Telephone: (856) 205569 3915, Email: sbounnack@gmail.com Professor Douangdao Soukaloun, Professor of Pediatrics/Deputy Director, Mahosot Hospital, Ministry of Health, Vientiane, the Lao People's Democratic Republic, Telephone: (856) 020 55682621, Email: dsoukaloun@yahoo.com MALAYSIA Dr Rima Marhayu Binti Abdul Rashid, Senior Principal Assistant Director, Ministry of Health, Putrajaya, Malaysia, Telephone: (03) 88832311, Email: drmarhayu@moh.gov.my

CAMBODIA

HONG KONG (SAR) CHINA

LAO PEOPLE'S DEMOCRATIC REPUBLIC

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Dr Diane Woei Quan Chong, Medical Officer, Institute for Health Systems Research, National Institutes of Health, Ministry of Health, Selangor, Malaysia, Telephone: (603) 3346 6400, Email: chong.dwq@ihsr.gov.my MONGOLIA Dr Tugsdelger Sovd, Director, Department of Monitoring and Evaluation, Internal Auditing Department, Ministry of Health, Ulaanbaatar, Mongolia, Telephone: (976) 99157560, Email: stugso@hotmail.com Dr Uranchimeg Tseden-ish, Deputy Director of the National Dermatology Center of Mongolia, Ministry of Health, Ulaanbaatar, Mongolia, Telephone: (976) 99157560, Email: urna74_dul@yahoo.com PHILIPPINES Dr Cirilo Galindez, Medical Center Chief III, Veterans Regional Hospital, Aritao, Nueva Vizcaya, Philippines, Telephone: (637) 88053560, Email: vrhro21995@gmail.com Dr LEE Heow Yong, Director, Hospital Services Division, Health Services Group, Ministry of Health, Singapore, Telephone: (65) 63251690, Email: lee_heow_yong@moh.gov.sg Ms Charmaine Tsui Hoon Ng, Assistant Director (Caregiver Support), Ministry of Health, Singapore, Telephone: (65) 96894255, Email: charmaine_NG@moh.gov.sg Ms Elaine Tan, Director, Primary and Community Care Division, Ministry of Health, Singapore, Telephone: (65) 63251014, Email: elaine_sl_tan@moh.gov.sg Dr Adelina Shuan Young, Assistant Director, Ministry of Health, Singapore, Telephone: (65) 6325 1277, Email: Adelina_YOUNG@moh.gov.sg VIET NAM Dr Luong Duong Huy, Vice Head of Quality Management Division, Ministry of Health, Hanoi, Viet Nam, Telephone: (84) 915363369, Email: Drluong.vn@gmail.com Dr Tra Ton Thanh, Head Quality Management Office, Nursing Service Department, Cho Ray Hospital, Ho Chi Minh, Viet Nam, Telephone: (84) 903 673 451, Email: tonthanhtra@yahoo.com

SINGAPORE

- 14 2. TEMPORARY ADVISERS Dr Yook Chin Chia, Head of Quality Assurance Unit, Department of Primary Care Medicine, University of Malaya, Kuala Lumpur, Malaysia, Telephone: (6012) 2739361, Email: chiayc@um.edu.my Dr Glendon Farrow, Director of Clinical Governance, Sydney Children's Hospitals Network, New South Wales, Sydney, Australia, Telephone: (61) 409 636 178, Email: glen.farrow@health.nsw.gov.au Dr Hiroto Ito, Director, Department of Social Psychiatry, National Center of Neurology and Psychiatry, Tokyo, Japan, Telephone: (81) 42 346 2046, Email: itoHiroto@ncnp.go.jp Dr Sui-Fai Lui, Clinical Professional Consultant, Chinese University of Hong Kong, Hong Kong, Hong Kong SAR (China), Telephone: (852) 95402336, Email: luisf@luisf.org Dr Kenneth Mak, Deputy Director of Medical Services, (Health Services Group), Ministry of Health, Singapore, Singapore, Telephone: (65) 6325 9220, Email: kenneth_MAK@moh.gov.sg Dr Clive Tan, Consultant, Ministry of Health, Singapore, Singapore, Telephone: (98) 272759, Email: clivetan@gmail.com Ms Mary Ann Tsao, Chairperson, TSAO Foundation, Central Plaza, Singapore 168730, Singapore, Telephone: (65) 9622-5825, Email: matsao@tsaofoundation.org Ms Stella Ward, Executive Director of Allied Health, Canterbury District Health Board Wellington, New Zealand, Telephone.: (64) 3644141, Email: stella.ward@cdhb.health.nz

3. OBSERVERS JAPAN Dr Kenichiro Taneda, Chief Senior Researcher, 2-3-6 Minami, Wako City, Saitama, Japan, Telephone: (81) 484586182, Email: kentaneda@niph.go.jp Dr Shin-ichiro Noda, Bureau of International Health Cooperation, National Centre for Global Health and Medicine, Tokyo, Japan, Telephone: (81) 3 3202 7181, Email: noda@it.ncgm.go.jp SINGAPORE Mr Chern Siang Jye, Chief Corporate Officer, Agency for Integrated Health Care, Singapore 069110, Singapore, Telephone: (65) 66036819, Email: siang.jye.chern@aic.sg Dr Wong Loong Mun, Principal Consultant, Agency for Integrated Health Care, Singapore 069110, Singapore, Telephone: (65) 66036908, Email: loong.mun.WONG@aic.sg

- 15 UNITED STATES OF AMERICA Dr Pierre Barker, Chief Global Partnerships and Programs Officer, Institute for Healthcare Improvement, Cambridge, Massachusetts 02138, United States of America, Telephone: (1919) 3601407, Email: pbarker@ihi.org

4. SECRETARIAT Dr Vivian Lin, Director, Division of Health Systems, WHO Regional Office for the Western Pacific, 1000 Manila, Philippines, Telephone: (632) 528 9802, Email: linv@who.int Dr Rasul Baghirov, Coordinator, Integrated Service Delivery, Division of Health Systems, WHO Regional Office for Western Pacific, 1000 Manila, Philippines, Telephone: (632) 528 9806, Email: baghirovr@who.int Ms Anjana Bhushan, Coordinator. Equity and Social Determinants, Division of Health Systems, WHO Regional Office for Western Pacific, 1000 Manila, Philippines, Telephone: (632) 528 9814, Email: Bhushana@who.int Ms Navreet Bhattal , Consultant, WHO Regional Office for Western Pacific, 1000 Manila, Philippines, Telephone: (632) 528 9048, Email: bhattaln@who.int Dr Juan Eduardo Tello, Programme Manager, Health Systems and Public Health WHO Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen, Denmark Telephone: (45) 45336868, Email: telloj@who.int Dr Tuohong Zhang, National Programme Officer, World Health Organization 401, Dongwai Diplomatic Office Building 23, Dongzhimenwai Dajie, Chaoyang District 100600 Beijing, China, Telephone: (8610) 6532-7189, Email: tuohongz@who.int Dr Hyobum Jang, Health Leadership Development Initiative Fellow World Health Organization, Office of the WHO Representative for Samoa, American Samoa, Cook Islands, Niue and Tokelau, Ioane Viliamu Building, P.O. Box 77, Apia, Samoa Telephone: (685) 24976, Email: jangh@who.int

- 16 Annex 2. Programme of activities POLICY ROUNDTABLE ON PEOPLE CENTRED INTEGRATED HEALTH SERVICES Singapore, 26–27 September 2016

PROGRAMME OF ACTIVITIES Meeting room 333 Suntec Singapore Convention and Exhibition Centre 1 TIME SESSION MODERATORS

Day 1: Monday, 26 September 2016 7:45–8:00 Registration 8:00–8:20 Welcome, opening remarks and introductions [20 mins] Welcome, administrative announcements Opening remarks and objectives of the meeting Introductions 8:20–10:00 Session 1: Setting the scene: lessons of overcoming challenges in implementing people-centred, integrated health services [100 mins] Key questions:  Why are health services not designed and delivered in a people-centred way?  How can we overcome these challenges in implementing people-centred integrated health services?  How can people-centredness contribute to improving quality in health services? Topical overview by Dr Rasul Baghirov (10 mins) Group work: table discussions (x4) with facilitator and rapporteur, with reporting back at plenary [30 min for group work, 30 min for reporting back, 30 min for discussion]. Role of facilitators and rapporteurs will be taken up by TAs and participants, and there will be one WHO representative at each table to observe the discussions. 10:00–10:10 10:10–10:30 10:30–12:00 Group photo Coffee break Session 2: Engaging and placing individuals, families and communities at the centre of health service delivery [90 mins] Reflecting on your country experiences, discuss the questions below. Key questions:  How do providers learn about what patients and families want and expect?  How can health-care providers and patients and families, especially from underserved groups, engage with each other to clarify expectations?  How can providers know they have made a difference in improving the quality of health services as well as overall health outcomes through improved patient, family and community engagement? Dr Vivian Lin Dr Rasul Baghirov WHO/WPRO

Dr Rasul Baghirov

Topical overview followed by group work

Dr Vivian Lin

Topical overview followed by moderated panel discussion

- 17 Panel: Dr Liu Siu Fai (Hong Kong SAR), Dr Mary Ann Tsao (Singapore), Professor Hiroto Ito (Japan) Topical overview by Dr Anjana Bhushan (10 mins) Moderated panel discussion: (80 mins) (Session lead to involve panel members in discussion 4 –6 weeks prior to event) 12:00–13:00 13:00–14:30 Welcome lunch Session 3: Re-designing health services around the needs of people: how to get the supply side right? [90 mins] Reflecting on your country experiences, discuss the questions below. Key questions:  What are the key drivers for better coordination of health services around the needs of people, including underserved population groups?  How the work in teams (multidisciplinary and interprofessional) can improve health outcomes and patient experiences? Session introduction by Dr Rasul Baghirov [10 mins] Group work: table discussions (x4) with facilitator and rapporteur, with reporting back at plenary [30 min for group work, 30 min for reporting back, 20 min for discussion]. Role of facilitators and rapporteurs will be taken up by TAs and participants, and there will be one WHO representative at each table to observe the discussions. (Draw out the point about coordinating health services around the needs of people)

Dr Juan Tello

Topical overview followed by group work

14:30–16:00

Session 4: Transforming governance for people-centred service delivery [90 mins] Key policy questions:  How have governments and institutions used regulation, governance, incentives, information systems and public–private partnerships to make health services more integrated and people-centred?  What are the country experiences to promote involvement of all stakeholders (civil society, private sector, health professionals, academics, etc.) to participate actively in policy dialogue and influence the way services are resourced, planned and delivered?

Dr Vivian Lin

Topical overview Plenary Session – format TBD [90 mins]. Invite expert panel to share first on the followed by key policy questions, or option of keeping session more open by having plenary Moderated panel discussion with pre-identified discussants Temporary advisers available to tap on: Associate Professor Kenneth Mak (Singapore), Dr Glendon Farrow (Australia), Ms Stella Ward (New Zealand)

(To engage experts in discussion 4–6 weeks prior to event) 16:00–16:30 16:30–17:00

Coffee break Session 5: Summary and conclusion [30 mins]

Participant reflections, and how do they plan to implement health services that are people-centred and well-integrated, in their settings?

Dr Rasul Baghirov

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Day 2: Tuesday, 27 September 2016 TIME SESSION 08:30–10:30

MODERATORS

Attend opening ceremony, welcome address and coffee break Country-specific sessions – China, Malaysia, Philippines Lunch at conference venue Country-specific sessions – Cambodia, The Lao People's Democratic Republic, Mongolia and Viet Nam Country-specific sessions – Australia, Hong Kong SAR (China), Singapore

10:30–12:00 12:00–13:00 13:00–14:30

Dr Vivian Lin Dr Rasul Baghirov Ms Anjana Bhushan Ms Navreet Bhattal Dr Tuohong Zhang Dr Jang Hyobum

14:30–16:30

16:30–17:30

WHO Secretariat meeting

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Annex 3. Regional Director’s speech Speech of Dr Shin Young‐soo WHO Regional Director for the Western Pacific at POLICY ROUNDTABLE ON PEOPLE-CENTRED INTEGRATED HEALTH SERVICES 26 SEPTEMBER 2016, SINGAPORE Participants of the Policy Roundtable on People-centred Integrated Health Services, experts and colleagues; 1. Dr Shin Young-soo, WHO Regional Director for the Western Pacific, regrets not being able to join us due to previous commitments. He has asked me to send his regards and deliver these words. 2. We are at the beginning of a new era in global health and development. The adoption of the sustainable development goals (SDGs) reflects a fundamental shift in political priorities, offering a major opportunity to accelerate progress in health. The SDGs emphasize the importance of a more integrated and holistic approach to good health, with universal health coverage (UHC) as the foundation for achieving all health-related SDGs and the development of strong resilient health systems. 3. In the pathway towards UHC, countries will need to make important efforts to improve health system performance through innovative approaches that strengthen core health system functions. 4. Across the Region, while there have been improvements in basic health infrastructure and essential health services, there are also growing community expectations from health systems, healthcare organizations and health practitioners. The issues related to quality, safety and patient experience have become paramount. 5. Further, the shift in the burden of disease represents a major challenge to health service delivery, particularly as people have continuing contact with multiple practitioners within the health system. There is an expectation to adopt a more coordinated, humanistic and holistic approach to health care, where the individual who needs care is viewed and respected as a whole person with multidimensional needs. Renewed effort to implement integrated people-centred services has become critical for this health agenda. 6. To respond to these fundamental challenges, there is a need to reorient health services to make an integrated people-centred approach a practical reality. Unless this approach is adopted, health services will continue to remain fragmented, inefficient and unsustainable. This will adversely affect both quality and continuity of care. The patient journey will not be a smooth one. 7. To improve patient experience and satisfaction with health services, countries in the region have undertaken efforts. For instance in New Zealand, the Whānau Ora programme has been introduced as a key cross-government approach that places families at the centre of service delivery, integrating health, education and social services. In China, to address to the needs of a rapidly ageing population, the service delivery model has been reoriented to focus on providing integrated peoplecentred primary care. The Solomon Islands is pursuing integrated care with the goal of improving the

- 20 range and quality of services available to the population in line with the concept of primary health care. 8. An integrated people-centred approach presents a compelling vision of a future in which all people have access to health services that are provided in a way that responds to their preferences, are coordinated around their needs and are safe, effective, timely, efficient and of an acceptable quality. 9. Given the importance of this vision, I am encouraged to see all of you here at this important policy roundtable. I hope the deliberations during the policy roundtable will help shape a transformative agenda towards an integrated people-centred health system. 10. I look forward to hearing the outcomes of this policy roundtable and I thank you again for your presence here today. 11. Thank you.

- 21 Annex 4. Summary of discussions with country participants The WHO Secretariat met with country participants on the second day of the policy roundtable to review the proceedings of the roundtable and to discuss recent initiatives that have been undertaken to adopt a people-centred integrated approach. The following summary of countries is informed by discussions with country participants at the policy roundtable. Cambodia o Provide technical support for reorienting health service delivery models to a people-centred and integrated health services approach, including knowledge brokerage and sharing of models from different countries to create a common understanding of the people-centred model (district health systems, primary health care and hospitals, with NGO involvement). o Support engagement with, and regulation of the private sector to establish baseline quality and safety that is considered acceptable; including consideration of appropriate patient experience and people-centred care indicators as well as appropriate information infrastructure to support monitoring activities. o Leverage on the Quality Assessment Level 2 tools to support integrated care and institutionalize quality improvement. Hong Kong SAR (China) o Provide technical support to strengthen health service delivery using a people-centred and integrated lens, including the hosting of a workshop to support a common understanding of people-centred health care. o Establish information sharing and reporting requirements through health-care law. Build on existing public–private partnerships and encourage interoperability between health information systems to support continuity of care, and information sharing. o Evaluate pilots and scale-up those that conform to system-wide approaches, reaching out to those left behind. o Identify best practices of people-centred care and sharing of experiences to facilitate and promote cross-country learning. o Assist in the design and introduction of financial incentives and bundled payments to ensure care is delivered in an integrated people-centred manner. o Build local leadership, and improve the understanding of social determinants of primary health care within civil society and health-care providers. The Lao People's Democratic Republic o Support localization and translation into Lao of the People-centred health care: A policy framework published by the Western Pacific Regional Office in 2007. o Promote the development, integration and implementation of people-centred health care at all levels of the health system and across all sectors and societies; foster effective leadership and partnership by hosting a national policy roundtable (including senior policy-makers, departments, provincial and hospital levels), giving priority to people-centred health care. o Support the monitoring and evaluation (both quantitative and qualitative) of people-centred policies and actions, designed to achieve integrated health care and a continuous flow of information feedback into the system. o Strengthen health workforce competencies through capacity-building, including training and educating the health workforce to coordinate care and engage patients, in order to prevent the overuse and misuse of care.

- 22 o Develop protocols to ensure that the roles and responsib22ilities of every individual, group and organization participating in the people-centred planning process is clearly understood and agreed by them and adequately supported.

Malaysia o Strengthen primary health-care provision and gatekeeping roles to reduce inappropriate referrals to secondary care; build on existing community clinics and mobile health teams and integrated health screening programmes, intended for holistic care of outpatients. Implement the One Family One Family Doctor concept to improve the quality, continuity of care and compliance towards treatment and management of chronic diseases; realign existing workforce capacities to support primary health-care delivery, such as the life-course approach. o Institute a financing structure that encourages integrated people-centred health care. Explore the introduction of financial incentives and bundled payments to ensure care is delivered in an integrated people-centred way, for example, clinical care pathways (diabetes screening). o Address gaps in the measurement of people-centred health care at all levels including individuals, families and communities and health-care providers. Support continuous quality improvement by encouraging information sharing and learning across countries. o Establish interoperability and information sharing frameworks to encourage information sharing and exchange. Mongolia o Support engagement with civil society, advocacy groups and patient rights’ groups to foster transformational change and co-design. Identify change champions that can mobilize and create a demand for people-centred care; support country exchanges with Malaysia, particularly on the PFPS programme and explore links with WHO collaborating centres. o Advocate for the integration and implementation of people-centred health care at all levels of the health system and across all sectors and societies with senior policy-makers. Philippines o Support a credible, transparent and comprehensive accreditation system of health professionals and health facilities. Ensure compliance with requirements for all professionals. Advocate with all concerned stakeholders, including providers to mobilize continuous quality improvements. o Support reforms on health financing and governance, including consideration of the national health insurance programme, and the devolution of responsibility for health services from the central government to the local governments to support access to quality health services; define roles and responsibilities of Service Delivery Networks. Viet Nam o Promote quality and safety in health services and people-centred health care by supporting a national conference. Support implementation of international quality standards and clinical guidelines, building on work being undertaken in collaboration with the National Institute for Health and Care Excellence (NICE) in the UK on NICE guidance and NICE-accredited sources; leverage existing quality improvement frameworks. o Develop a model hospital for people-centred health care that uses patient identification, clinical care pathways and applies a multidisciplinary approach. The experience from this

- 23 hospital can then be shared with other hospitals in the country, and support on-the-job training and problem-solving to redesign service delivery processes. Strengthen health workforce capacities through capacity-building, including training and educating the health workforce to coordinate care and engage with patients. Provide technical support on reorienting health service delivery models to a people-centred and integrated health services approach. Engage with different stakeholders and sectors.

o o o

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