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International Health

Health Systems Program

Date: Nov 7, 2016

We’re excited to announce that Health Systems Program is on social media! We’ve made the leap to sharing our student & faculty news and our research stories in a broader capacity. We have joined Facebook and Twitter. I invite those of you that use those social media platforms to collaborate with us by liking our Facebook page and following us on Twitter. 

Veena Sriram, a Health Systems Program doctoral student, was recently selected to be one of the “Emerging Voices” at the Fourth Global Symposium on Health Systems Research in Vancouver in November, 2016. Veena’s noteworthy research, which earned her a prized place on the Emerging Voices for Global Health (EV4GH) training program, examines the power dynamics in play in the specialization of medical services in low- and middle-income countries (LMICs), using emergency medicine (EM) in India as a case study.

Sriram’s work centers on the dual concepts of equitable access to health care and how medical specialties are regulated in India. Developed in response to a lack of emphasis in health systems research on governance and regulation, her study examines how new medical specialties emerge in India, and how regulatory institutions within a country decide whether to include a specialty or not. She also wants to interrogate the idea of ‘specialization’ as a solution to service delivery problems, such as weak emergency care, and understand how stakeholders perceive the impact of specialization on health systems and equitable access to care.

Sriram is using the evolution of Emergency Medicine, a specialty formally approved by the Medical Council of India in 2009, to explore these questions. In addition to understanding how medical specialties develop, Sriram will also explore how power dynamics have shaped processes and decision making in this case. The role of power is not well understood in health systems research, and she hopes that this can contribute to the knowledge gap around this topic.

Sriram, who conducted her research based out of New Delhi and Chennai in Southern India, states that her findings are still a work in progress but so far has been a great opportunity to do research on medical specialization and the regulation of postgraduate medical education - two topics that have not been the subject of much research in low- and middle-income countries such as India.

Veena has been specializing in governance and human resources for health through the Health Systems Program after studying emergency care with the Program’s International Injury Research Unit (IIRU) in the summer of 2013. Sriram conducted case studies of three prehospital care organizations in Bengaluru, Karachi and Lahore, which opened the door for her to study emergency care in South Asia. She defended her proposal in the summer of 2014, receiving the Health Systems Program award, as well as a fellowship from the American Institute of Indian Studies. She launched her study in 2015 and analyzed the data in 2016; she hopes to be wrapped up in February 2017. 

Changing ingrained attitudes, perceptions and cultural norms that lead to harmful behavior can be one of the trickiest challenges in public health. There are varying disciplines that attempt to examine why social and behavioral change can be so difficult to accomplish. One of those fields, Health Economics, examines how to design incentives to motivate people to take care of themselves. Dr. Antonio Trujillo, co-director of Health Systems Program’s Master of Health Science (MHS) in Health Economics academic program, spearheads a study in Peru that attempts to understand why people with diabetes fail to take care of themselves over and over again.

In collaboration with the Center of Excellence in Chronic Diseases (CRONICAS) in Peru, Dr. Trujillo’s study looks at the role group incentives play in promoting healthier behavior, specifically, how we can use the combination of cooperation and group monetary rewards to encourage people with diabetes to take care of themselves. Past studies have examined the use of individual monetary incentives to accomplish certain outcomes when trying to change behavior; however, individual cash rewards have increasingly been found to work short-term but not in the long run. In addition to a lack of long-term success for consistent healthy behavior, they are often infeasible and unaffordable to scale-up to larger projects and studies, and frequently face rejection from the general public who are opposed to paying individuals to take care of themselves.

This Health Systems Program project examines the viability of a mixed-incentive study that combines both group motivation and monetary reward. Using a teamwork approach, there are two participants: one patient implements the suggested lifestyle changes while their partner, designated as a “motivator,” encourages them to stick to the new regimen. If the person implementing the suggested changes makes the goal, then they both get rewarded. The aim of the design is to foster cooperation and synergies between participants. The use of social networks and personal connections establishes a more meaningful tie to the healthier routine.

Challenges to introducing behavior change over the long haul still persist and a big part of Dr. Trujillo’s work is understanding these challenges and how best to mitigate them. One such challenge touches upon one of the basic fundamentals of public health - people in many areas of the world lack the information and knowledge, access to primary care and insurance, and do not have the income to support a steady upkeep of their health. These obstacles persist across all geographic areas, and failures to take care of diabetes are similar in both the U.S. and Peru. Dr. Trujillo and the Health Systems Program wish to see gains happen across all different types of behaviors, starting with designing better programs to address chronic disease; however, in order to achieve that, it’s necessary to help people develop a habit of taking care of themselves – all around the world. 

Dear Colleagues and Friends,

It is my pleasure to welcome you to the Department of International Health’s Health Systems Program inaugural blog. Our Program’s goal is to enhance the capacity of communities to improve the health of their people, and we hope to share stories from around the world about our efforts. Our multidisciplinary faculty work in partnership with local governments, community leaders, ministries of health, community-based health and human service agencies, universities and research institutes to address health burdens that span a wide range of fields. From humanitarian relief, to mobile health technology, to addressing the burden of chronic conditions, to injury prevention, our intent is to promote sustainable and community-driven health care and health system interventions.

In light of many global changes, such as the transition from Millennium Development Goals to Sustainable Development Goals and the impending threat of global warming, we hope to join a very important conversation on the future of health systems and define what a cost-effective, equitable and resilient health system should look like. We will do this online, at conferences, and in person as we travel the globe.

I am excited about several items our Program has slated for this year: we launched our Facebook and Twitter accounts so that we can share with you and also hear what you have to say; we have released our first Annual Report for 2015; and most importantly, we welcomed our new Health Systems students into our MSPH, PhD and MHS in Health Economics degree programs. We look forward to sharing more exciting developments with you.

Signature

Adnan A. Hyder, MD, MPH, PhD

Director, Health Systems Program

Professor and Associate Chair, Department of International Health

Diabetes and other chronic conditions are not often the first thing that comes to mind when discussions around treating Syrian refugees arise. Non-communicable diseases (NCDs), such as diabetes, are often a focal point when educating those in non-conflict settings about the importance of diet and physical activity; however they don’t occupy much real estate in the humanitarian sector when it comes to funding and support.

Dr. Shannon Doocy, from the Health Systems Program’s is attempting to target NCDs and other health burdens with a new mobile health (m-Health) app in order to make strides in the field of humanitarian relief for Syrian refugees in Lebanon. Her work in Lebanon centers on developing an app to improve management of hypertension and diabetes in refugee patients from Syria, as well as Lebanese host community members.

Addressing chronic conditions is new for humanitarian agencies - money is already stretched very thin in other immediate-need areas; however, this doesn’t mean that there won’t be dire consequences for failing to take into account the impact of untreated chronic conditions. “Treatment for chronic conditions like hypertension and type II diabetes requires continuous monitoring over time and uninterrupted adherence to treatment regiments, both of which are challenging in ideal settings, but exponentially more difficult in situations of displacement,” states Emily Lyles, a Research Assistant and PhD candidate collecting data on-site in Lebanon. Dr. Doocy hopes to mitigate the additional burden that chronic conditions might bring by improving the quality of care refugees receive and the information provided to them about their chronic conditions.

The application itself, launched in collaboration with a developer from MIT, creates a print-out for patients on the status of their health care. Since refugees are constantly in transition, the print-out allows them to improve the continuity of their care while traveling or being herded from place to place. The app aims to benefit both patients, who upon receiving the print-out perceive the quality of care they are getting to be higher, and local health care providers in Lebanon who are now prompted to ask the patients about their lifestyle choices and other related health matters, thus collecting a whole spectrum of information. The suite of information makes it possible for clinicians to view patient history over time, an important factor for NCD management - especially amongst displaced patients who may be constantly on the move.

The project is not without its challenges: the Lebanese government is currently developing NCD guidelines causing approvals to take longer than anticipated and local medical providers are seeing their caseload increase during an already stressful time period, leaving little extra time during patient consultations. Together with partner organization, International Organization for Migration (IOM), the Center for Humanitarian Health is striving to address the lack of access to and high cost of health care for many refugees who at this time, need care in every form, including against the burden of chronic conditions. The consortium hopes this study will have a sustainable impact on the introduction of m-Health care for chronic conditions in the field of humanitarian relief and provide a seamless transition for mobile populations such as refugees.