Hospitals for Health - Amanda Glassman

Summary

The CGD Podcast Episode Summary

Episode Title: Hospitals for Health – Amanda Glassman
Date: September 22, 2014
Host: Lawrence MacDonald (Center for Global Development)
Guest: Amanda Glassman (Senior Fellow, Director of Global Health Program, CGD)

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Episode Overview

In this episode of the Global Prosperity Wonkcast, Lawrence MacDonald interviews Amanda Glassman about the CGD’s new initiative: the Hospital Collaborative for emerging markets. The discussion centers on the overlooked role of hospitals within health systems in developing countries, the need for better data, and the launch of a global collaborative to improve hospital performance and policy. The podcast also highlights lessons from the Ebola epidemic and encourages a more holistic approach to global health development.

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Key Discussion Points & Insights

1. Why Focus on Hospitals Now?

• Past international aid has prioritized primary health care in developing countries, addressing preventive and easily treatable health needs.
• Glassman points out that while this "low-hanging fruit" of primary care is largely picked, health systems now need to advance to provide more complex care, in which hospitals play a crucial role.
  • [00:42] Amanda Glassman:
    “We’ve pretty much picked that low hanging fruit and now we’re talking about thinking about the health system in a more integral way. And the hospital plays a really important role in producing health. And it’s also what people really want to use.”
• Hospitals are essential for emergencies, maternity care, and conditions unsuited to primary care facilities.

2. Hospitals in crisis: The Case of Ebola

• The devastating Ebola outbreak in West Africa highlighted the dire shortage of functioning hospital beds; families were turned away due to lack of capacity.
  • [01:42] Lawrence MacDonald:
    "These terrible stories about families going back and forth across the city and taxis and wheelbarrows being turned away because there are just no beds for them."
  • [02:08] Amanda Glassman:
    "The hospital has a really important rescue function, emergency response function, and there’s just been an incredible amount of underinvestment in hospitals."
• Glassman critiques donor approaches that focus on building hospitals without ensuring sustainability, staffing, and operational effectiveness.

3. The Challenge of Data and Measurement

• The current global data on hospital capacity is inadequate, using simple metrics like beds-per-population and average length of stay, which may obscure crucial performance issues.
  • [03:07] Amanda Glassman:
    “We have these basic ratios of beds to population, but that’s not a really informative indicator… In some countries, they're using old technologies […] then you’re in the hospital for seven days because maybe they’re being reimbursed on a bed day basis.”
• There’s a need for more nuanced hospital performance data, including quality and efficiency metrics.

4. Examples and Equity Concerns in Hospital Provision

• Glassman describes successful hospital models in low- and middle-income countries, often in the private sector or through public-private partnerships.
  • [04:31] Amanda Glassman:
    "There are lots of great examples of hospitals that have made it work in low and middle income settings... The trouble many times people are concerned about that the poor don't have access to those services. And that's a really important issue."
• The importance of building functioning facilities, even if initially accessed mostly by those able to pay, is discussed—with the caveat that public policy should ensure poor people get access through subsidies.

5. The “Hospital Collaborative” Initiative

• The CGD’s working group seeks to reframe hospitals as central to health systems and develop tools to compare and benchmark hospital performance across countries.
  • [06:46] Amanda Glassman:
    “First a worldview that places the hospital right in the center of the health system. So it articulates a role for the hospital that can be health and equity enhancing.”
• Hospital sector diagnostics and comparable analysis are part of the recommended approach.

6. Model for Global Collaboration

• MacDonald draws a parallel to CGD’s earlier work on impact evaluation (3ie), which led to a global entity.
  • [08:33] Amanda Glassman:
    “I absolutely do. I think it’s a great model. I could imagine such a mechanism being placed in an organization such as the World Bank that actually has an enormous amount of demand for lending on hospitals and needs these resources.”
• Discussion on potential hosts for the new collaborative (e.g., World Bank, universities, WHO), but consensus that it needs to be flexible and data-focused.

7. Not About Funding, But About Knowledge and Policy

• The goal of the collaborative is not to directly fund hospitals but to provide better information, benchmarking, and policy advice.
  • [10:37] Amanda Glassman:
    “There’s plenty of money in hospitals. The issue is really not the financing, although of course, you can always spend more. The issue is about what’s the kind of policy, advice and support that’s required to make the hospital work for health in those countries.”

8. Interest and Multisectoral Engagement

• The initiative sparked significant interest, bringing together experts from eight countries, public and private sectors, NGOs, and global health organizations.
  • [12:32] Amanda Glassman:
    "We have private sector leaders, the chairman of one of the largest private sector hospitals in India, but we also have person in charge of health reform and hospital policy in Indonesia. We have people from Colombia, Brazil... We just have an enormous group, an incredible amount of expertise, and we've really benefited from that."

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Notable Quotes & Memorable Moments

• On the neglect of hospitals:
  “There’s just been an incredible amount of underinvestment in hospitals. Although some donors love to give hospital buildings, they don’t always think about everything else that needs to be in place to make the hospital work.”
  — Amanda Glassman, [02:08]
• On the need for empirical data:
  “We have these basic ratios of beds to population, but that’s not a really informative indicator.”
  — Amanda Glassman, [03:07]
• On the importance of hospitals:
  “Hospitals matter, hospitals matter.”
  — Lawrence MacDonald, [06:58]
• On the approach for strengthening hospitals:
  “Trying to benchmark what's happening in different places. I think there's probably first a need to establish some kind of baseline for what's going on because we really don't have a lot of the information we need.”
  — Amanda Glassman, [07:00]
• On equity and system design:
  “If you don’t have any infrastructure at all to provide, maybe it’s better to have facility that actually works and then put in subsidies so the poor can use rather than trying to generate a hospital from nothing.”
  — Amanda Glassman, [04:31]
• Closing reflection:
  “I would just ask all of us that work in the field of global health and development to reflect on themselves and where they would need or want to seek care if something serious happened to them. Because something serious will happen to all of us sooner or later, unfortunately. And to not have a good hospital or urgent care available when you have an emergency or you need more sophisticated services is really a tough situation.”
  — Amanda Glassman, [14:05]

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Important Timestamps

• 00:42 – Why focus on hospitals now?
• 01:42 – Hospitals during the Ebola crisis
• 02:08 – Donor neglect beyond hospital buildings
• 03:07 – State of hospital data and metrics
• 04:31 – Examples of successful and equitable hospital provision
• 06:46 – Unbundling the “hospital problem” and the worldview shift
• 07:38 – Benchmarking and data needs
• 08:33 – The model for a hospital collaborative and institutional hosting
• 10:37 – Primacy of knowledge over funding for this collaborative
• 12:32 – Composition of the CGD working group
• 14:05 – Glassman’s closing reflection on the need for hospitals

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Final Thoughts

Amanda Glassman calls for a reevaluation of how the global health community supports hospitals, urging that hospitals be recognized as indispensable elements of robust health systems. She invites broader participation and feedback in shaping the CGD’s forthcoming recommendations:

“Please stay tuned for the consultation draft of working group report. We welcome comments and input from anyone, regardless of background and how we can improve it, how we can make our recommendations more practical and more actionable. All of that is welcome.” [14:43]

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For listeners interested in global health or health systems development, this episode offers a rich, empirical, and highly relevant discussion on the evolving needs and strategies for strengthening hospital care in low- and middle-income countries.

Transcript

[A]

Welcome to the Global Prosperity wonkcast. I'm Lawrence MacDonald. My guest today is Amanda Glassman. She's a senior fellow here at the center for Global Development and the director of our global health program. Amanda, welcome to the show.

[B]

Thank you.

[A]

We're here today to talk about a new effort that you are leading, shorthand name Hospital Collaborative for emerging markets. We were talking before, it's not only about emerging markets, it's about hospitals in developing countries. The rich world has put a lot of energy into healthcare in the developing world, led by the Gates foundation and lots of money from bilateral donors. Why think now about hospitals?

[B]

Well, there's been an enormous amount of attention to primary health care. So the basic preventive services, the low hanging fruit that can really be transformative for health status. But I'd say we've pretty much picked that low hanging fruit and now we're talking about thinking about the health system in a more integral way. And the hospital plays a really important role in producing health. And it's also what people really want to use. You know, when you break your arm, you want someone to see you right away. And that's something that perhaps a primary health care center cannot deal with. Also, there's a push for maternity care and hospital births. Well, to get that done, we really need better facilities and hospitals. So basically this group is seeing a lot of neglect around the issue of hospitals and hospital policy and trying to think about what can we do at the global level or working in partnership with other countries to enhance the health impact of the hospital in the health system.

[A]

The lack of hospitals is in the news every day now with the terrible news coming out of West Africa about the Ebola epidemic where there are just not enough beds. These terrible stories about families going back and forth across the city and taxis and wheelbarrows being turned away because there are just no beds for them. Presumably the hospital situation was pretty dire in those countries even before Ebola.

[B]

That's right. I mean, the hospital has a really important rescue function, emergency response function, and there's just been an incredible amount of underinvestment in hospitals. Although some donors love to give hospital buildings, they don't always think about everything else that needs to be in place to make the hospital work. And that's been something common with Chinese aid. For example, in Liberia there's a China donated hospital, but it was never fully staffed, it was never fully operative. Same as the case in Afghanistan where several countries gave hospital facilities but didn't start thinking about how can we make this hospital run? How can we make it accessible to the entire population? What are the needs? So these are the kinds of issues that we're concerned with in this group.

[A]

I know that one of the distinguishing features of the work here at center for Global Development is we try and make it be empirical, derived from data. What's the state of data concerning the availability of hospitals in the developing world?

[B]

Well, I mean, we have these basic ratios of beds to population, but that's not a really informative indicator. We have things like average length of stay, which tends to be much longer in the developing world than in wealthier countries. So, you know, if you went in for an appendectomy, maybe in the, I don't want to use the US as an example, but let's say in Canada you might go in two days for an appendectomy and be done by laparoscopy. You'd be stitched up and you'd be going home the very next day.

[A]

Partly because the costs are high. They want you in and out. Right.

[B]

But it also has, it has the basis of, of protocols that make sense from a quality and cost effectiveness point of view. So in some countries, they're using old technologies that open up your entire abdomen in order to take out your appendix and then you're in the hospital for seven days because maybe they're being reimbursed on a bed day basis. So it's really not just about getting the costs under control, but making sure that those hospitals are delivering quality care at a reasonable price in a way that enhances its impact.

[A]

Are there any lower middle income countries that have done a really good job with hospitals? Anybody we can point to and say be more like so and so. I know one of your blog posts on this is about Lesotho, but I gather it's mostly controversy about whether or not they should have invested in the hospital.

[B]

Well, you know, I think there are lots of great examples of hospitals that have made it work in low and middle income settings. And they are many times in the private sector, many times they're public, private partnerships. So it just shows that with the right kind of available financing and technical assistance and support, hospital can do quite well at producing better health care and being more responsive to patients. The trouble many times people are concerned about that the poor don't have access to those services. And that's a really important issue. But on the other hand, if you don't have any infrastructure at all to provide, maybe it's better to have facility that actually works and then put in subsidies so the poor can Use rather than trying to generate a hospital from nothing or, you know, I mean, I guess the public sector doesn't have a great track record in some of the low and middle income countries in terms of quality and performance. I think, you know, exceptions to that would be South Africa, which has a very good public hospital system, Brazil, countries like that, sort of the very large countries that have achieved a certain level of coverage. They have hospitals that work relatively well, but they still face challenges in terms of efficiency, in terms of concentration of spend, in terms of adhering to quality protocols. There's still lots of room to learn from other places and do better.

[A]

Obviously, describing the problem clearly defining the problem is an important part of any issue like this. And I should mention that as we often do here at the center for Global Development, you've assembled a very impressive group of people who have experienced it with this problem from a wide variety of, of perspectives. This working group, you'll be releasing a draft consultation report in South Africa. What do you think is the most innovative piece of that analysis? It's sort of like, I think of it like, sounds like a big ball of tangled yarn. You know, you could go on and on and on about how terrible these things are. But what's the one piece that you would advise people to tease out? To say, okay, maybe if you pull on this strand, you'll begin to make some progress at untangling this problem. What's the piece that's going to give us a way to unbundle this mess?

[B]

So I guess the idea is first a worldview that places the hospital right in the center of the health system. So it articulates a role for the hospital that can be health and equity enhancing.

[A]

So hospitals matter, hospitals matter.

[B]

So I think that's an important insight, even if it's just kind of high level appreciation. And then the other idea that we had through our discussions is that this is a pretty specialized area and there could be a lot of benefit from doing kind of hospital sector diagnostics, looking at management, finance and operations in a comparable way across countries or within a health system, across different hospitals. So trying to benchmark what's happening in different places. I think there's probably a first a need to establish some kind of baseline for what's going on because we really don't have a lot of the information we need to do the kind of.

[A]

Analysis relates back to my question about the data.

[B]

Exactly. So there's some role, I think, for a global collaborative, we're calling it, to help with data collection, with analysis, with recommending directions for possible reform or adjustment and for learning one from the other.

[A]

When you say a global collaborative and a global effort to sort of establish standards and then collect data and benchmark and share experiences, I'm tempted to go in the direction of the iii, where there was a problem with insufficient impact evaluation. CGD had a working group led by our friend and colleague Ruth Levine that identified the problem. Ultimately, funders put some money on the table. We helped to incubate and spin off a new international entity that has since led the charge to improve impact evaluation. Do you see that as a sort of model for the hospital collaborative?

[B]

I absolutely do. I think it's a great model. I could imagine such a mechanism being placed in an organization such as the World bank that actually has an enormous amount of demand for lending on hospitals and needs these resources. But if the World bank doesn't have the scope to do that kind of knowledge generation analysis, I can easily imagine it being placed in possibly some consortium of consulting with universities or something like that.

[A]

In a university that had itself a major school of medicine, for example.

[B]

Exactly, exactly.

[A]

Excuse me, what about the World Health Organization? I mean, wouldn't that be kind of an obvious place to put the, you know, hospital collaborative?

[B]

Well, I mean, I think, you know, it's definitely one of the options. There is also International association of Hospitals that does some of this kind of exchange between wealthier countries and to some extent developing countries. That's another option. But, you know, the who, I think now more than ever needs to be focused on those global public goods of disease surveillance, control, prevention, as we're seeing in the case of Ebola. And these kinds of collaboratives sometimes can be quite flexible if they happen outside of one of the standard organizations. So definitely WHO needs to be deeply involved. I don't know. You know, at the moment, it's tough to think about placing it there. But these, again, are just my ideas. I'm not speaking on behalf of the working group right now, I'm just speculating.

[A]

But it sounds, just to clarify though, it sounds like this, you know, as perhaps with the International Initiative for Impact Evaluation, that a portion of it would be funding. But this is not primarily about funding. This is about information sharing, benchmarking, standard setting, awareness raising, so that the budgetary needs for such an entity, while not nothing, are not of the order of magnitude that it's going to take to invest in hospitals all around the world.

[B]

Exactly. I mean, there's plenty of money in hospitals. The issue is really not the financing, although of course, you can always spend more. The issue is about what's the kind of policy, advice and support that's required to make the hospital work for health in those countries. So that's, I think, what we're mostly considered concerned with.

[A]

We'll take a quick break. This is the Global Prosperity Wonkcast from the center for Global development. I'm Lawrence MacDonald. My guest is Amanda Glassman, and we're talking about new efforts here at the center for Global Development to focus on hospitals, why they matter, why they're lacking, and what to do. We'll be back in a minute. Amanda, I recall when you kicked off the initial consultation here at CGD about this. I wasn't in the meeting. I wasn't part of it. But I passed by, we've got these glass walls, and there were all kinds of people in there, people I had never seen in the building before. They were intensely engaged in the discussion. And I felt like you had really tapped into a vein of interest that people felt a real need to want to address this problem.

[B]

Yeah, I think there is really growing interest because these countries are growing economically. There's a huge private sector opportunity, but there's also a huge public sector imperative to provide more equitable care. And there's a very large role for nonprofits as well. In many countries, religious organizations or nonprofits like even partners in health run hospitals in country or have built hospitals, Haiti being a great example. So there was just a lot of interest and. And I guess collectively also we knew very little about what was going on and what's happening with hospital performance. So it's just a great opportunity to bring people together with people from eight different countries.

[A]

Tell me about your working group.

[B]

So we're a group of about 20 people. We have private sector leaders, the chairman of one of the largest private sector hospitals in India, but we also have person in charge of health reform and hospital policy in Indonesia. We have people from Colombia, Brazil. We have people from Management Sciences for health and Partners in Health. We have someone from the institute for healthcare Improvement, which is led by Don Berwick, who is one of the very important people in the quality revolution in healthcare in the United States as well. So we just have an enormous group, an incredible amount of expertise, and we've really benefited from that. And of course, Jerry laforge, also from the World bank, has been a real leader in this space. So it's a privilege to work with this group.

[A]

So, yes, it sounds like a terrific group. And I think this is interesting not only because of hospitals, but for those that are curious. What really does a think tank do? This is a great example. This is something that's not going to happen in a large multilateral organization. In the same way, there's more naturally, they're larger, more cumbersome in terms of bureaucracy. It's not going to happen in the university in the same way. And I feel like you're giving listeners sort of an insight into a think tank process before the product comes out.

[B]

Yeah. Yeah.

[A]

Any final thought you want to leave with our listeners about this hospital work?

[B]

Well, I would just ask all of us that work in the field of global health and development to reflect on themselves and where they would need want to seek care if something serious happened to them. Because something serious will happen to all of us sooner or later, unfortunately. And to not have a good hospital or urgent care available when you have an emergency or you need more sophisticated services is really a tough situation. I don't think we should be advocating for just primary health care packages for everyone and for the rest of the palliative care and pain management, that's just not feasible. So we really need to think about a whole health system response and provide support in that way so hospitals really matter. And then the second thing I'd like to say is please stay tuned for the consultation draft of working group report. We welcome comments and input from anyone, regardless of background and how we can improve it, how we can make our recommendations more practical and more actionable. All of that is welcome.

[A]

Terrific. Thanks very much. I always learn when I have a chance to chat with you. This has been the Global Prosperity Wonkcast from the center for Global Development. My guest today is Amanda Glassman and we've been discussing forthcoming CGD work on hospitals in developing countries. You can find the Wonkast online on itunes and on Stitcher. Just search for wonkcast or CGD and sign up to hear a new interview every week. Until next time, I'm Lawrence MacDonald. Thanks for listening.