With the increasing complexity of globalisation, escalating cost of healthcare and rapid advances in technology—both equipment and IT—the challenges and choices facing the practising physician, managers and leaders are daunting. The effects of these changes on patient care may be even more difficult to discern.
Good health for all populations is a recognised international goal. There have been broad gains in life expectancy over the past century, but the health inequalities between the rich and the poor still persist. The prospects for future health depend increasingly on the relatively complicated process of globalisation.1 Health is not only a benefit of development, but is also indispensable to development.2 Illness too often leads to ‘medical poverty traps’,3 creating a vicious circle of poor nutrition, forgone education and more illness. All of these undermine the economic growth that is necessary, although not sufficient, for widespread improvements in health status. Social determinants of health, broadly stated, are the conditions under which people live and work, which affect their opportunities to lead healthy lives. Good medical care is vital, but unless the root social causes that undermine people’s health are addressed, the opportunity for well-being cannot be achieved.
Globalisation results in greater integration within the world economy, through movements of goods and services, capital, technology and labour, which leads increasingly to economic decisions being influenced by global conditions.4 This resulted in the increasing interdependence and interaction among people, companies, and governments of different nations, driven by international trade and made possible by innovations in information technology. Globalisation has become a two-way street as developed and developing countries tap each other’s markets and economies creating a virtual world labour and market force.5 Globalisation today is viewed as a more comprehensive phenomenon which is being shaped by a multitude of factors and events but at the same time is reshaping our society rapidly.6,7,8
| The emergent global marketplace has taken on the following features9: • New global governance structure which influences the interdependence among nations as well as the nation state's sovereignty • Global markets characterised by emergence of global markets and a global trading system. • Global communication and diffusion of information enabling the sharing of information and the exchange of experiences around common problems. • Global mobility resulting in a major increase in the extensity, intensity and velocity of movement and by a wide variety in 'types' of mobility. • Cross-cultural interaction between global and local cultural elements. • Global environmental changes threatening the ecosystems include global climate change, loss of biodiversity, global ozone depletion and the global decline in natural areas. |
Globalisation should not be seen as a process that is inherently ‘bad’ or ‘good’ but rather, a process capable of both positive and negative outcomes. The outcomes of globalisation are entirely dependent on how policies are guided and implemented. The promotion and resistance of globalisation has taken shape both at a population and governmental level. It is believed that such efforts can only hope to steer globalisation and not alter it. Sadly, globalisation, to a large extent, appears to have economically benefited the heavily industrialised countries with serious adverse consequences for developing nations, with some notable exceptions. They are alternative pathways for developing countries to allow a more gradual approach to introducing market economics thus allowing developing nations to claim a stake on the potential profits of globalisation.
In the medical domain, economic aspects of globalisation of healthcare have been the driving force behind the overall process of globalisation over the last two decades.10 Irrespective of the state of development, globalisation has resulted in the increased speed with which information about new treatments, technologies and strategies for health promotion can be diffused. There are also more opportunities for enhanced political participation and social inclusion that are offered by new, potentially widely accessible forms of electronic communication.
o How can countries deal with globalisation in the context of their existing cultures, beliefs, resources and systems?
o How do we deal with the impact of globalisation on the healthcare delivery systems of the various jurisdictions? 10
o How does one cope with the massive impact on a country’s economy of claiming a share of the economic activity that the health industries and service sectors represent, which incidentally is the largest industry on a global scale?10
o How can developing nations protect their indigenous treatments from being patented in industrialised nations?
o How can the serious brain drain of the limited healthcare personnel from developing nations toward the industrialised West be moderated to ensure the needy have access to the services of this invaluable resource?
o What mechanisms should be in place to ensure universal access to essential medication and basic imaging facilities?
The consumer of the 21st century is increasingly critical of quality and service, but more importantly he wants the consultation, diagnosis and treatment, and if possible, cure, right there! In addition, these consumers have educated themselves on their medical condition and are prepared to question their healthcare provider on the choices available to them.11 They even come with stacks of printed copies of information downloaded from the Internet for confirmation and clarification. The increased presence of the Personal Health Records (PHR),12 centered on consumer, is empowering them with full control over their healthcare needs. It is not unthinkable for them to insist that their health information is updated into their records for second opinion and safe keeping. They will become their own gatekeepers.
With the growing trend in healthcare toward higher operational costs, reduced reimbursement and heightened competition among imaging service providers, healthcare facilities must carefully plan capital equipment acquisitions and budgets. Many of today’s high-end modalities such as CT, MRI and PET / CT are multi-million dollar purchases that require strategic planning for implementation as well as detailed marketing initiatives that can help maximise utilisation.
For organisations or practices to remain competitive in this global environment, they must recognise the new healthcare marketplace and its effects on their practices. These changes encompass health consumerism, marketing, service, recruiting11 and the networks.
Global marketing
While consumers search the Internet to gain better knowledge about their health and medical conditions, they are also seeking out the most attractive healthcare provider locally, regionally and internationally.13 They look at comments by third-party providers and by the patients themselves on blogs or testimonials.
Virtual services
Healthcare providers must now make their services more readily accessible than was ever physically possible and at an amazingly reduced cost. Already, this inevitability has reached the individual clinician where doctors / institutions / service providers recognise that Web-based technologies will inevitably become more central to their work.14
Health tourism is another consequence of this trend where we will see greater collaboration between services and centres across oceans providing complex care. For example, health insurance companies providing services for their clients in other nations. The rationale being increased speed of care at lower cost with a seaside holiday thrown in for recovery.
Global / Virtual recruiting
There is increasingly much broader and more severe worldwide shortage of healthcare workers than the periodic shortages over the past four decades. This shortage reflects growing demand, shifting demographics, a change in career expectations and attitudes about work, and worker dissatisfaction within healthcare15 as well as greater mobility and international recognition. To meet this demand, providers will be forced to recruit staff worldwide taking into consideration the heterogeneous needs of workers from various cultures.
Global networks
Global networks in medicine have allowed individuals an access to organisational and business linkages in both international health and global medicine. These networks have promoted cooperative relationships in areas such as standards and formulation of practice guidelines, research in multi-centre and multinational trials, visitor exchange, humanitarian service as well as medicine and supply donation.
Even though branding is very often used to sell products with no real value beyond what is often perceived by the buyer, the promotion of vital and good technology i.e. digital image management, in the bigger picture may be pointless unless its ‘brand’ is perceived to be of value and requires the necessary buy-in from governments, professionals, managers and the public. Therefore, the use of price as the sole criterion for success in the information-based industry may not be enough15 as the tools for conducting business electronically are low.
Other than medical imaging, digital imaging and Information Technology (IT) are also productivity drivers as they allow providers to better manage vast volumes of data at a lower cost. The prevailing perception amongst hospital administrators and physicians is that implementation of IT will provide a competitive advantage. The better use of technology and interoperable electronic networks should accelerate integration; standardisation and knowledge transfer of the administrative and clinical information especially in the context of the globalisation of healthcare and efforts in many countries to create a sustainable health system. Only two elements exist in a connected world: the customer and the information.16 The key to the former lies in managing the latter.
There is a trend toward using IT solutions and sophisticated practice management tools to help physicians and administrators manage their practice as a business. It is envisioned that the key business data would be seamlessly available for decision support. This could cut costs by identifying and managing process inefficiencies and track revenues to improve business. Ultimately, it is hoped that such use of data-mining would result in better outcomes, more cost-effective processes and overall improved healthcare.
The future of healthcare outsourcing and offshore services will vary across the provider, payer, and supplier sectors. The jury is still out, since major challenges occur when one looks at issues of cross-border transfer of digital image information whether for purposes of reading or management. This is, in part, due to the highly regulatory environment and national compliance requirements. It is essential that organisations consider the use of offshore services as a strategic tool which must be integrated with their business model. For example, would the offshore services support and improve the organisation’s overall ability to deliver quality services? Would patient safety or improved care delivery efficiencies and service levels get better?
On the downside, the implementation of sophisticated healthcare IT systems requires heavy initial investment. Upgrades or changes to the systems to stay current come with risks and inconvenience to the users who have to learn to use a variety of different logins, platforms and formats to access the data mergers, and acquisitions between organisations—big and small and raises additional issues of integration of the digital management systems.
In addtion, the role of IT in healthcare in developing nations, where the basic healthcare needs have not been met, has not been clearly defined. Technology is very often promoted as the saviour to overcome the myriad of challenges faced by developing nations. Technology is not infrequently seen as an end in itself and not an enabler. Nations are often seduced into acquiring expensive technology because it is seen as sexy! Or, technology is acquired as a marketing tool to convince the public that this is the “happening” community or hospital at the forefront of healthcare!
Would the accrual of benefits highlighted for the developed nations be applicable to others? At what level and at what cost? What models will be most appropriate for this wide range of development states? What level of technology would be most appropriate? What necessary actions have to be taken by nations to make IT deliver its potential and promise in healthcare sector? Is the promotion of healthcare information technology relevant? Are doctors to be equally blamed for these excesses as a result of creative marketing? We may not have the answers today, but these are the issues that we must face sooner or later.
Conclusion
The increasingly complex and integrated world is blurring the borders between economics, culture and politics. This has resulted in changes in how our societies function today. These changes have the potential for serious consequences, which challenge the economic and political stability of the world. However, these very changes could provide tremendous opportunity for us to create a better world. Therefore, to comprehend the interconnected nature of a globalised world and to understand the consequences of our policy choices and grasp the new face of the world, all of us need to understand how globalisation works, what policy choices we have now, and what are the consequences of such choices. While thoughtful, deliberate, and innovative leadership is necessary to help shape globalisation, the process itself is inevitable, even if the final form may be very different.
Due to the rising costs of living, access to affordable health has become an area of increased concern to the public. The need to embrace sustainable development that ensures equitable access to healthcare for our future generations is both a necessity and yet a tremendous challenge in view of the different perspectives, priorities and interests between the nations, governments, business and communities. Even though we are unable to predict the future, we have an opportunity to shape our operating systems, determine the future scope and design of our healthcare systems. The need to balance healthcare costs while providing high-quality care and universal access is nothing less than an exercise in leadership for this 21st century.16
AUTHOR BIO
Basri JJ Abdullah is currently teaching at the Department of Biomedical Imaging, University of Malaya and Consultant Radiologist at the Biomedical Imaging Unit, University of Malaya Medical Centre. He is currently a member of the Executive Committee of the Asian Ocean Society of Radiology as well as the President of the ASEAN Association of Interventional Radiology and Treasurer for the ASEAN Association of Academic Radiologists.
Ranjit Kaur is currently a lecturer in the Department of Biomedical Imaging, University of Malaya and Consultant Radiologist at the Biomedical Imaging Unit, University of Malaya Medical Centre. Ranjit is currently actively involved in women’s imaging and musculoskeletal radiology. She is also a fellow of the Royal College of Radiologists.
References:
1. World Health Organization. World Health Report 2004: Changing History. Geneva: World Health Organization; 2004.
2. World Health Organization. Macroeconomics and Health: Investing in Health for Economic Development. Geneva: World Health Organization; 2001.
3. Whitehead M, Dahlgren G, Evans T. Equity and health sector reforms: can low-income countries escape the medical poverty trap? Lancet 2001;358:833-836.
4. Jenkins R. Globalization, production, employment and poverty: debates and evidence. Journal of International Development 2004;16:1-12.
5, 6. Mathews P. What globalization in healthcare means to you. [Online] 2005. [cited 2008 Feb 2]. Available from: http://www.healthcareitnews.com/story.cms?id=3639
6. Huynen MMTE, Martens P, Hilderink HBM. The health impacts of globalisation: a conceptual framework Globalization and Health 2005;1:14 doi:10.1186/1744-8603-1-14.
7. Woodward D, Drager N, Beaglehole R, et al. Globalization and health: a framework for analysis and action. Bulletin of the World Health Organization 2001;79:875-881.
8. Labonte R, Torgerson R. Frameworks for analyzing the links between globalization and health. Draft report to the World Health Organization. Saskatoon, SPHERU, University of Saskatchewan; 2002.
9. Labonté R, Schrecker T. Globalization and social determinants of health: Introduction and methodological background (part 1 of 3). Globalization and Health 2007;3:5 doi:10.1186/1744-8603-3-5.
10. Ellis P. Globalisation of Healthcare: a UK Perspective. Healthcare papers 2003;4:45-49.
11. Nash MG, Gremillion C. Globalization Impacts the Healthcare Organization of the 21st Century. Demanding New Ways to Market Product Lines Successfully. Nurs Admin Q. 2004;28:86–91
12. Tang PC, Ash JS, Bates DW, Overhage JC, et al. White Paper. Personal Health Records: Definitions, Benefits, and Strategies for Overcoming Barriers to Adoption Journal of the American Medical Informatics Association. 2006; 13: 121-126
13. 2001: an interactive PR odyssey where health content is king. Healthcare PR & Marketing News. 2000;9:1
14. Smith EM., Massat MB. What must radiologists do to remain relevant (Adaptable or Endangered: Radiology Redefines its Destiny.
The accessibility of imaging exams to other physicians may threaten the role of radiology. (http://new.reillycomm.com/imaging/article_print.php?id=493)].
15. AHA Commission on Workforce for Hospitals and Health Systems. In our hands. In: AHA Meeting Series; August 2002; Denver, Colo]
16. Hays, PG. Observations on Apparent Paradoxes: Health Care Markets in the New Millennium. Health Care Management Review 2000;25: 79-84.
