The World Innovation Summit for Health (WISH) is a bit of a strange animal.
On the surface, it is one among many international conferences on health.
But as an initiative of the Qatar Foundation for Education, Science and Community Development, it aims to be a platform for action, both internationally and locally in the small oil-rich state.
Its executive chair Professor the Lord Dr Ara Darzi of Denham explained: “It’s about, really, dissemination of evidence-based research and policy across areas of unmet need or the big challenges, which are facing health systems across the globe.”
For example, among the topics covered in the third and latest WISH held in Doha, Qatar, recently, were precision medicine, accountable care, autism, dementia, healthy populations, investing in health and infectious diseases.
Speaking at the pre-summit press conference, WISH CEO Egbert Schillings said: “WISH is not a conference.
“WISH is a community of leaders like the people you see on this panel, and many others who are dedicated to making a difference in healthcare.
“And that is ultimately, why we convene this summit, because that creates for us, the resources that we can then use domestically and globally to make a change in healthcare.”
He gave the example of the Al-Wakra SMART clinic initiative, which is the realisation of accountable care policy ideas mooted in the first WISH in 2013.
The patient-centred pilot project in the city on the east coast of Qatar aims to screen, diagnose and manage diabetes in the local community.
Around 9,800 people from the Al-Wakra population were invited to come for screening at the clinic launched in January 2016.
Last year, 1,580 were screened, of which 44 were found to be diabetic and 32 pre-diabetic.
“This is the beauty of this programme, once you can identify the pre-diabetics, you can start preventive treatment,” said Dr Mariam Ali Abdulmalik, managing director of Qatar’s Primary Health Care Corporation.
She added: “This project has helped us to do more coordinated kind of work – very comprehensive, very integrated between primary and secondary care across the health system.
“It led to proper continuous care that showed patients the success of their management plan.”
The conference proper is actually a platform for expert advisory groups to share their findings on specific topics researched between each WISH with the invited international audience of policymakers, researchers and innovators.
The findings are also discussed by a separate panel of experts at forums during the conference.
The last two conferences have also seen policy briefing sessions being held.
Malaysia, a case study
In fact, Malaysia was one of the two case studies presented during the Health Affairs – Using Evidence-Based Policy Solutions To Address Health Challenges policy briefing at the recent WISH.
Dr Ravindra P. Rannan-Eliya, executive director of the Institute of Health Policy in Colombo, Sri Lanka, shared the results of his study on the unusual success of Malaysia’s dual universal healthcare system, published in the journal Health Affairs last year.
He noted that the unusual thing about Malaysia is that while it has been developing fast as an upper middle-income country, it still has the health system of a developing nation.
“It has very low levels of public spending – around 2% of GDP (gross domestic product) – and that’s meant it has very high levels of private spending, around 1.5% of GDP.
“And this is despite its good MCH (maternal and child health) indicators,” he said.
Despite that, Dr Ravindra observed that Malaysia performs much better than other countries known to have good universal health coverage (UHC), like Taiwan or Turkey.
It also has relatively good healthcare outcomes; relatively equal utilisation of medical services, where people get the services they want and need; and very low levels of financial impoverishment.
“In fact, the kind of bizarre finding was that although it has a relatively high share of private spending, its financial risk outcomes are akin to a country like Denmark’s.
“And this is despite only having a public spending of 2% of GDP,” he said.
This finding led him and his colleagues, including officers from the Malaysian Health Ministry, to conclude that the popularly accepted indicator for financial risk protection, the share of total spending that is out-of-pocket, is not that accurate.
“What’s really more critical is the actual level,” he said.
“The actual level of out-of-pocket spending in Malaysia is only around 1% of GDP – that’s the same as in Sweden.
“So it’s not surprising that Malaysia has similar financial risk protection outcomes.”
However, he added that the country does have two particular problems.
One is the constant political pressure on the Government by middle income citizens who don’t like the inconvenience of the public health sector, but also dislike the high prices of the private sector.
The other is the lack of integration between the public and private healthcare systems, especially in primary care.
In addition, he noted that while their research indicated that the public sector generally offered better clinical care – comparable to the United States and Australia – the quality decreased when it came to high-end clinical care.
For example, he said that a heart attack patient may not immediately get the high-end angiogram in a public hospital.
“It has a political price. But unless the government is willing to pay the political price of raising taxation or other forms of public funding, it’s sort of stuck with this situation of things not quite being right at the boundaries or the edges,” he said.
For countries looking to achieve UHC, Dr Ravindra said: “Malaysia is really an example of one option – if you can replicate what they are doing – of how to move towards UHC, if you can’t get over the public financing barrier.
“It’s another route; it doesn’t solve all the problems, but it’s a solution for those countries.”
Changing behaviour
An area that has been receiving increasing amount of attention from researchers and policymakers worldwide was also addressed for the first time at the summit.
The Behavioural Insights forum was chaired by Dr David Halpern, chief executive of the government-linked social purpose company Behavioural Insights Team (BIT) in Britain.
In an interview with Fit for life, he said: “The majority of years of healthy life lost are a result of behavioural and lifestyle factors.
“And the weird thing about that is that’s not where we spend our money or our time, neither on our research or in terms of our health expenditure.”
He explained: “The way human brains operate, most of it is driven essentially through micro-unconscious or automatic processes.”
Giving the example of reaching for a chocolate bar, he asked if the act is really of our conscious choice or if it is because we have been primed to do it by numerous subtle cues in our environment?
How then can societies change unhealthy behaviours?
“If you really want to change human behaviour, you want to think about (the framework of) easy, attractive, social and timely (EAST),” Dr Halpern said.
Giving the example of a trial on beverages his team ran in a Melbourne hospital in Australia, he shared: “We didn’t ban any of the drinks, but the most unhealthy drinks, the very high-sugar drinks, were just (made) harder to reach physically.
“There was a 20% reduction in their consumption and an increase in the consumption of the other drinks – just by making it easier or more difficult (to reach).
“Only about one in a hundred or so (customers) even noticed the change, even though it affects their behaviour dramatically.
“So, make (behavioural change) easy, make it attractive.”
He also said that people are incredibly influenced by what other people are doing – the social aspect.
In an experiment to reduce unnecessary antibiotic prescriptions, the BIT, along with Public Health England and England’s Chief Medical Officer, identified the general practitioner (GP) clinics that were within the top 20% of antibiotic prescribers within their local area.
Half the GPs identified were sent a letter stating that they were prescribing more antibiotics than 80% of the GPs in their area, and offered them three alternatives to help reduce this number.
Their antibiotic prescription rates reduced by 3.3%, or 73,406 prescriptions, compared to the half who didn’t receive the letter, over a six-month period.
Referring to timely interventions, Dr Halpern mentioned a diabetes screening programme that was conducted in Qatar during Ramadan in 2014 and 2015.
Twenty teams of two nurses each were stationed around one of the large mosques in Doha during Friday and terawih prayers to offer the fasting and post-prandial (or after meal) blood glucose tests respectively.
This took advantage of the fact that the mosque-goers had been fasting for more than eight hours already by the time for Friday prayers – the requirement for the fasting blood glucose test – and would have broken their fast around three to four hours before the terawih prayers.
“It’s a timely intervention,” said Dr Halpern.
“This is true for a lot of behavioural things, which is that if you want to shape behaviour, there are certain moments when it’s right to do.”
However, he noted: “In our experience, one of the problems with governments is that they have a mental model of human beings, which is often just naive or wrong.
“So, in that sense, you need a deep change at the top to realise you’ve got an assumption that’s wrong about your theory of the world.”
He added: “But on the other hand, it needs to come from the bottom of the community in two ways.
“One is that you need to understand human behaviour in its real context – what is your life, what else is going on, what are those pressures?
“User-centred design, it is known as.”
The other, he said, was the importance of informing the public of the evidence shown by behavioural research and allowing them to offer feedback on what needs to be done.
On the surface, it is one among many international conferences on health.
But as an initiative of the Qatar Foundation for Education, Science and Community Development, it aims to be a platform for action, both internationally and locally in the small oil-rich state.
Its executive chair Professor the Lord Dr Ara Darzi of Denham explained: “It’s about, really, dissemination of evidence-based research and policy across areas of unmet need or the big challenges, which are facing health systems across the globe.”
For example, among the topics covered in the third and latest WISH held in Doha, Qatar, recently, were precision medicine, accountable care, autism, dementia, healthy populations, investing in health and infectious diseases.
Speaking at the pre-summit press conference, WISH CEO Egbert Schillings said: “WISH is not a conference.
“WISH is a community of leaders like the people you see on this panel, and many others who are dedicated to making a difference in healthcare.
“And that is ultimately, why we convene this summit, because that creates for us, the resources that we can then use domestically and globally to make a change in healthcare.”
He gave the example of the Al-Wakra SMART clinic initiative, which is the realisation of accountable care policy ideas mooted in the first WISH in 2013.
The patient-centred pilot project in the city on the east coast of Qatar aims to screen, diagnose and manage diabetes in the local community.
Around 9,800 people from the Al-Wakra population were invited to come for screening at the clinic launched in January 2016.
Last year, 1,580 were screened, of which 44 were found to be diabetic and 32 pre-diabetic.
“This is the beauty of this programme, once you can identify the pre-diabetics, you can start preventive treatment,” said Dr Mariam Ali Abdulmalik, managing director of Qatar’s Primary Health Care Corporation.
She added: “This project has helped us to do more coordinated kind of work – very comprehensive, very integrated between primary and secondary care across the health system.
“It led to proper continuous care that showed patients the success of their management plan.”
The conference proper is actually a platform for expert advisory groups to share their findings on specific topics researched between each WISH with the invited international audience of policymakers, researchers and innovators.
The findings are also discussed by a separate panel of experts at forums during the conference.
The last two conferences have also seen policy briefing sessions being held.
Malaysia, a case study
In fact, Malaysia was one of the two case studies presented during the Health Affairs – Using Evidence-Based Policy Solutions To Address Health Challenges policy briefing at the recent WISH.
Dr Ravindra P. Rannan-Eliya, executive director of the Institute of Health Policy in Colombo, Sri Lanka, shared the results of his study on the unusual success of Malaysia’s dual universal healthcare system, published in the journal Health Affairs last year.
He noted that the unusual thing about Malaysia is that while it has been developing fast as an upper middle-income country, it still has the health system of a developing nation.
“It has very low levels of public spending – around 2% of GDP (gross domestic product) – and that’s meant it has very high levels of private spending, around 1.5% of GDP.
“And this is despite its good MCH (maternal and child health) indicators,” he said.
Despite that, Dr Ravindra observed that Malaysia performs much better than other countries known to have good universal health coverage (UHC), like Taiwan or Turkey.
It also has relatively good healthcare outcomes; relatively equal utilisation of medical services, where people get the services they want and need; and very low levels of financial impoverishment.
“In fact, the kind of bizarre finding was that although it has a relatively high share of private spending, its financial risk outcomes are akin to a country like Denmark’s.
“And this is despite only having a public spending of 2% of GDP,” he said.
This finding led him and his colleagues, including officers from the Malaysian Health Ministry, to conclude that the popularly accepted indicator for financial risk protection, the share of total spending that is out-of-pocket, is not that accurate.
“What’s really more critical is the actual level,” he said.
“The actual level of out-of-pocket spending in Malaysia is only around 1% of GDP – that’s the same as in Sweden.
“So it’s not surprising that Malaysia has similar financial risk protection outcomes.”
However, he added that the country does have two particular problems.
One is the constant political pressure on the Government by middle income citizens who don’t like the inconvenience of the public health sector, but also dislike the high prices of the private sector.
The other is the lack of integration between the public and private healthcare systems, especially in primary care.
In addition, he noted that while their research indicated that the public sector generally offered better clinical care – comparable to the United States and Australia – the quality decreased when it came to high-end clinical care.
For example, he said that a heart attack patient may not immediately get the high-end angiogram in a public hospital.
“It has a political price. But unless the government is willing to pay the political price of raising taxation or other forms of public funding, it’s sort of stuck with this situation of things not quite being right at the boundaries or the edges,” he said.
For countries looking to achieve UHC, Dr Ravindra said: “Malaysia is really an example of one option – if you can replicate what they are doing – of how to move towards UHC, if you can’t get over the public financing barrier.
“It’s another route; it doesn’t solve all the problems, but it’s a solution for those countries.”
Changing behaviour
An area that has been receiving increasing amount of attention from researchers and policymakers worldwide was also addressed for the first time at the summit.
The Behavioural Insights forum was chaired by Dr David Halpern, chief executive of the government-linked social purpose company Behavioural Insights Team (BIT) in Britain.
In an interview with Fit for life, he said: “The majority of years of healthy life lost are a result of behavioural and lifestyle factors.
“And the weird thing about that is that’s not where we spend our money or our time, neither on our research or in terms of our health expenditure.”
He explained: “The way human brains operate, most of it is driven essentially through micro-unconscious or automatic processes.”
Giving the example of reaching for a chocolate bar, he asked if the act is really of our conscious choice or if it is because we have been primed to do it by numerous subtle cues in our environment?
How then can societies change unhealthy behaviours?
“If you really want to change human behaviour, you want to think about (the framework of) easy, attractive, social and timely (EAST),” Dr Halpern said.
Giving the example of a trial on beverages his team ran in a Melbourne hospital in Australia, he shared: “We didn’t ban any of the drinks, but the most unhealthy drinks, the very high-sugar drinks, were just (made) harder to reach physically.
“There was a 20% reduction in their consumption and an increase in the consumption of the other drinks – just by making it easier or more difficult (to reach).
“Only about one in a hundred or so (customers) even noticed the change, even though it affects their behaviour dramatically.
“So, make (behavioural change) easy, make it attractive.”
He also said that people are incredibly influenced by what other people are doing – the social aspect.
In an experiment to reduce unnecessary antibiotic prescriptions, the BIT, along with Public Health England and England’s Chief Medical Officer, identified the general practitioner (GP) clinics that were within the top 20% of antibiotic prescribers within their local area.
Half the GPs identified were sent a letter stating that they were prescribing more antibiotics than 80% of the GPs in their area, and offered them three alternatives to help reduce this number.
Their antibiotic prescription rates reduced by 3.3%, or 73,406 prescriptions, compared to the half who didn’t receive the letter, over a six-month period.
Referring to timely interventions, Dr Halpern mentioned a diabetes screening programme that was conducted in Qatar during Ramadan in 2014 and 2015.
Twenty teams of two nurses each were stationed around one of the large mosques in Doha during Friday and terawih prayers to offer the fasting and post-prandial (or after meal) blood glucose tests respectively.
This took advantage of the fact that the mosque-goers had been fasting for more than eight hours already by the time for Friday prayers – the requirement for the fasting blood glucose test – and would have broken their fast around three to four hours before the terawih prayers.
“It’s a timely intervention,” said Dr Halpern.
“This is true for a lot of behavioural things, which is that if you want to shape behaviour, there are certain moments when it’s right to do.”
However, he noted: “In our experience, one of the problems with governments is that they have a mental model of human beings, which is often just naive or wrong.
“So, in that sense, you need a deep change at the top to realise you’ve got an assumption that’s wrong about your theory of the world.”
He added: “But on the other hand, it needs to come from the bottom of the community in two ways.
“One is that you need to understand human behaviour in its real context – what is your life, what else is going on, what are those pressures?
“User-centred design, it is known as.”
The other, he said, was the importance of informing the public of the evidence shown by behavioural research and allowing them to offer feedback on what needs to be done.
Genetics and Islam
Another session that was introduced for the first time at the summit was Genomics In The Gulf Region And Islamic Ethics.
“One of the key elements and characteristics of the genomics revolution is the explosion of knowledge,” said the forum’s chair Prof Dr Mohammed Ghaly.
The professor of Islam and Biomedical Ethics at Hamid Bin Khalifa University’s Research Centre of Islamic Legislation and Ethics (CILE) in Doha, added that this know-ledge might not always be what the patient, researcher or doctor were looking for.
With this in mind, he and his team looked into the ethical management of incidental, or accidental, findings in genomics as related to Islam.
Prof Ghaly noted: “Islamic ethics is not something for aliens; it is not something for strange and weird people.
“We are humans who also use their ethical and intellectual reasoning. But we have a specific package of values that are rooted in the religion, which might make some conclusions different.”
He said that cultural practices that differ between Muslim communities and countries also need to be taken into account.
For example, ancestry is a very important issue in some Arab communities, affecting not only social standing and acceptance, but also legal rights and customary duties.
As such, Prof Ghaly and his team conclu- ded that an incidental finding of someone not being the biological child of their supposed father is forbidden (haram) to be disclosed to the affected person and their family, in accordance with the Shariah principle of protecting offspring.
He explained: “Paternity in the Islamic tradition is not exclusively biological.
“Paternity in the Islamic tradition has a social component, consisting of a valid marital contract between the two parents. It is not the role of the physician to get involved in this.”
Similarly, incidental findings that have no clinical relevance – sometimes because they cannot be treated – should not be disclosed to the patient as it would only cause them more anxiety.
Meanwhile, it is obligatory (harus) to inform patients or participants in genetic research that incidental findings may arise in the course of their genetic analysis, i.e. obtaining informed consent.
Likewise, any incidental genetic information that can lead to lifesaving measures must also be disclosed to the patients or participants.
This, Prof Ghaly said, is in accordance with the Islamic values of honesty, transparency and saving lives.
“What’s important between obligatory actions and forbidden actions – that grey space which is in between – needs further discussion. There is no one-size-fits-all approach for incidental findings,” he said.
Relating to this, one of the forum’s panellists, CILE executive director and University of Oxford professor of Contemporary Islam Dr Tariq Ramadan said: “We need a transdisciplinary approach between the two know- ledges, so to speak.
“No way can you deal with bioethics, no way can you deal with medical knowledge today, without people coming together.”
He stressed that neither Islamic scholars nor scientists, who might have economic forces behind them, alone should determine what Islamic bioethics in genomics should be.
“My feeling is that the very old traditional (Islamic) framework is not enough to come up with responses to these details,” he said.
Prof Ghaly said that he sees Islamic bio- ethical deliberations as part of the dialogue between scientists, Islamic scholars and ethicists worldwide, regardless of religion. “It is a matter of cross-fertilisation of ideas and thoughts.”
Concluding the forum, he said: “I think empowering the research participant, empowering the patient, and respecting their worldview – how they think about this life, why do they live this life – is very critical in developing any standards in the field of genomics and incidental findings in particular.”
Another session that was introduced for the first time at the summit was Genomics In The Gulf Region And Islamic Ethics.
“One of the key elements and characteristics of the genomics revolution is the explosion of knowledge,” said the forum’s chair Prof Dr Mohammed Ghaly.
The professor of Islam and Biomedical Ethics at Hamid Bin Khalifa University’s Research Centre of Islamic Legislation and Ethics (CILE) in Doha, added that this know-ledge might not always be what the patient, researcher or doctor were looking for.
With this in mind, he and his team looked into the ethical management of incidental, or accidental, findings in genomics as related to Islam.
Prof Ghaly noted: “Islamic ethics is not something for aliens; it is not something for strange and weird people.
“We are humans who also use their ethical and intellectual reasoning. But we have a specific package of values that are rooted in the religion, which might make some conclusions different.”
He said that cultural practices that differ between Muslim communities and countries also need to be taken into account.
For example, ancestry is a very important issue in some Arab communities, affecting not only social standing and acceptance, but also legal rights and customary duties.
As such, Prof Ghaly and his team conclu- ded that an incidental finding of someone not being the biological child of their supposed father is forbidden (haram) to be disclosed to the affected person and their family, in accordance with the Shariah principle of protecting offspring.
He explained: “Paternity in the Islamic tradition is not exclusively biological.
“Paternity in the Islamic tradition has a social component, consisting of a valid marital contract between the two parents. It is not the role of the physician to get involved in this.”
Similarly, incidental findings that have no clinical relevance – sometimes because they cannot be treated – should not be disclosed to the patient as it would only cause them more anxiety.
Meanwhile, it is obligatory (harus) to inform patients or participants in genetic research that incidental findings may arise in the course of their genetic analysis, i.e. obtaining informed consent.
Likewise, any incidental genetic information that can lead to lifesaving measures must also be disclosed to the patients or participants.
This, Prof Ghaly said, is in accordance with the Islamic values of honesty, transparency and saving lives.
“What’s important between obligatory actions and forbidden actions – that grey space which is in between – needs further discussion. There is no one-size-fits-all approach for incidental findings,” he said.
Relating to this, one of the forum’s panellists, CILE executive director and University of Oxford professor of Contemporary Islam Dr Tariq Ramadan said: “We need a transdisciplinary approach between the two know- ledges, so to speak.
“No way can you deal with bioethics, no way can you deal with medical knowledge today, without people coming together.”
He stressed that neither Islamic scholars nor scientists, who might have economic forces behind them, alone should determine what Islamic bioethics in genomics should be.
“My feeling is that the very old traditional (Islamic) framework is not enough to come up with responses to these details,” he said.
Prof Ghaly said that he sees Islamic bio- ethical deliberations as part of the dialogue between scientists, Islamic scholars and ethicists worldwide, regardless of religion. “It is a matter of cross-fertilisation of ideas and thoughts.”
Concluding the forum, he said: “I think empowering the research participant, empowering the patient, and respecting their worldview – how they think about this life, why do they live this life – is very critical in developing any standards in the field of genomics and incidental findings in particular.”
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