Eiu Health System Preparedness Final

Assessing health system
preparedness for multiple

chronic conditions
Methods and findings report
Assessing health system preparedness for multiple chronic conditions
1
Contents
2 About this report
3 Project overview
3 Project objectives
3 Terminology and definitions
5 The Index
5 Index methods
6 Notes on interpretation
6 Index findings
8 Key takeaways
14 Discussion of findings by country
25 Opportunities for action
26 A framework for action
27 Appendix 1: scorecard framework and detailed indication descriptions
27 Literature review
27 Preliminary indicators selection
27 Country selection
28 Construction of the preparedness groups
28 Weightings and index consistency
29 Quantitative and qualitative indicators
30 References
34 Appendix 2: Best practice case studies
34 Brazil: dealing with the MCC challenge in a middle-income country
39 China: the family doctor team
42 Spain: Models of care for improved integration of care in Spain
46 UK: Guy’s and St Thomas’ Charity Programme on Multiple Long-term
Conditions
50 UK: Multi-morbidity guidelines and integrated care in the UK
54 US: The AGING Initiative: devising a new paradigm of medical
education in the US
57 References
© The Economist Intelligence Unit Limited 2020

2
About this report

This report describes the methods and main findings from The Economist Intelligence Unit’s
assessment of health system preparedness for multiple chronic conditions (MCC) in 25 countries
across the globe. The research programme consists of an Index of Health System Preparedness,
which measures how ready healthcare systems are for the challenge of MCC and identifies
opportunities for health systems to improve their management of MCC. This report describes
the methods used to build the index and discusses the key findings.
The study was sponsored by Teva, a global generics pharmaceutical company. The Economist
Intelligence Unit bears sole responsibility for the content of this report and the associated executive
summary. The views expressed in the report do not necessarily reflect the views of the sponsor.
We would like to thank the following individuals and organisations for sharing their insights and
experience.
International advisory panel Alan Lopez, Professor of Global and Public

Health and Epidemiologist (University of
Mônica Viegas Andrade, Professor of Economics
Melbourne, Australia)
and Population Health (Federal University of
Minas Gerais, Brazil) Stephen MacMahon, Professor of Cardiovascular
Medicine (Principle Director of the George
Francesco Barbabella, Associate Researcher,
Institute for Global Health, Australia)
Centre for Aging and Life-Course Studies (Linnaeus
University, Sweden) Srinath Reddy, Professor of Cardiology
(President of the Public Health Foundation of
Nina Barnett, Professor and Consultant
India, India)
Pharmacist, care of older people (London North
West Healthcare NHS Trust & NHS Specialist Barbara Reichwein, Programme Director,
Pharmacy Service, UK) Multiple long-term conditions (Guy’s and St
Thomas’ Charity, UK)
Juan Carlos Contel, Nurse and Researcher
(University of Barcelona, Spain) Josep Roca, Professor of Medicine and Senior
Consultant at Hospital Clinic de Barcelona
Lord Nigel Crisp, Co-Chair of Nursing Now
and Senior Researcher at IDIBAPS, Barcelona
(independent crossbench member of the House
(University of Barcelona, Spain)
of Lords, UK)
Harry Wang, Associate Professor at the School of
Tracy Eastman, Global Lead, KTU – BMJ Practical
Public Health (Sun Yat-Sen University, China)
Approach to Care Kit, UK
Heather Whitson, Geriatric Medicine Specialist
Diane Finegood, Professor and Fellow at Simon
(the Duke Centre for Ageing, US)
Fraser University’s Morris J. Wosk Centre for
Dialogue (Simon Fraser University, Canada) Ane Fullando Zabala, Coordination Manager of
the Multimorbid Integration Programme (ACT@
Bruce Guthrie, Professor of General Practice and
scale, Spain)
practicing GP (University of Edinburgh, Scotland)
Cother Hajat, Public Health Physician and Clinical Other contributors
Epidemiologist (Royal College of Physicians, UK)
Chrissy Bishop – EIU project lead
Ian Litchfield, Research Fellow, Institute
Alicia White – EIU project oversight
of Applied Health Research (University of
Birmingham, UK) Anelia Boshnakova – EIU project oversight
Paul Tucker – Editor

3
Project overview
Project objectives As well as discussing the results of the index

by country, this report also explores some
There has been significant progress towards best practices in selected countries, through
reducing mortality and increasing life interviews with experts. The case studies
expectancy around the world.1 Yet although help provide examples of implementing
health systems have improved globally, and MCC initiatives, whereas the index measures
more and more people are living longer, they aspirations from governments, rather than
are doing so with the effects of functional their effectiveness in practice or the quality
health loss and disability.2 Many countries of the implementation of programmes or
struggle to care for people who are living with objectives.
the effects of MCC. This further disadvantages
a large section of the population already
Terminology and definitions
suffering worse health outcomes than
people who do not have MCC.3,4 People with There is interchangeable terminology across
MCC also cost the health service more and the scientific and policy literature to describe
are increasingly complex to manage. It is a people with MCC. By nature, MCC are
challenge for health systems that are made up complex combinations of diseases, with the
of services organised around specialist clinics combinations varying across individuals.
for treating singular conditions to then cope
with several conditions in one person.5 With Establishing a standardised definition for
the advent of covid-19, the impact of MCC people who have more than one chronic
has become even more paramount, given condition is important to enable accurate
evidence to suggest people with underlying prevalence estimates and permit reliable
comorbidities have an increasingly rapid and comparisons of prevalence, both over
severe progression of the virus.6 time and between countries and regions.5,7
A standard definition also facilitates the
The Economist Intelligence Unit has provision of consistent information to people
created a comparative framework that with MCC and helps services to identify and
identifies countries’ ability to respond to provide the right support to these people.
the MCC challenge. This framework aims There is as yet no universally accepted
to comprehensively capture the level of standardised definition of MCC.
policy maturity and the capabilities of health
systems to respond to MCC across 25 different A chronic condition has been defined as
geographies. The results form an index—a tool a condition that lasts a year or more and
that will enable individual countries to assess requires ongoing medical attention and/or
their achievements and learn from others as limits activities of daily living.7 Both physical
they look to improve their performance. and mental conditions can be chronic.
Examples include dementia, depression and
arthritis, as well as developmental disabilities.7

4
The terminology used for one person diagnosis.8 A key defining factor of using
experiencing more than one chronic this term to describe a patient’s status,
condition at a time is more varied. Some unlike with the commonly used term,
of the most commonly used terms include “comorbidity”, is that it does not place
“multi-morbidity”, “MCC”, “comorbidity” and emphasis on any one of the co-‐existent
“polychronicity”.8 This variation reflects the conditions: it is unambiguous, has been used
lack of a standard definition. in both academic and non-‐academic settings,
and incorporates physical and mental health
In this report, we use the term “MCC” to disorders.7,8
describe people who are living with more
than one concurrent chronic disease

5
The Index
Index methods alignment with best practice (as measured

by the index). The countries are arranged
The Index of Health System Preparedness for into preparedness groups according to their
MCC seeks to answer the following question: scores; dark green for “most prepared”, light
how well prepared are healthcare systems green for “fairly prepared”, yellow for “less
to manage the growing prevalence of people prepared” and red for “not very prepared”.
with MCC? This report describes the methods Countries are listed in alphabetical order
used to build the index and includes a within each preparedness group rather than
discussion of the main findings. placing them in a leaderboard.
The index explores the issue of health The design of the index was driven by the
system preparedness through five broad creation of a theoretical framework based
domains: guidelines and policy to support on a collection of indicators that measure
MCC; health system infrastructure to elements of health system preparedness for
support MCC; patient--centricity, training MCC that are inherently desirable. Therefore,
and research; clinical information systems/ it is possible to take standalone domains and
digital transformation; and planning, indicators to help drive specific discussions
prevention and risk management. The first and offer value beyond the overall score for
domain focuses on levers that are mostly each country. In addition to the index, we
in the hands of policymakers. The second have also collected data on ten background
domain looks at whether health systems indicators to support correlation analysis.
have the infrastructure to manage MCC, These indicators provide context but are
which includes financing systems, staffing, not computed in the index scores; they
approach to care and patient advocacy. The include indicators of healthcare spend, health
third domain seeks to understand whether outcomes and risk factors for MCC.
healthcare systems are appropriately
training the healthcare workforce to The index was built following a literature
effectively manage people with MCC, and review and expert panel meeting. The
the fourth investigates whether healthcare 25 countries within the index cover four
systems have the appropriate information geographical regions (the Americas, East Asia
technology systems to collect, organise and and the Pacific, Europe and Central Asia, and
manage information about patients with the Middle East and Africa), three World
MCC. The final domain aims to find out if Bank income groups (lower-‐middle income,
countries have appropriate surveillance upper-‐middle income and high income) and
systems to collect data on and appropriately differing proportions of population older
assess the risk of MCC among their than 65 years (less than 10%, 10-‐15%, 15-‐20%
population, and whether they take steps to or more than 20%). (See Appendix 1 for a
prevent them. The five domains are broken detailed description of the indicators and
down into 20 subdomains and 38 indicators. scoring guidelines.)
Scores are weighted and normalised, so
that the final score for each country ranges
from 0 to 100, with 100 being the highest
possible score, representing complete

6
Notes on interpretation
We describe here five potential cautions differing frequencies. Therefore, there may
on interpreting the Index of Health System be some lags in the situation depicted by
Preparedness for multiple chronic conditions: certain indicators as regards the situation
on the ground.
1. Qualitative and quantitative indicators used
in the index to measure the availability and 5. The study offers a simplified view of the
strength of primary care services favour complex landscape of MCC preparedness
countries that have a robust primary care based on indicators deemed the most
system, which is more likely to be publically representative across selected topics.
funded. Some countries in the index, such Selection was informed by an examination of
as China, Turkey and Ukraine, are still in the literature and consultations with experts,
the early stages of developing a primary but is limited in scope. Consequently, some
care system that mirrors those of western, areas of health system preparedness may
developed healthcare systems. The limitation not have been addressed.
of this approach is that the patients in these
countries may be receiving healthcare for Index findings
conditions that might normally be dealt
with in primary care from other healthcare Figure 1 presents a snapshot of how the index
providers—perhaps secondary care or groups countries within each domain of the
private doctors and funded out-of-pocket. index as well as colour coding each country
according to the preparedness group within
2. Many of the qualitative indicators used in which they sit. These groupings are based on
the index are based on the exploration of the assessment of national policy documents,
national policies and plans, which should be comparative studies, published academic
interpreted as aspirations from governments, papers and publically available datasets. We
rather than as a measure of effectiveness list in the references some of the key sources
or quality of the implementation of for data collection or validation that cover
programmes or objectives. multiple countries. Both figures 1 and 2 colour
code countries according to how well prepared
3. Research for this project was carried out they are: dark green for “most prepared”, light
in the first half of 2020 and considered green for “fairly prepared”, yellow for “less
the best evidence available at the time prepared” and red for “not very prepared”.
on matters relating to health system
The findings are discussed in two parts. Firstly,
preparedness for MCC. Local country
in terms of key takeaways that all health
contributors were used to improve the
systems should be thinking about to provide
penetration of the local healthcare system.
good quality healthcare to people with MCC.
This is a landscape that is undergoing
Secondly, the index showed that no individual
continuous change, and so the situation in
health system has all the answers, but lessons
some countries may since have moved on.
or examples were gleaned from how different
4. For quantitative indicators, the index relies health systems are preparing. Thus, the second
on the best available data. Databases from part of the discussion delves into the findings at
different organisations are updated with a country level.

7
Figure 1: Country scores by domain
1 2 3 4 5
OVERALL SCORE GUIDLINES AND HEALTH SYSTEM PATIENT-CENTRICITY, CLINICAL PLANNING,
POLICY TO SUPPORT INFRASTRUCTURE TO TRAINING AND INFORMATION PREVENTION AND
MCC SUPPORT MCC RESEARCH SYSTEMS/DIGITAL RISK MANAGEMENT
TRANSFORMATION
Australia Australia Australia Australia Australia Australia
Brazil Brazil Brazil Brazil Brazil Brazil
Canada Canada Canada Canada Canada Canada
Chile Chile Chile Chile Chile Chile
China China China China China China
Croatia Croatia Croatia Croatia Croatia Croatia
Denmark Denmark Denmark Denmark Denmark Denmark
France France France France France France
Germany Germany Germany Germany Germany Germany
Indonesia Indonesia Indonesia Indonesia Indonesia Indonesia
Israel Israel Israel Israel Israel Israel
Italy Italy Italy Italy Italy Italy
Japan Japan Japan Japan Japan Japan
Mexico Mexico Mexico Mexico Mexico Mexico
Netherlands Netherlands Netherlands Netherlands Netherlands Netherlands
Peru Peru Peru Peru Peru Peru
Russia Russia Russia Russia Russia Russia
Saudi Arabia Saudi Arabia Saudi Arabia Saudi Arabia Saudi Arabia Saudi Arabia
South Africa South Africa South Africa South Africa South Africa South Africa
Spain Spain Spain Spain Spain Spain
Thailand Thailand Thailand Thailand Thailand Thailand
Turkey Turkey Turkey Turkey Turkey Turkey
United Kingdom United Kingdom United Kingdom United Kingdom United Kingdom United Kingdom
Ukraine Ukraine Ukraine Ukraine Ukraine Ukraine
United States United States United States United States United States United States
 PREPARED  FAIRLY PREPARED  LESS PREPARED  NOT VERY PREPARED

8
Key takeaways 30% and 81%—in this instance, the former

considers only eight chronic conditions for
MCC data collection, prevalence and people aged 18 and above, whereas 185
incidence estimates conditions for people aged 50 and above
were considered in the latter.9 The methods
• Prevalence, incidence and mortality data
for assessing MCC prevalence need to be
are essential to healthcare systems when
standardised in order to yield comparable
planning for the future burden of diseases.
global epidemiological data.
It was not possible to include prevalence
of MCC in the index owing to the lack of • Research into MCC is dominated
a standardised definition for MCC and by a predominance of studies in
therefore lack of consistent reporting of Western countries, especially the
prevalence. Countries include various age US.10 Scientific papers that research
bands when calculating prevalence of MCC MCC are predominantly published in
and some include different combinations of journals devoted to neuropsychiatry
chronic conditions. For example, in Canada, and neurosciences, which reflects the
reported MCC prevalence ranges from 55% importance of mental health as a significant
to 39% for people aged 60-79, owing to the comorbidity of physical health conditions
inclusion of differing ranges of conditions such as cardiovascular disease, cancer and
in the calculations. Similarly, in the UK, other chronic disorders.10
reported MCC prevalence ranges between
Figure 2: The correlation between overall score and guidelines and policies to support MCC
Correlation (X, Y) 0.87
100
1) GUIDLINES AND POLICY TO SUPPORT MCC
90
80
70
60
50
40
30
20
10
0
0 10 20 30 40 50 60 70 80 90 100
OVERALL SCORE
Source: The Economist Intelligence Unit

9
National strategies, guidelines and policies one disease conflicts the other.
for MCC are rare, and in many countries do
• For all of the European countries in the
not exist.
index, the Eurozone crisis is likely to
• Figure 2 shows the positive correlation have had an effect on the organisation
between country scores in domain 1, of healthcare and the top-‐down drivers
guidelines and policy to support MCC, that affect things such as policies and
and the overall score. This basically guidelines.11 A ripple effect of the Eurozone
means that countries are more prepared crisis was a project piloted in EU member
for MCC if they have guidelines and states called the European Collaboration
policies for MCC. While all countries for Healthcare Optimisation, or ECHO.
assessed had at least one evidence-‐based The aim of this project was to highlight
guideline for select chronic conditions unwarranted variation in healthcare
that mentioned managing common delivery that cannot be explained by
comorbidities, only six countries have a illness, medical evidence or patient
national guideline specifically on MCC preference. This kind of deep dive
care. On the whole, however, MCCs into a health system can provide new
are not given exclusive attention in perspectives on national performances
guidelines and policies. The trouble with and lead to enquiries about why these
single disease guidelines, which focus on variations have occurred. The Eurozone
one organ or one disease, is that they can crisis, then, has ultimately encouraged
inadvertently drive polypharmacy (the EU member states to reduce variation in
concurrent use of multiple medications) healthcare practice. This may have had
and problems with medication an influence on the guidelines and system
compliance for patients when advice for reorganisation that has boosted the health
system preparedness scores for countries
Figure 3: Correlation between the health system infrastructure domain and overall index score
Correlation (X, Y) 0.95
100
90
80
2) HEALTH SYSTEM INFRASTRUCTURE
70
60
50
40
TO SUPPORT MCC
30
20
10
0
0 10 20 30 40 50 60 70 80 90 100
OVERALL SCORE

10
covered in the ECHO project, such as (IQWIG).14 IQWIG is a resource for healthcare
Denmark, England and Spain.12 professionals that lists the guidelines that
are recommended for specific conditions. In
• Developing evidence-based clinical this way, the care provision delivered in the
practice guidelines is a time-consuming German health system is standardised.
and resource-intensive process. It involves
systematically reviewing all available
evidence on the clinical issue in question,
Of all five domains, health system
and doing so using a multi-professional
infrastructure had the strongest
review team, as well as members of the
correlation with the overall score
public and patients.13 This means that
developed healthcare systems, such as • Health system infrastructure, which is a
those that, on the whole, exist in high- composite indicator comprising of how
income countries, are more likely to much a country spends on healthcare, and
develop their own clinical guidelines. The the availability of healthcare professionals
index scores reflect this, with the developed such as general practitioners (GPs) and
healthcare systems of France, Germany, community health workers, as well as
the Netherlands, Spain, the UK and the US pharmacy services and patient advocacy
all having an MCC guideline. The index also groups (detailed indicator descriptions can
found a positive correlation, albeit a weak be found in the Appendix), has the strongest
one, between countries that spend the influence on determining how prepared a
most on healthcare and those that have a country is for MCC. Figure 3 demonstrates
guideline and/or policy on MCC. this correlation.
• Most clinical practice guidelines from • All countries in the “prepared” category
internationally respected guideline have public healthcare systems, apart from
development agencies such as the National the US. Healthcare systems with universal
Institute for Health and Care Excellence healthcare coverage are more efficient,
(NICE) in the UK and the Australian National integrated, person-centred and actively take
Health and Medical Research Council, are steps to inform and encourage people to
freely available and accessible online to stay healthy and prevent illness. Integrated
all. Some countries use and adapt clinical care, which is person-centred and
guidelines that were developed by other encourages people to self-‐manage, includes
countries and/or professional societies.13 many elements we determined to be key to
On the whole, countries using professional managing MCC.15
guidelines not produced by their own
governments were not given points for • Effective chronic disease management
doing so, unless these guidelines were programmes are highly dependent on
explicitly adopted as national policy. well-‐ functioning national health systems.16
There was one exception to this scoring Perhaps not surprisingly, factors that limit a
system: Germany uses clinical guidelines country’s capacity to implement strategies
from professional societies but also takes to manage chronic conditions relate to
steps to systematise how these guidelines the way health systems are designed and
are used in clinical practice. It does this function. There is a lack of understanding
using an independent health technology that significant attention to health systems
assessment organisation called the Institute is part of an active response to chronic
for Quality and Efficiency in Health Care diseases.17 Efforts to scale up interventions

11
for managing common chronic diseases too • On a positive note, some countries
often focus on one disease and its causes; (such as Brazil) demonstrate a growing
they are fragmented in their approach and appreciation for recycled models of primary
vertical in their health system penetration. care, focusing on community-‐directed
Instead, the approach should include a interventions and the increasing use of
strengthening of health systems to deliver a community health workers. This community
comprehensive range of services. outreach approach to primary care allows
expansive coverage and is proving to be
• The Innovative Care for Chronic Conditions cost-‐effective.17
Framework, which is adapted from the
Chronic Care Model, lays out the building • Low and middle income countries are
blocks needed to organise healthcare often more likely to suffer from increasing
systems in low-and middle-income prevalence of chronic diseases. This is
countries so that they are prepared to cope because adults who have grown up in
with chronic conditions.18 Although there deprived communities are more prone
is some evidence that the Chronic Care to functional decline caused by chronic
Model has been adopted in the US, the UK, diseases at younger ages. Failing to respond
Canada, the Netherlands and Australia, the to this shift in disease profile will mean
adapted framework is not used as a credible higher health and welfare expenditure for
alternative in low-and middle-‐income countries, and this may reduce national
countries. This is probably because the productivity and competitiveness.19 The
Chronic Care Model requires a level of worsening financial constraints that most
capacity and resourcing that is not feasible health systems are under, partly a result
for many such countries.17 of changing patient demographics, might
just be the incentive that drives healthcare
policymakers to consider chronicity in
High income countries do better overall, primary care models.17
but there are some exceptions
• In all but Saudi Arabia and Israel it appears Generalist healthcare professionals are
that health systems in high income countries key for managing both the treatment and
do better in terms of preparedness for the co-ordination of care for people with
managing patients with MCC. This is most MCC.
likely due to chronic conditions being an area
of focus in developed, high income countries • The nature of the healthcare workforce in
for much longer than in developing ones.19 each country is key to care management.
As measured within the health system
• Primary care in lower middle income infrastructure domain, this included the
countries is focused on episodic care and number of generalists, skilled health workers,
in many cases is poorly situated to deliver pharmacists, mental health doctors and
access to the affordable prevention, mental health nurses. When speaking to
diagnosis and treatment services that many MCC experts as part of this project, most
chronic diseases require. More low-‐cost mentioned the importance of a “generalist”,
investment is needed to elevate primary who could be either a nurse or a doctor.
care as the main platform for responding to A generalist is a professional who can
chronic diseases in the health systems of apply their medical skills across a range of
low-‐income nations.19 conditions—the opposite of a specialist. In

12
some countries, generalists may also be Care co-‐ordination is paramount, but not
healthcare assistants and community health necessarily the norm
workers.
• The patient-centricity, training and research
• More and more evidence suggests that an domain is also positively correlated with
increase in lower-‐cost community health overall score. Within this domain the
workers can increase the coverage and index measures the average duration of
quality of care. These kinds of staffing primary care visits in a country as a proxy
solutions have worked well in the context for whether primary care is equipped to
of HIV/AIDS and have been effective in manage patients with MCC. This is because
compensating for overburdened health people with MCC will require a longer
systems, especially in rural settings.19 consultation to give healthcare providers
These strategies may also prove useful the time to treat and co-‐ordinate care,
in the context of non-communicable so as to make sure that patients receive
diseases (NCDs). support for each condition. Only six
countries (Canada, Chile, France, Peru,
• Nurses are the largest part of the professional
Russia and the US) had primary care visits
health workforce, and they are trained to
lasting 15 minutes or more. In the case of
take on various roles in healthcare. Because
Canada, France and the US, these are all
of this, both the scale and range of skills
high-income countries with developed
required to tackle MCC exist within nursing.
healthcare systems. In Chile and Peru,
Nurses are often the first point of contact,
consultation lengths are a little longer, but
and in some countries the only point of
they are not of high quality. In Russia, the
contact, for people who are unwell.20
results are based on data from Moscow,23
• Community pharmacists can also provide thus consultations may not be 15 minutes or
generalist healthcare services. Their role more in all of Russia.
in the management of MCC is especially
• Average consultation length is also
important owing to the high number of
something that the World Health
drugs required for treating people with
Organisation (WHO) determines is
several different chronic conditions.
a quality indicator of safe and cost-
Pharmacists can visit people at home,
effective use of drugs. For patients with
provide advice on managing chronic diseases,
MCC, there is trial evidence that longer
prevent adverse drug reactions, promote
consultations lead to an improved quality
medication adherence and help reduce
of life and encourage patients to be more
hospital admissions, while also strengthening
independent.24
integrated primary care delivery (see case
study 1).21,22 Seventeen countries covered in • A majority of countries have made efforts to
the index have designed policies that equip train and employ healthcare professionals
community pharmacists with expanded whose role it is to co-‐ordinate the care of
community responsibilities. Twelve countries people with MCC. This is slightly different
in the index provided both a policy that to the work of a generalist, although it is
evidences expanded roles of community possible for a generalist to also perform a
pharmacies and a training programme to care co-ordination role. For example, in the
equip them for such a role. A further five UK it is possible for a clinical nurse specialist
countries had policies but no evidence of to play a dual role as a generalist and care
training programmes. co-ordinator. However, it was not possible

13
to find evidence of such professionals • Some countries have an EMR system but
in seven countries: Croatia, Denmark, do not score a point in this sub-domain,
Indonesia, Peru, Saudi Arabia, Turkey and because the system only exists within
the Ukraine. large organisations, in cities or specific
regions, and/or does not expand to
• Although both the health and social care national levels.
systems of just over half of the countries
in the index are co-ordinated by the same
ministry, this does not tell us much about
Patient advocacy groups play a critical
the extent to which the health and social
role in self-care of MCCs, but rarely exist
care systems are co-ordinated. Integrating
care across silos is difficult, even in • Three countries—Australia, Spain and
countries where primary care, community the US—have advocacy groups for MCC.
care and social services all operate under All but three—Indonesia, Saudi Arabia
one national body.25 and Ukraine—have advocacy groups for
individual chronic conditions such as heart
disease, diabetes or hypertension. Patient
Electronic medical record (EMR) systems advocacy groups offer both patient and
are a key facilitator for the care co-‐ caregiver education and support for a
ordination of MCC range of specific conditions. Their mission
is to help people who have been affected
• There is a convincing body of evidence that by a disease, as well as to educate and/or
EMR systems promote the co-‐ordination help the families and carers of the patient.
of care and improve quality and safety Patient advocacy groups also help to raise
of patient care.26,27 For an EMR system public awareness of a disease, the risk
to have been successfully implemented, factors involved and treatment options, as
countries have usually received a well as promoting research to help improve
commitment from the funders of the treatments available.29
local healthcare system, which might
be a mixture of governments, national • The transition from disease-focused to
insurance schemes or third parties, to patient-centred models of care, where
meet the costs of IT solutions.28 patients, families and carers are part of the
decision-making process, is slow. Just over
• For MCC, EMR systems are especially a third of the countries studied emphasise
critical, as they can alert healthcare within their guidelines and/or policy for
professionals to adverse drug reactions MCC care the importance of self-care.
and provide decision support algorithms, Self-care is a term used to include all the
which also help to improve the efficiency actions taken by people to recognise, treat
of clinicians’ time and resource use. Our and manage their own health. Self-‐care
index measured whether a country’s might include health promotion, disease
EMR system incorporates a pharmacy prevention, providing care to dependent
information system for monitoring adverse people, and seeking hospital and specialist
drug reactions, data which the WHO care when relevant. Community health
collects routinely. workers who visit people with MCC in their
own homes can help to promote self-care.3

14
Discussion of findings by country to encourage people to self-‐manage their

conditions. Australia also does a thorough
In terms of having a healthcare system that job of case-management, using patient
is prepared for MCC, Australia, Canada, navigators. In some parts of Australia, patient
France, Germany Spain, the UK and the US navigators are a free service for people
lead the way, in the process demonstrating with diabetes and/or heart disease, heart
several inspirational approaches to patient-‐ failure or long-term lung conditions such as
centred care. emphysema, chronic bronchitis and asthma.34
Australia is the highest ranked country Canada is also doing better than most,
in East Asia and the Pacific. In particular, despite the existence of some regional
Australia does well in the clinical information disparities in the way that healthcare is
systems and digital transformation domain, organised. The healthcare system (Medicare)
health system infrastructure and patient is not a completely national healthcare
centricity, training and research. Australia service; rather, each territory has its own
recognises that the appropriate use of health department and health insurance plan,
so the population in each region is covered
slightly differently. However, despite territorial
Most prepared: Australia, variations, healthcare is accessed based on
Canada, France, Germany, need, not the ability to pay.35
Spain, UK and the US
The healthcare system in Canada does several
things well, but worth particular attention is
the PRISMA model for integrated care, which
digital technology and telehealth can enable was developed in Quebec. PRISMA is a French
people to take control over their health acronym for the Programme of Research to
and support person-centred care and self- Integrate the Services for the Maintenance of
management.31 A likely boost to Australia’s Autonomy. It was established to address lack of
digital achievements was the improvement continuity of care for older people with chronic
of fixed wireless and satellite access through conditions, aiming to evaluate the impact of
the National Broadband Network in 2009.32 integrated service delivery. A special feature
of this approach is the co-ordination and case-‐
Australia has also taken several steps to make management approach. Most case managers
sure that the care of patients with MCC is are social workers or nurses, but members
integrated. A patient advocacy group exists, of other professions such as occupational
bringing together many different advocacy therapists can equally take on the role.36 Case
groups for single chronic conditions. Described managers have a responsibility to develop
as an “alliance”, this was mainly formed based care plans that incorporate all the professional
on the fact that chronic diseases share many services between primary and secondary
of the same risk factors, supporting the idea care. PRISMA works as a co-ordination model,
of tackling these together in an integrated and it depends on the ability of local providers
manner through integrated risk-‐assessment to give up a little of their own autonomy. As
programmes and guideline development with the Spanish model, PRISMA requires
activities.33 The Australian National Strategic the engagement and will of the healthcare
Framework for Chronic Conditions mentions providers. All ten provinces in Canada are
that increased access to a range of services now implementing features of the PRISMA
and self-management support is essential model to some degree.

15
In France, major concerns about the lack of pays an important role in this.39 Unregulated
co--ordination and continuity of care within direct out-of-pocket charges for health care in
the health sector arose in the mid-1990s. a country often constitute a major barrier to
This prompted a series of initiatives. These accessing necessary healthcare and can cause
included a strategy for addressing chronic problems related to financial protection. 40
disease, including reinforcing prevention
France only really falls short on its clinical
and patient education, making sure that
information systems, which have run
medical tasks were shared between doctors
into a few problems relating to patient
and nurses, and developing new ways of
confidentiality, leaving hospitals a little
delivering care. In France, clinical guidelines
reluctant to implement EMR systems.
are very inclusive of the care of people with
However, in 2011 the Ministry of Social Affairs
MCC. There is both a guideline and policy on
and Health re-launched its EMR project
MCC care. In 2009 the Hospital, Patients,
with a primary aim of making all healthcare
Health and Territories Act set out a series
vendors EMR compatible. 41
of measures to boost the quality of care for
people with chronic disease. These included In Spain, the public health system, the
specific attention to integrated care, Sistema Nacional de Salud (SNS) is funded
making sure that there were contractual almost entirely from general taxation. This
agreements between professionals and means that public healthcare, aside from
regulations pertaining to multidisciplinary pharmaceuticals, is free at the point of use
and multi-‐professional healthcare centres. for all residents who have a social security
card. Because of public spending cuts in
The French health system organises the
2012-14, the government has made several
delivery of healthcare into something known
efforts to reduce debt, including publishing
as a provider network. These networks aim
an atlas to highlight unwarranted variation in
to improve co-ordinated care for people with
healthcare delivery. This initiative may have
complex needs and measure their success
played a role in encouraging the country’s
across four domains: care pathways, co-
healthcare system to improve its integrated
ordination, efficiency and satisfaction, and
care strategies. 42
cost-effectiveness. There are more than 1,000
of these networks in France, some of which Although the SNS is comprised of 17 regional
are specific to certain population groups, health ministries, the Ministry of Health,
such as older people. These networks can be Social Services and Equality is responsible
accessed directly or through GPs, are free for certain strategic areas at a national level.
of charge and are regulated by the Ministry One of these areas is the use of a method
of Health. France also finances the health used to stratify the health of the population,
system in a way that promotes integrated called Adjusted Morbidity Groups (AMG).
care, further complimented by pay-for- This method was initially developed in
performance mechanisms.37 Catalonia and is now used in most Spanish
regions. Use of the AMG system helps to
France also has increased healthcare spending
group populations according to their health
compared to most EU countries, at 11.5%
status, which provides health authorities
of GDP, which is above the EU average of
with valuable information about how to
9.6% of GDP spent on health.38 The share of
plan services and resource use. The AMG
out-of-pocket spending is low, as over three-‐
tool has allowed better identification of the
quarters of health expenditure is publicly
number of people with chronic diseases of
funded, and complimentary health insurance

16
different complexity levels. 43 This kind of attempts to reform the health system in the
model is particularly relevant for addressing interests of efficiency. There is also a strong
patients with MCC from both a system-wide segregation between primary care, hospital
perspective and a clinical approach. Patients care and specialist care, which has led to
can be easily identified and targeted for case-‐ a lack of continuity and co-‐ordination, and,
management programmes. 43 consequently, negative consequences for
quality and efficiency of care. Germany is not
Spain scores highly on the guidelines and doing as well as other European countries
policy to support MCC domain, as it has in its efforts to shift service provision away
both a policy and guideline on the care of from inpatient care to outpatient care.38
people with MCC. In Spain, on June 27th 2012, There is also limited state control over the
the Ministry of Health, Social Services and health system, which means that clinical
Equality published an action plan for tackling guidelines are not produced by the a single
MCC in six key areas: health promotion, national body.
prevention of health conditions and chronic
activity limitations, continuity of care services, The UK does a good job in the guidelines and
reorientation of health care services, health policy to support MCC domain. The UK has
equity and equal treatment, and research an internationally respected guideline body,
and innovation.31 Furthermore, a guideline for the National Institute for Health and Care
chronic conditions care exists, the “Approach Excellence (NICE), which includes specific
to Comorbidity and Multiple Pathology”, which guidelines for multi-morbidity. The multi-‐
was published in in 2015 by GuíaSalud—the morbidity guidelines have a strong emphasis
repository of clinical care standards guidelines on the empowerment of patients in clinical
for the SNS—and the health ministry. 44 decision-‐making, allowing patients to have
control over their care. This approach should
Spain has a comprehensive EMR system which not be limited to just multi-morbid patients; it
was developed with the aim to integrate the should be something that everyone in need of
EMR systems of all autonomous communities. healthcare should experience, as is mentioned
It is still in development however and currently in the guideline. The key difference in terms
operates in 15 Spanish regions to varying of the approach outlined in this guideline, and
degrees. 45 The system also includes electronic something that all countries should adopt,
prescriptions, which shows the prescribing comes through addressing existing disease
physicians the active ingredients of drugs, and treatment burden in conjunction with
and also the cost. Since 2006 all the regional establishing future goals, values and priorities
ministries and regional health services have of the patient. This will require a different
been working together on the development of approach to clinical consultations—one that is
the online healthcare programme in Spain. 46 longer in length, to incorporate all the nuances
The EMR system used in Spain are marked across all conditions.5
as key to the success of the AMG method for
identifying people with MCC, and so are likely For people with MCC, functional
to continue to improve. 43 impairment and disability associated with
chronic physical health problems can greatly
Germany, which has a good primary care increase the risk of depression. Depression
system, falls short on clinical information is also a risk factor in the development
systems/digital transformation. A strong role of a range of physical illnesses, including
is played by self-governing bodies, which cardiovascular disease. 47 It is important,
shape political decisions, complicating then, that guidelines are nuanced enough

17
to address both physical and mental health powerhouse. In terms of the latter, despite
comorbidities. NICE pays special attention scoring highly, regional disparities and
to this too, evidenced in their development inequitable access in the US healthcare
of a specific guideline addressing the system still exist. Notwithstanding the
management of depression in adults aged Affordable Care Act of 2010 establishing
18 years and older who also have a chronic a shared responsibility between the
physical health problem. 47 Although NICE government, employers and individuals for
guidelines technically only hold authority ensuring that all Americans have access
in England, their publications are seen as to affordable health insurance, health
providing high-‐quality evidence worldwide. coverage remains fragmented. There are
some steps in the right direction, including
As is the case with France, the UK falls short in moving away from specialist-driven care
terms of the digitisation of its health system. to a health system built around primary
For the UK National Health Service (NHS), care and the introduction of accountable
digitisation began well in 2002, when the UK care organisations, a network of providers
government launched a National Programme that are responsible for certain catchment
for Information Technology, the NHS Care areas.50 There is evidence that the US is
Records Service. This had the intention of trying to make a difference for people with
delivering an electronic records system MCC. For example, as part of Department
across the UK. However, there were problems of Health and Human Services’ Initiative
using it, and the UK experienced the same on Multiple Chronic Conditions, they have
issues France faced in addressing patient launched a set of Education and Training
confidentiality, as well as costs becoming a materials for healthcare professionals on
lot higher than was expected. As a result, the managing patients with MCC, and there is
system was closed down in 2011. 48 Although a high volume of research into the care of
EMR systems exist in the UK—in some NHS patients with MCC.51 There is also both a
trusts they are comprehensive—they do not guideline and a policy for managing people
operate consistently across different regions with MCC.
of the UK. 49
The US scores less well on clinical information
In the US, the healthcare system focuses systems. The Health Information Technology
on volume of care rather than value and for Economic and Clinical Health Act
the appropriate goals of care.11 Despite (HITECH) was signed into law in 2009, giving
being categorised as “prepared” the US has health providers the incentive to adopt EMR
a fairly inconsistent set of scores across all systems. However, this process has been slow,
five domains in the index. The US does well owing to a mixture of issues similar to those
in patient-centricity, training and research experienced by the UK—namely cost, patient
as well as health system infrastructure. In confidentiality and interoperability. 49
terms of the former, the US is a research

18
Italy, sits in the “prepared” group in terms Care Association (JPCA) was established in
of its clinical information systems. According 2010 as the certifying body for primary care
to the WHO, Italy’s EMR system offers the physicians. As it is relatively new, the JPCA
ability to share digital data between health will need a little more time to have an effect
professionals in other health services, as on the number of primary care physicians
well as allowing individuals to access their practicing in the country. A further factor
own health-related data and specify which supportive of MCC care is the development
health-related data from their EMR can of an independent third-party initiative,
“board-certified GPs”. A certification board
will assess GPs on competencies such as
Fairly prepared: Italy, Japan person-centred care, comprehensive care,
and the Netherlands integrated care, community orientation and
inter-professional working.54
The Netherlands, does particularly well

be shared. In addition, Italy is investing in
in patient centricity, training and research.
training more nurses to deal with the issues
The Netherlands has a large body of research
arising from population ageing.52
into MCC, with only Denmark exceeding it on
There is an emphasis on a primary care the number of publications per one million
approach in Italy, with GPs acting as care co-‐ inhabitants. The Netherlands also offers
ordinators. Furthermore, financial incentives training for healthcare professionals on MCC
are being provided for GPs to follow certain care in all medical schools, as well as in nursing
group practice approaches, involving qualifications. The long-‐term care system
multi-disciplinary care. Some regions have was reformed in 2015 to contain costs but
introduced chronic disease management also to make care more patient-‐centred.
programmes, focusing on conditions such District nurses play a key role in integrating
as diabetes, chronic heart failure and different aspects of care and support.55
respiratory diseases.52 The primary care system is also strong, with
primary care professionals usually working
Japan is the only non-European country in in multidisciplinary teams. Community
the “fairly prepared” group and the second pharmacists work alongside GPs in their
country (along with Australia) in the East catchment areas, with nurse practitioners
Asia and the Pacific region that is doing having the skills to prescribe medicines, taking
reasonably well. Japan is in the top ten for some of the workload burden off the GPs.
all domains apart from clinical information
systems/digital transformation. Although Overall, there have been significant efforts to
Japan adopted a policy for eHealth in 2014 shift care from secondary care to primary care,
and the use of EMR generally increased mainly for chronic diseases and simple low-
between 2008 and 2014, there are disparities risk treatments.55 There are also several pilot
in EMR adoption on both a regional and an projects that concentrate on integrated care
individual facility level. Hospitals in larger for chronic diseases and care for people with
cities are more likely to adopt EMR systems multi-morbidities, shifting the responsibility of
than clinics or primary care facilities and care to lower levels.55 The Netherlands falls into
hospitals in smaller towns.53 the same bucket as the UK and France when it
comes to digitisation of the health system, and
Another concern in Japan is a lack of scores poorly on this domain owing to sparse
primary care doctors. The Japan Primary coverage of EMR systems.

19
Among the Latin American countries covered but also specifically regarding MCC, a fairly
in this index—Brazil, Chile, Mexico and Peru impressive feat, given that the country’s
(the latter two which will be discussed in policymakers and health authorities have
the “not very prepared” group)—there is a the world’s largest population to consider.
common problem: they all suffer when it There are some great examples of regional
comes to providing comprehensive, integrated healthcare incentives that, although they
care, partly due to the split between public did not end up improving China’s grouping
and private healthcare. This fragmentation in the index—the country’s size means
typifies Latin American healthcare systems, that regional examples do not count—are
and, despite some regional improvements worth mentioning in terms of aspirations
in health indicators, there are inequalities for the future. For example, in September
in health status, alongside inequitable 2017 the Ministry of Health launched a new
access to and use of health services. Some
improvements can be seen in Brazil and
Chile, which both introduced health reforms Less prepared: Brazil, Chile,
to support the integration of healthcare China, Croatia, Denmark,
delivery, the former in 2001 and the latter in Russia, Saudi Arabia, South
1989.56 This may have some bearing on the Africa and Ukraine
fact that Chile and Brazil are slightly more
prepared for MCC than Mexico.
approach to people-centred, integrated
Chile scores well in the patient centricity, care called the Louhu Model, piloted in the
training and research domain, as it has Louhu district of the southeastern city of
the most academic research on MCC Shenzhen. This model was launched as
compared with Brazil. Brazil and Chile both a response to the problems faced by the
employ healthcare professionals capable existing healthcare system, including the
of coordination tasks, although they differ lack of integrated healthcare to address the
slightly in their exact job descriptions. Brazil growing population of people with MCC. A
is the only Latin American country covered key issue in China is the ongoing lack of trust
in the index that does not have an electronic in the primary care system, and, therefore,
medical record system. Owing to the the reliance on hospital care for even minor
characteristics of health systems in Latin ailments. (This does not bode well for the
America, there is a lack of legislation at the treatment of MCC, which requires a strong
country level on the use of EMR systems, a general practice foundation.) The Louhu
lack of consensus between different state Model recommends primary healthcare as
and private players, and a limited number the first point of contact for care, as well
of professionals trained to work in medical as endorsing multidisciplinary teams and
informatics.57 Despite the implementation of eHealth, among other factors.59
integrated healthcare systems in the region,
the impact of these are largely unknown, Countering its deficiencies in health
as data on actual use of health services are infrastructure, China falls in the “prepared”
unexplored.58 group in the clinical information systems/
digital transformation domain. According
China is a few steps ahead of Indonesia to the WHO, China has an eHealth policy
and Thailand in the East Asia and the Pacific and an electronic medical record system
group. China is making progress, not only in that includes a pharmacy information
terms of the general delivery of healthcare, system capable of highlighting adverse

20
drug reactions. That said, despite almost digital transformation domain. Clinical
90% of hospitals using electronic medical information systems are something that
records, the accessibility and quality of Denmark excels in. Denmark has strong
the data could be improved. This is mainly mobile connectivity, an eHealth policy, a
due to incompatibility between different national EMR service that is robust enough
hospital systems. Health authorities are to enable sharing of data between health
yet to agree on how to improve hospital professionals in different health services
information systems.60 China also does not and a pharmacy information system.
score well in the guidelines and policy to
support MCC domain. This is because China Health system infrastructure is not
has not yet developed guidelines or policies Denmark’s strong point. Some plausible
related to integrated care or MCC. Although explanations for this include a fall in the
guidelines exist for chronic conditions such number of GPs, resulting in less availability
as hypertension, diabetes, heart failure, of primary care, which is essential for the
stroke, and Chronic Obstructive Pulmonary management of MCC. In addition, the
Disease which mention comorbidities in number of primary care clinics fell by 5.9%
care management, they do not go as far to from 2007 to 2017. A reduced number
include prompts on self-‐care or including of GPs is predicted to have an effect on
family members in the care plan. later referral of patients to specialists and
hospitals. Denmark also scores poorly on
Croatia is the only county that does not patient centricity, training and research.
have any operational plans on healthy living, Although Denmark produces a lot of
according to the WHO; such plans are key to scientific publications in the field of MCC,
reducing the risk factors for MCC. Croatia, there are no training frameworks on MCC or
as with Turkey and Ukraine, also does incentives to train healthcare professionals
not have a NCD policy that describes an to become care co-ordinators or nurse
integrated approach to both these diseases practitioners.
and their risk factors – the sort of approach
that will be needed for MCC. Human Russia, sores “less prepared” in all the
resource in Croatia’s health system is low, domains apart from clinical information
with fewer physicians and nurses than in systems/digital transformation. According to
many other EU countries. This shortage of the WHO, Russia has a national electronic
physicians lies in primary care, which does medical record system that was introduced
not do the care of MCC any favours, given in 2013.62 Several hospitals have switched
the general consensus that good MCC care from paper-based medical records to
goes hand in hand with comprehensive an EMR system designed to provide fast
primary care. Croatia spends a lot on EMR exchange while also meeting stricter
primary care—at around 35% of total health medical record information requirements
expenditure in 2015—yet primary care is still and delivering more secure access to patient
underdeveloped, with very little emphasis on information.
primary prevention and co-ordination of care Russia does not have particularly holistic
for people with chronic illnesses.61 guidelines of the sort that promote
multidisciplinary care for people with MCC.
It might be quite surprising that Denmark
Although there is a policy on integrated care,
falls in the “less prepared” category,
polices and/or guidelines on MCC do not
although it does gain some credit because of
its score in the clinical information systems/

21
exist yet in Russia. Of five selected clinical profit organisations. For example, community
guidelines for chronic conditions, three are health workers are used to improve access
nuanced enough to mention comorbidities in to healthcare by encouraging community
clinical management. participation (similarly to community health
workers in Brazil).64 The use of non-profits
Saudi Arabia is one of two high-income and tackling alternate health problems,
countries (alongside Israel) in our index which makes it difficult to compare South Africa to
sits in the latter two preparedness groups for the other countries in the index. However,
MCC. There are a few plausible explanations South Africa does rank relatively creditably
for this. Firstly, the index tells us that having in the patient centricity, training and
a robust health system infrastructure is one research domain. This is due to the existence
of the most influential factors for effectively of a national community health worker
preparing a health system for MCC, and programme called the ward-based outreach
Saudi Arabia scores poorly in this domain. team, multi-disciplinary healthcare teams
This is most likely because Saudi Arabia which help integrate care at the community
relies heavily on an expatriate population level.65 South Africa also scores points in the
to provide and deliver healthcare services, guidelines and policy to support MCC domain.
the nomadic nature of which makes it very It does have a policy on integrated care called
difficult to quantify. Reliance on such an the Integrated Chronic Disease Management
amorphous workforce also means that there Model, which was initiated in 2011. The chronic
is high staff turnover, leading to instability disease guidelines for five selected chronic
in the healthcare system. The nursing conditions also all mention comorbidities.
workforce is especially affected, as it is
largely recruited from abroad. Ukraine does fairly well in the guidelines
and policy to support MCC domain, its
The quality of data is also poor in Saudi chronic condition guidelines are nuanced
Arabia, and adoption of e-Health systems has for the management of comorbidities, and
been slow in Ministry of Health institutions.63 are developed with multidisciplinary teams.
Medical research is limited, with only a few Ukraine does less well in the health system
institutions capable of conducting it; even infrastructure domain. Similarly to South
then, this is focused on cancer, genetics, Africa, however, it is difficult to compare
infectious diseases and cardiovascular Ukraine to some of the other countries in the
diseases—not MCC. Papers produced in index because of the developing nature of the
Saudi Arabia are infrequently cited by country’s healthcare system. For example,
other researchers, indicating that research it was not possible to measure the number
conducted within the country has limited of generalists in the country, because the
impact. concept of a generalist does not exist. Ukraine
In South Africa, the health and wellbeing is also the only country in the index that
of most citizens has been inundated with does not have an operational unit, branch
challenges far more pressing than MCC. or department in the Ministry of Health that
These include a constant stream of infectious has a responsibility for NCDs. These units are
and non-‐communicable diseases, social likely to evolve to also be responsible for MCC
disparities, and poor human resources care. Ukraine is also the only country in the
through which to provide care for the Europe and Central Asia group that does not
growing population. Much of South Africa’s have patient advocacy groups for people with
healthcare workforce is provided by non- chronic conditions.

22
Despite these shortfalls, since 2018 Ukraine Israel has fluctuating scores across the five
has been implementing profound reforms to domains in the index, reflecting the complex
the healthcare sector. These reforms aim to nature of the health service. Although
move the country towards universal health the 1995 National Health Insurance Law
coverage, as well as enhancing efficiency mandates universal coverage, only 62%
and equity in public spending. Although of health expenditures were publically
Ukraine offers all citizens and permanent financed in 2015, one of the lowest levels
residents free healthcare in public facilities, among OECD countries. Within the national
coverage is poor, leading to high levels of health insurance framework, there are four
unmet need. The current system limits the non-‐profit competing plans that provide
Government’s ability to protect poor people different levels of coverage. The majority
and regular users of healthcare, such as those of primary care physicians in Israel provide
with chronic conditions, from out-of-pocket care through only one of the four plans,
payments.66 Clalit, meaning that the other three offer
varying levels of primary care access. In
Indonesia, although sitting in the “not
the Clalit plan each patient has a primary
very prepared” group, did fairly well in
the guidelines and policy to support MCC
domain. Although there are no clinical Not very prepared: Indonesia,
guidelines or policies on MCC care in Israel, Mexico, Peru, Thailand
Indonesia, there are clinical guidelines
and Turkey
for chronic conditions which mention
within them the management of comorbid
conditions. Some of these guidelines
care physician who co-ordinates care,
are comprehensive enough to include
whereas the other three do not receive any
information on self-care and include family
care co-ordination support. Although there
members in the care plan.67
are efforts to improve access to primary
The geography of Indonesia (the country’s care and associate all those covered under
population is spread across more than 2,000 the four plans with a specific primary care
islands) will always make the delivery of physician, Clalit is the only plan that also
effective and efficient healthcare a challenge. refers people to secondary care.68
However, eHealth is one of the solutions
A further barrier to MCC care in Israel
expected to bring the health system together.
comes via the provision of mental health
Although Indonesia currently scores poorly
services, which, although it exists, has limited
on the clinical information systems/digital
integration with primary care. Despite falling
transformation domain, there are several
in the not very prepared category, things may
initiatives to introduce eHealth services.
improve rapidly for Israel if the government
However, these are currently only being
supports it appropriately. Currently access
conducted by certain institutions and their
to primary and secondary care across the
use is not evenly distributed throughout
different health plans in Israel is disjointed,
the country.62 Indonesia also scores very
but the fact that they are both insurers as
poorly–alongside Turkey–in patient centricity,
well as the main providers of both primary
training and research. Research into MCCs is
and secondary care means that they are
very limited in Indonesia, with the country
structurally capable of providing integrated
producing the fewest research papers of all 25
care for all those insured. This would greatly
countries in the index.

23
benefit people with MCC. Furthermore, the Peru ranks poorly on the index overall.
EMR system in Israel has decent coverage, There seems to be a lack of national clinical
with every primary care physician using guidelines for MCC in Peru, although there
an EMR system, and the Ministry of Health are guidelines for the management of NCDs.
working on further improving the linkage Furthermore, individual chronic condition
of data between primary and secondary guidelines only exist for some conditions,
care.68 Israel also scores highly on the such as diabetes and cardiovascular
patient-centricity, training and research disease, although these do mention the
domain because the healthcare workforce clinical management of comorbidities.
includes professionals trained to undertake Some chronic care guidelines promote
healthcare co-ordination tasks, and there is self-care, but others do not. This lack of
also a fairly high volume of research on MCC comprehensive national guidelines causes
stemming from Israeli universities. However problems for delivering care to people with
Israel scores poorly in terms of its clinical MCC.
guidelines, as there is also no evidence of a
systematic approach to the availability of Peru’s approach to MCC is not all bad: the
clinical practice guidelines in Israel, instead country scores fairly high in the clinical
clinical/medical associations endorse the use information systems/digital transformation
of international guidelines.69 domain. According to the WHO, Peru’s EMR
system is national in scope. However, it does
not operate in primary care clinics, only in
Mexico falls short when it comes to secondary and tertiary care facilities. Even
employing healthcare professionals capable
then, the adoption of EMR systems is low,
of care co-ordination tasks. On the other
covering less than 25% of patients.62
hand, Mexico has the strongest guidelines
and better clinical information systems Thailand placing in the “not very prepared”
than Brazil and Chile. Mexico’s system group may seem somewhat surprising,
is comprehensive enough to allow the given Thailand’s achievements in terms of
sharing of data between professionals, as establishing universal healthcare in 2002,
well as allowing individuals to access their which resulted in a significant reduction in out-
own data and specify which data can be of-pocket expenditure (from 27.2% to 12.4%).
shared, although the Mexican system only However, despite relatively good healthcare
covers 25-50% of primary care facilities.62 being available at a low cost, adult mortality
Mexico also does better in the patient levels have not decreased notably compared
centricity, training and research domain, with neighbouring countries.
as primary care visits (albeit only for those
who have health insurance) are between Among other problems, Thailand continues
10-14 minutes long, giving enough time to to face challenges in terms of financing and
discuss more than one health condition and service-provision for the elderly and gaps in
there are healthcare professionals trained urban primary healthcare, two factors that
to undertake healthcare coordination tasks, are likely to have the most impact on the care
although it is unclear to what extent this of people with MCC.70 The country’s clinical
training is implemented in practice. guidelines are also not very supportive of

24
MCC; most clinical guidelines for chronic In 2004 Turkey introduced the family
conditions in Thailand address treatment of practice model to address equity gaps in
specific chronic diseases in complete isolation healthcare. This model established family
to others, nor are they nuanced enough health centres and community health
to encourage self-care or involving family centres as the backbone of first contact
members in decisions. care, led by a family doctor and an auxiliary
health worker. In addition, a new cadre
In Turkey, like South Africa, the country of providers called “field co-‐ordinators”
has been pre-‐occupied with other threats. It collaborated with family health centres to
has suffered in terms of regional warfare, the serve as a communication link with relevant
Syrian refugee crisis and political upheaval, stakeholders in the Ministry of Health. The
all of which threaten both health financing issue with this model is that 20,000-45,000
and political focus on the healthcare system, family doctors were estimated to be needed
thus hindering further reforms.64 to implement it, but there were only 1,200
By the late 1990s, Turkey’s primary in Turkey in 2004. Although efforts were
healthcare system had become highly made to increase this number, geographical
fragmented, mainly owing to it being disparities exist and improvements in access
governed by two ministries and regulated are still required. Major political challenges
by multiple health insurance schemes, with since 2004 have made further progress
only two-thirds of the population covered difficult. Despite its difficulties, the health
by health insurance. Similar to attitudes in transformation plan also included a number
China, primary health care was generally not of successful healthcare IT infrastructures
trusted, owing to poor quality of care, with in Turkey, including the creation of an
most people accessing care directly from EMR system.71 According to the WHO, the
hospitals and private centres. Consequential national EMR system, which was introduced
overcrowding and high out-‐of-‐pocket costs in 2008, has pretty good coverage across
encouraged the government to launch primary and secondary care (>75%).62 Turkey
a health transformation plan in 2003, in therefore has a solid EMR foundation for
conjunction with the World Bank and the MCC care, capable of managing the growth
WHO. of the primary care system.

25
Opportunities for action
The index has helped to identify The index also identified headwinds
some emerging tailwinds for the that are likely to hinder the care of
care of people with MCC: people with MCC:
• Very few countries are routinely collecting • Complex, disjointed healthcare systems
data on the incidence and prevalence of comprising elements that do not talk to
MCC. These efforts are being hampered each other. These are a huge barrier to
by the lack of a universally accepted providing co-ordinated care even for those
definition. Greater efforts to understand the with single conditions—let alone to a
epidemiology of MCC are needed. patient with many conditions.
• Strong political leadership is essential. • Gaps in healthcare coverage. These increase

Political instability is a huge barrier in terms the complexity of the healthcare system
of making effective and efficient healthcare and can accrue high costs for patients due to
decisions. An unstable political climate often out-of-pocket spending.
leads to infrastructure change which hinders
streamlined care, essential for MCC. • Funding and workforce efforts are often
channeled into treatment of chronic
• Access to and efficient use of information diseases, rather than prevention. This does
and technology is paramount for MCC not solve growing disease prevalence.
management. Coordinated efforts to prevent as well as
treat MCC are required.
• Placing families and carers at the centre of
care is essential and should be reflected in
the organisation of services and in clinical
guidelines.

26
A framework for action

The Venn diagram represents the varying pressures that countries are under—politically,
economically, culturally and from the consumer market—and that they need to respond to
in order to meet the demands of MCC.
Politics and culture:

Providers competing in
a free market vs top
down protocols
Adoption of IT: Workforce:

Systems talking to each Integration and co-
other vs those that are built MCC care ordination across
but do not safeguard traditional workforce
sharing sensitive boundaries vs silos
information
Population ageing:
Living longer lives in
many advanced
economies vs living
longer with MCCs

27
Appendix 1: scorecard framework and

detailed indication descriptions
Literature review domains.
The initial step in the development of Further to expert recommendations, we

the index methodology was a literature performed additional rounds of verifications
review carried out by experienced health to establish best possible metrics, such as data
specialists at The Economist Intelligence audits, literature searches and data analysis.
Unit (EIU). The search took in health policy We would like to thank the following experts:
documents, academic literature and other
health system studies. Its goal was to • Ian Litchfield – (University of Birmingham,
identify existing frameworks, indicators UK)
and data sources on the topic of health • Cother Hajat – (Royal College of Physicians,
system preparedness for multiple chronic UK)
conditions (MCC). The literature review used
a range of search approaches, including a • Juan Carlos Contel Segura – (University of
focused bibliographic database search (in Barcelona, Spain)
MEDLINE, PubMed and Embase); iterative
• Srinath Reddy – (Public Health Foundation
grey literature searches; and supplemental
of India, India)
search techniques such as citation and
author searches, scanning of references lists • Stephen MacMahon – (The George Institute
and related-‐articles searching. for Global Health, Australia)
Preliminary indicators selection • Alan Lopez – (University of Melbourne,

Australia)
An initial set of domains and indicators were
then selected, guided by the concept of “tracer • Nigel Crisp – (Nursing Now, Independent
indicators”, which involves the selection of a Crossbench member of the House of Lords,
subset of indicators that are representative UK)
of a group of services. Such an approach has
been used in multiple publications identified Country selection
in the literature review—and recently by The index covers 25 countries from across
the World Health Organisation (WHO) in five broad regions of the world. These include
developing a universal health coverage index the Americas, East Asia and the Pacific,
published in 2016. Europe and Central Asia, and the Middle
We then convened a panel of international East and Africa (table 1). Within each region,
experts in chronic conditions management we tended to select countries with the
to discuss and validate the preliminary largest populations, along with examples of
approach during a virtual teleconference in smaller countries that represent interesting
London. During this session, the most relevant or unusual approaches to health system
indicators of health system preparedness preparedness for MCC. We wanted to not only
were determined for each of the index capture the diversity in policy adoption and
implementation in high-‐income countries,

28
but also include comparisons from where the Weightings and index consistency
burden of MCC is more of an urgent problem:
in upper- and lower-middle income countries. Weightings are intended to reflect the
We hope to extend the research to more importance attached to each dimension of the
countries in future iterations of the index. index. We decided—through discussion with
the expert panel—that the first two domains
were relatively more impactful than the latter
Construction of the preparedness
three, and they consisted of more indicators.
groups
Therefore, we attached 30% weights to
The Index of Health System Preparedness domain 1 (guidelines and policy to support
is a composite index, and overall scores MCC) and 40% to domain 2 (health system
for each country are produced through infrastructure to support MCC). Within domain
normalising, weighting and combining 1, two of the subdomains were considered to
scores of the five domains and their hold more importance for health systems to
indicators. In turn, sub-domain scores are be prepared for MCC, so were given a higher
calculated as the weighted sum of individual weighting.
indicator scores.All scores are presented in a
These were integrated care and MCC policy
normalised scale of 1 to 100 (where 100 is the
and guidelines. Similarly, in domain 3, two
best possible score), displaying the relative
of the subdomains were considered to hold
performance of each country.
higher importance for MCC, so were weighted
higher. These were training and continuing
Normalisation is based on a improvement and personalised care. However,
formula: there is functionality in the workbook that
allows the user to apply different weights and
x = (x -Min(x)) / (Max(x) -Min(x)) recalculate index results.
We checked the consistency of the

Min(x) and Max(x) are, respectively, the index by running correlations between
lowest and highest values possible for any subdomains. None were found to be
given indicator. For quantitative indicators significantly overlapping or co-‐linear. We
with pre-existing data sets—for example did not run a formal principal component
the number of clinical oncologists in a analysis or sensitivity analysis, because
country—Max(x) is simply the highest the index was designed as a combination
score in the data set. For qualitative data of desired policy inputs, and so has value
sets, where we set the scoring range (see beyond simply giving a final composite
section on qualitative indicators on the next score; the framework is not statistically
page), Max(x) is the highest possible score, determined, but rather based on elements
whether or not any country actually met of health system preparedness that are
that score. We used the min-max technique, inherently desirable. Moreover, given the
as it is widely accepted, frequently used relatively limited number of countries
and an easily understandable method of included in the first wave of the study, and
normalisation. Countries are then placed with the vision to expand the coverage in
into preparedness groups, dependent on the future, a purely statistically determined
their scores. framework would be sensitive to addition
of any new countries. Rankings and scores
were checked in an iterative process by EIU

29
specialists, which allowed us to identify data • Eight indicators assess the health system
anomalies that could then be corrected. infrastructure to support MCC care. The
first of these looks at whether community
Quantitative and qualitative pharmacy services exist, and if they are
indicators trained to provide generalist services,
while the following three dig into the
The 18 quantitative indicators in the reimbursement structure in a country –
index draw on numeric raw data from key whether there are performance based
global healthcare organisations including payment models in hospitals, primary
the WHO and the World Bank. Where care, and financial protection for people
possible, missing data points were imputed with MCC. Two indicators address the
by calculating regional averages or using existence of patient advocacy groups,
alternative datasets. A total of 20 qualitative one which assesses the availability
indicators were designed by The EIU for of advocacy groups for people with
this study; they analyse topics for which MCC, and another looking for advocacy
no cross-country data were previously groups for specific chronic conditions.
available. These are based on standardised The final two of the eight assess self-‐care
assessments of country performance management. They do so by checking the
using detailed scoring guidelines and are MCC guidelines, and/or policies, as well
displayed as scores in a numeric scale as chronic condition guidelines in each
(usually 0 to 3, where 3 is best): country specify the importance of self-‐
care.
• Seven indicators measure the existence
and scope of clinical guidelines and policies • Four indicators assess the level of training,
to support MCC care. The first two of the research and patient-‐centred approaches
seven address integrated care including; adopted by healthcare staff. This includes
the presence or absence of a specific two indicators which assess training
policy, strategy or action plan on integrated programmes and the existence of a
care, and whether health and social care healthcare quality improvement initiative.
is coordinated by the same ministry. The Another two indicators assess whether
following four indicators assess the presence primary care consultations are long
or absence of clinical guidelines and policies enough to provide person centred care,
for MCC. The first two of the four specifically and the existence of staff whose particular
look for MCC guidelines and policies, and role it is to assist with care coordination.
the second two look for chronic conditions
• One indicator assesses the existence of
guidelines which include the management
national bodies that function as public health
of comorbidities within them. The seventh
observatories, collecting data on population
indicator assesses the coverage of mental
risk factors for chronic diseases such as
health guidelines for including family and
smoking, poverty and socioeconomic status.
carers in managing the care, and whether
they consider physical health comorbidities.

30
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34
Appendix 2: Best practice case studies
Brazil: dealing with the MCC interest in improving integrated primary

challenge in a middle-income healthcare in Brazil, which has contributed
country to the development of the public Unified
Health System (SUS) and the Family Health
The challenge of multiple chronic conditions Strategy (FHS).74 The FHS was created in
(MCCs) is a reality for low- and middle- 1994 to consolidate primary care, and since
income countries (LMICs), many of which its inception has rapidly increased coverage
are still struggling to construct healthcare to reach about two–thirds of the Brazilian
systems capable of tackling population population by 2015.74, 75
needs. Brazil is one such example. As a whole,
chronic diseases were responsible for 73% A key component of the FHS are family health
of deaths in Brazil in 2016.72 National surveys teams, community primary healthcare clinics
in 2013/14 found that between 17% and 24% that are staffed with health professionals
of adults self-reported having two or more responsible for a particular neighbourhood.
chronic conditions.73 But although Brazil is a Each team consists of a physician, a nurse,
large and politically complicated country, a two nurse assistants and six full-time salaried
scattering of examples exist in several states community health workers, who are recruited
of good practice in delivering healthcare for from the neighbourhoods they serve. Each team
How do you get the mayors of 5,570

municipalities in Brazil to agree with your
idea? That is a lot of people to influence on
a topic as critical as healthcare, which often
divides opinions.
Professor Mônica Viegas Andrade, economist and population
health expert, Federal University of Minas Gerais, Brazil
people with MCCs. At a national level, the serves a population of up to 1,000 households.73
government has recognised and made efforts The Ministry of Health also targeted three cities
to manage the growing number of people with in Brazil to launch the Lab for Innovation in
MCCs; one solution is to provide integrated Chronic Conditions Care (LIACC), a forward-
healthcare teams. There has been growing thinking primary care pilot project operating
within community primary healthcare clinics.2

35
Mônica Viegas Andrade, an economist and and goals for conditions. The community
population health expert who is involved health workers encourage people to attend.
in the LIACC pilot, explains that the project
In Brazil, and many other LMICs, healthcare
works by setting protocols and standards
systems have scarce resources. With
specific to the care of chronic conditions,
the growth in chronic conditions and
to guide care by primary health providers.
comorbidities in ageing populations, cost-
Implementation of these protocols are then
effective ways of staffing a healthcare
supported and monitored by community
workforce are needed. Nurses, with their
health managers assigned to each primary
holistic values and patient-centred practice,
health network. Within each primary care
are ideally placed to provide the sort of care
practice, community health workers are
that is needed as the number of people
responsible for day-to-day tasks such as
with chronic conditions grow and caring for
visiting the households registered to each
people becomes more complex. The World
primary health network.76
Health Organisation (WHO) recognises that
Ms Viegas Andrade elaborates: nurses have especially crucial roles to play
in health promotion and health literacy. Ms
“The key to the success of primary care Viegas Andrade talks passionately about how
are the community health workers, healthcare systems must adapt their approach
as they bridge the gap between the to manage chronic conditions in the same way
community and the health system. They that the LIACC does.78 She makes it very clear,
visit patients registered with the primary
both verbally and in her academic work, that
care practice in their own homes and
the nursing profession forms the backbone of
keep an eye out for signs of vulnerability
primary care.
or ill health. They do this on a monthly
basis and report back to the surgery. They “The manager of the practice is also a
also check things like immunisations nurse,” she says. “Aside from one doctor,
and medications for older people, the primary care practice is run entirely
and also check the status of certain by nurses and community health workers.
chronic conditions, mainly diabetes and If more specialist skills are needed the
hypertension.” primary care practice is linked with
another health centre where specialists
Building a rapport with patients—and
can be accessed.”
therefore trust in health professionals—is
known to improve health outcomes.77 Ms With the right support, knowledge, skills
Viegas Andrade describes how the innovation and financial backing, nurses are uniquely
lab leverages social capital in Brazilian placed to act as effective practitioners, health
communities to target people with chronic coaches and a source of information and
conditions: support for people with chronic conditions at
any age.78 In many LMICs, a nurse or midwife
What is really important is that the community may be the only health professional that sick
health workers in each primary care practice people ever see, and are often the sole source
belong to the community that they work of training and knowledge for the primary care
in. Although they have no formal medical practice and community health workers.
training, they are under the supervision of the
nurse. The innovation lab also runs community Nursing Now, a campaign that recognises
groups, which helps people understand the the central role of nurses globally, across
importance of self-care, as well as set targets all country income groups, was launched in

36
2018 to improve health globally by raising

the profile and the status of the nursing Nursing Now has representation in
profession. Its overall aim is to influence Brazil and advocates the following
policymakers and support nurses to lead, learn goals for the nursing profession in the
and build a global movement. Nursing Now country:
groups have been established and launched
in 40 countries, from the UK to South • invest in strengthening the education
Africa. Because nurses often live within the and development of nursing
community that they serve, they understand professionals with a focus on
the needs of isolated individuals and hard- leadership;
to-reach populations, as well as being able
to design services accordingly.78 Lord Nigel • invest in improving the working
Crisp, who co-chairs Nursing Now and is also conditions of nursing professionals;
an independent crossbench member of the and
House of Lords in the UK, provides his insights • disseminate effective and innovative
on the importance of the nursing profession nursing practices based on scientific
for managing chronic conditions: evidence, at the national and regional
“Nurses are generally women which levels.
means by and large they suffer from the
disadvantages that most women suffer
around the world. Nurses are undervalued
and are not able to work to the top of their One example of a nurse-led initiative to
licence. What is clear is that healthcare improve access to primary care in Brazil
expenditure in the future is around 60- for a hard to reach group is a service set up
70% attributable to chronic conditions, by a nurse working in the Albert Einstein
and the mind-set you need to tackle Hospital in São Paulo.78 This service, Bar
chronic conditions is a bio-psychosocial Talk, was set up in 2013, for men living in the
one. Nurses are trained in bio- Paraisópolis district. As with many deprived
psychosocial approaches throughout their communities, there is a reliance in Paraisópolis
professional practice. The key message is: on emergency health services and limited
if you want to develop your health service, understanding of primary care. This nurse held
you have to develop nurses.” meetings in local bars on a monthly basis for
men aged between 20 and 59, to cover topics
Nursing Now, which was inspired by and that men might otherwise feel too inhibited
continues to advocate for nurses playing a to discuss. A week later, at the local primary
leading role in new and innovative services, is healthcare centre, a follow-up clinic was held,
assessed in “Nursing and Midwifery, the key called After-Bar, which allowed men attending
to the rapid and cost effective expansion of the Bar Talk sessions to book an appointment
high-quality universal health coverage,” a 2018 with a doctor to talk about their health needs
report produced by Lord Crisp and colleagues in more detail. Because of Bar Talk and the
to address global healthcare challenges from initiative of one nurse, male visits to the
within the nursing profession. As well as primary health care centre increased by 80%;
Nursing Now, the report provides examples of the programme has since expanded to other
nurse-led initiatives to tackle chronic diseases bars in the same area.78
in Brazil and improve access to care.

37
before working as a health manager, mainly

There are currently not enough nurses in health IT systems. She moved to the UK
in primary care. We need to turn in 2004, and now leads the BMJ Knowledge
the world upside down. Currently, in Centre/University of Cape Town Knowledge
developed countries it is the norm to Translation Unit (KTU) partnership which
have more doctors in primary care is disseminating PACK. Dr Eastman’s wide-
and less nurses, whereas in developing ranging professional experience informs her
countries there are not many doctors view on the benefits of an approach such as
but more nurses. Last year the number that taken by PACK:
of staff in primary care [in the UK] went
The people that deliver care in primary care
up by 4000—that was an increase
practices and health centres in low- and
of 5000 nurses and a reduction of
middle-income countries are usually nurses,
1000 GPs. It may not be policy that is
midwifes, community health officers who
making that change, but that change
perhaps have two to three years of training,
is happening. The reason that change
community health workers who have no
is happening is not just that nurses are
[formal] training, and sometimes doctors. The
better equipped for primary care; the
PACK philosophy is to deliver care not just
other reason is that not all doctors want
on a vertical level [for specific diseases] but
to work in primary care.
also a horizontal level [across disease areas].
Historically, funding for programmes has often
been based on a disease-based vertical, such
as allocating funding for specific diseases only,
Both the LIACC and Nursing Now assist nurses
such as malaria. At PACK, non-communicable
in being the driving force behind successful
diseases are one vertical, but we also include
primary care services. Lord Crisp states:
communicable diseases, women’s health,
The Practical Approach to Care Kit (PACK) mental health, palliative care and, more
programme is another solution designed widely, we are trying to get coverage for
to empower and strengthen the delivery of all the common symptoms and conditions
primary care by all healthcare professionals that present in primary care and need to be
across primary care in LMICs. PACK, which managed.
was initially developed, tested and scaled up
In Brazil, PACK is being implemented in
in South Africa, provides locally applicable,
Florianópolis municipality, in the southern
evidence-informed guidance and training
state of Santa Catarina. “The primary
for clinicians working in primary healthcare.
care practices in Florianópolis have a
Since being established, the programme
high turnover of staff, so the aim was
has expanded from South Africa to Nigeria,
to provide PACK training with the hope
Ethiopia and Brazil. The Brazilian programme
of helping the staff feel equipped and
is reported to be the first localisation of
confident in their roles and improving
PACK being led by an in-country team, with
staff retention,” says Dr Eastman. “All
mentorship provided by the developers in
49 clinics in Florianópolis, which is
South Africa.79
around 250 medical staff, were exposed
Dr Tracy Eastman, the Global Lead for to PACK. The training was scaled for
the implementation of PACK, has a varied nurses, community health workers and
professional background, having started her doctors [and tailored] according to their
career as a medical doctor in South Africa, prescribing rights.”

38
Dr Eastman has received quite a lot of interest belief in the change process, driven by the
from different states in Brazil for PACK healthcare professionals delivering the care,
implementation and is currently in discussion are a driving force in Brazil. “Yes of course,
with these different states, including the state in Brazil political will is a problem”, she
of Santa Catarina itself. There has also been says. “But I think the approach taken
interest in PACK from academic institutions by the innovation lab will have great
and the private sector in Brazil. The impact of success, as it is not only beneficial in
PACK on chronic diseases is being assessed terms of healthcare and welfare of local
in two randomised studies, one looking at the communities, it also saves money. This
impact on chronic lower respiratory diseases should grab [politicians’] attention.”
and the other at cardiovascular disease
and diabetes. The studies are due to be Ms Viegas Andrade, Lord Crisp and
completed in 2019. Should positive outcomes Dr Eastman all share a common goal:
be reported, this is likely to further increase empowering nurses and community health
interest in its implementation.79 workers to provide effective primary care
services, and in doing so, increasing the nurse
Perhaps not surprisingly, the localisation and to doctor ratio. Dr Eastman also thinks that
implementation of the PACK programme is the value of PACK for upskilling nurses and
being affected by an unpredictable period community health workers to manage primary
in Brazil, marked by austerity measures and care practices when face to face contact with
political instability, coupled with frequent doctors is precious may not be limited to
changes to leadership in healthcare.80 But Ms LMICs:
Viegas Andrade believes that both loyalty and
I have been working with PACK for four years and have been
approached many times to adapt PACK for implementation in
high-income countries. There is no problem with doing that,
aside from time and resources. Currently, the senior staff
and I at PACK devote our time to low- and middle-income
countries, but that does not mean high-income countries
can’t use our model to save on resources.
Dr Tracy Eastman, the Global Lead for the implementation of PACK

39
China: the family doctor team into the development and implementation
of primary care since 2010, this case study
In China, the world’s most populous country, aims to describe an emerging primary care
primary care has been developing for the model known as the family doctor team. Mr
past few decades. In 2009 8,669 community Wang has established and currently leads a
health centres were established. By 2014 such community-based study investigating the care
centres employed more than 300,000 staff.81 of multiple chronic conditions in Guangdong
There have been other great progressions, Province.
such as the expansion of health insurance,
public hospital reform and the strengthening With a large chunk of the Chinese population
of primary care.82 However, China’s healthcare heading straight to hospital to seek treatment
system still faces significant challenges in even for minor ailments, China will struggle
terms of structural characteristics, policies to sustain a workable response to health
and quality of care. National policies are challenges in the future. Some evidence
trying to create better primary care facilities suggests that China’s reliance on healthcare
to essentially form the foundation of the delivered at the hospital level is the result of
healthcare system, improve access for all, and limited education and awareness in relation
reduce the spread of chronic conditions and to primary care.84 People who could receive
multi-morbidity.83 less costly health services from GPs in primary
Chinese people do not access

primary care as much as
secondary care, as they do not
see primary care as safe.
Mr Harry Wang, Associate Professor at
the School of Public Health, Sun Yat-Sen
University, China
The main problem in China is that the health care centres are more likely to choose costlier
system is dominated by a hospital-centric specialist physicians in tertiary hospitals, a
approach. Community health centres are trend that is likely to be linked to patients
underused because of public mistrust,81 with having limited knowledge about GP services.85
people favouring the hospital system more There is a general perception that the quality
than primary care. Using insights from Mr of care provided in hospitals is better. Mr
Harry Wang, Associate Professor at the School Wang reveals that this is partly because,
of Public Health, Sun Yat-Sen University in traditionally speaking, doctors that work in
China, who has been conducting research Chinese hospitals get paid more; on the whole,

40
blood pressure checks, blood glucose checks,

The Healthy China 2030 plan is a a follow-up twice a year, providing health
policy initiative which aims to improve education and sending health education
healthcare across all departments. materials to patient’s homes. The government
This plan encourages the Chinese is therefore making some effort towards
population to use primary care services chronic care management at the community
to alleviate the burden on secondary level rather than the hospital level.
care. In terms of service provision and
Since 2011 encouraging organisational models
the care of multiple chronic conditions,
of service provision with the aim of improving
the government is trying to streamline
the referral system between primary care
more services at the community level
and secondary care has been the focus of
rather than the hospital level.
those tasked with strengthening primary care.
Steps to achieve this include employing more
staff and changing the slow manner in which
service provision is currently organised.82 And,
this has attracted the best doctors to hospitals
as Mr Wang explains, changing staff payment
rather than primary care. But, he says,
schemes are also an important factor:
policymaking is moving in the right direction:
“Improved policies are one approach
The Healthy China 2030 plan, introduced by
which may encourage doctors to consider
the government in October 2016, is the first
the primary care sector and raise their
medium to long term strategic health sector
income level so they are willing to work
plan developed at the national level since the
in primary care. There are very large
founding of the People’s Republic of China
differences in the income levels between
in 1949.86 This plan provides a glimmer of
doctors in primary and secondary care.”
hope that China is politically committed to
participating in Global Health Governance At the national level and in response to Healthy
and also aligning with the UN Sustainable China 2030, the “family doctor team” model
Development Goals agenda. Multi-sectorial was developed as an emerging primary care
collaboration is highlighted as a key model that attempts to embrace family-
component to making this plan work, which centred, co-ordinated care, as opposed to
will require drawing on one of China’s key episodic care. One of the motivations for the
strengths, its innovative health science and model is to tackle the increasing complexity of
technology sector, which is among the best patients’ needs as presented at the doorstep
in the world. Healthy China 2030 recognises of China’s healthcare system. On top of routine
that primary care is the most efficient and care such as diagnosis and treatment of
cost-effective way to meet the health needs of general health concerns, the service will also
people.86 Mr Wang adds some context: address preventative care (including health
assessment), health interventions with follow-
Healthy China 2030 encourages the
up, health advice and, where necessary, home
government to provide primary care services
visits.84 Preliminary evidence has shown that
to alleviate the burden on secondary care. This
the care services delivered through the family
also includes service provision at a primary
doctor team model are more satisfactory than
care level with a particular focus on the care
those delivered by a single physician.87 Partly,
of two chronic conditions—hypertension and
Mr Wang explains, this is because China has
diabetes. This includes free services provided
limited resources when it comes to GPs:
to people with these conditions. For example,

41
A typical family doctor team will consist

of one GP, a nurse, public health doctors, The national target is to have three
and, if possible, pharmacists, psychology GPs per 10,000 population by 2020; this
consultants and social workers. This multi- is still a very low number. Therefore,
disciplinary approach both addresses the to manage the population of people
physician shortage in China and the need with multiple chronic conditions, other
for more complex patient care. The family healthcare professionals also need
doctor team also encourages other healthcare to take responsibility in the delivery
professionals working in primary care to of the family doctor team. The idea
develop their expertise to the extent that they is that the local community will be
too may lighten GPs’ load.84 But although this registered with a certain family doctor
approach is incentivised at a national level, Mr team, so the team as a whole will take
Wang says that its implementation currently responsibility for registered individuals.
only exists in pockets across China: This model will help develop integrated
care and solve the problem of physician
“The family doctor team is already
shortage.
implemented in certain states in China,
but there is also no clear definition of this
model or a clear checklist for what sort of
model or services this should include. It’s the standards for healthcare delivery and
difficult to therefore to expect all regions the availability and safety of medicines.88
to follow a rigid plan, which means Generally speaking, restructuring China’s
achieving a consistent family doctor team healthcare system will require co-operation
across all regions in China is difficult.” and co-ordination between public hospitals, a
A more recent step in the right direction, strengthening of primary care, and payment
in December 2017 China published a draft reform. And, as with most systemic changes
National Health and Health Promotion Law, to a healthcare system, success will not be
which makes access to basic healthcare achieved without strong political will and
services a legal right. Further new measures, leadership.82
announced in November 2018, aim to set

42
Spain: Models of care for improved Scale ran from 2016 to 2019 and aimed to scale
integration of care in Spain up the best practices identified in the original
programme to reach 100,000 patients in six
These are the words of Juan Carlos Contel, regions across five countries (Spain, Denmark,
a qualified nurse who has dedicated his the Netherlands, Germany and Scotland).
career to research into chronic disease This project has organised integrated care,
prevention and integrated health and telehealth and care co-ordination in two
social care programmes with the Catalonia waves across the six European regions
Department of Health in Spain. Despite a involved.90
lack of international alignment, a healthy
scattering exists of wholly- or part-funded “I think there are examples of best
projects aimed at improving care for people practice in integration of healthcare
with multiple chronic conditions (MCC) across services in Europe,” says Dr Josep Roca,
the EU. These include ICARE4EU, ACT@Scale, Professor of Medicine at the University
Scirocco and ICT4Life, with several interesting of Barcelona. “The ACT@Scale project
case studies coming out of these projects. [was] precisely devoted to characterising
A large chunk of these EU-focused projects holistic services, including deciding what
have been based in Spain, a country that in exactly the drivers are and how these
2011 estimated just over half of its population should be measured.”
had multimorbidity.89 Three of these projects
To decide which projects had the potential
are described here in a little more detail, with
to be scaled up, ACT@scale identified four
insights from some of the Spanish affiliates
drivers that most significantly contributed to
responsible for developing these projects
the sustainability of services. These drivers
locally in Spain.
were chosen based on the experience of
The ACT@Scale project, like its predecessor, ACT@scale members and the research
the Advancing Care Co-ordination & literature. The drivers were:
Telehealth Deployment (ACT) Programme,
• Citizen empowerment. Citizen-centred
was a collaboration between European
care is essential to the delivery of integrated
healthcare authorities and providers, as well
care. This driver sought aspects of each
as industry and academic institutions. ACT@
There is no international code

related to multi-morbidity or
complex conditions.
Juan Carlos Contel, nurse

43
project that engaged users, such as shared Integration Programme chosen for ACT@scale.
decision making, attention to patient “There were 13 different integrated care
journeys, development of empowerment organisations in the Basque country, and
skills and citizen networks. we introduced a common care pathway
across all of these. Of course there was
• Service selection. The healthcare services resistance at first [from staff], everyone
chosen to be scaled up had to be dynamic thought they were too different for one
enough to cover the needs of the patients pathway. We worked with individual
and populations, as well as encouraging risk centres to help them adapt, and tell us
stratification and prediction. [programme coordinators] why they were
• Stakeholder and change management. different, which not only helped us but
There had to be evidence of strong have them a sense of belonging in the
organisational adaptations that supported change process.”
change, such as staff engagement, change The Innovating care for people with multiple
management and stakeholder management. chronic conditions in Europe (ICARE4EU)
• Sustainability and business models. To project, which ran from 2013 to 2016, identified
increase the chance of the service achieving and analysed innovative approaches in
long-term adoption into routine care the multidisciplinary care that were being used
projects had to be cost-effective. for people with MCC across 31 European
countries.
Two of the European regions chosen for
ACT@scale projects were in Spain: Catalonia The project found 101 approaches that had
and the Basque Country. One example of been implemented in 25 of these countries
a chosen best practice is the Multimorbid to deliver care to people with complex,
Integration Programme, which was based long-term health problems, including people
in the Basque Country. This programme with multimorbidity. However, hardly any
aimed to provide patients with several co- countries or regions had strategies or policies
morbidities with co-ordinated multi-level focused on integrated care for people with
and multidisciplinary care. The service was multimorbidity specifically; most chronic
designed to make sure that such patients, disease policies were focused on a single
each with complex healthcare needs and who illness.
might otherwise be at high risk of hospital or Most often, these approaches focused on
care home admission, could lead independent increasing multidisciplinary collaboration,
lives and have improved clinical outcomes. improving patient involvement and/
The programme achieved this using ICT- or improving care co-ordination. Most
enabled health and social care service co- approaches were being implemented in
ordination, monitoring, care involvement, primary care, and most had only a relatively
and patient self-management. The ICT- limited scope (for example, addressing a
based platforms in this project had the specific combination of diseases, or integrating
potential to improve treatment compliance, only specific organisations or disciplines).
enhance self-management, and increase the
understanding of multi-morbidity for both In ICARE4EU, the largest number of
patients and professionals.91 “We redefined programmes identified (15 of the 101) were
the care pathways across the whole of the in Spain. The Strategy for Chronic Care in
Basque country” says Ane Fullando Zabala, the Valencia Region is one such programme,
coordination manager of the Multimorbid introduced by the regional Ministry of Health

44
in 2014 to promote change in the healthcare Despite this, the ICARE4EU project found
system towards organising care for people that eHealth does not yet play a major part in
with chronic conditions and multi-morbidity. most European health systems, with better
In defining a patient with complex needs, the regulation, funding and standardisation of
approach in Valencia is holistic, paying special these tools required.
attention to not only multimorbidity, but also
The Sustainable intEgrated care modeLs
the patient’s family circumstances and their
for multi-morbidity: delivery, FInancing and
environment. The model incorporates primary
performancE (SELFIE) project has developed
care services, hospital and community
and compared new models for safe and
healthcare to ensure that each patient is
efficient prevention-oriented health and care
monitored across the care pathway. The
systems. The Spanish partner in the SELFIE
model also assigns two nurses to manage
project is based in Catalonia and backed
care co-ordination and case management.
by the regional government, which has a
The model also requires ICT support and
health system supported by one public payer
information systems that can stratify the
that provides healthcare to a population of
population into risk profiles. The whole
7.5m.92 The region is attempting to develop
strategy is financed through the regional
health system, which is largely funded by an ambitious plan for the deployment of
general taxation. eHealth-supported integrated care for people
with chronic conditions. Mr Contel further
A key takeaway from the ICARE4EU project elaborates on the professional activities within
was the importance of eHealth, otherwise the Chronic Prevention and Care Programme
known as services delivered through ICT. at the Department of Health:
These have the potential to improve MCC care
through: “In Catalonia over 90% of GP surgeries use
the same clinical records. Because of this
• allowing better integration and co- high coverage, it is expected that primary
ordination of care by facilitating sharing of care physicians can establish prevalence
information between professionals, patients of MCC and share this in the electronic
and carers; medical record which is made accessible
for any organisation that has involvement
• supporting self-management by providing
in [caring for] the particular patient.”
the patient with feedback or checking
adherence to treatment; Healthcare professionals can benefit greatly
• improving clinical decision-making by from the shared electronic medical record
providing decision support systems that system in Catalonia, as it can be used as
help to share evidence on how best to deal a tool to support clinicians in making the
with MCC; best decisions about patient care. Shared
electronic medical records promote continuity
• making care more proactive by monitoring of care and improves co-ordination between
and analysing risk factors to identify the care levels, including primary care and
patients who are the most complex and specialised care.93 Mr Contel tells us about
most in need of care; and
other features of the system:
• increasing access to care for people with
“As well as prevalence, we are also
MCC living in more remote or deprived
developing a system in Catalonia in which
areas through mobile applications or
all patients can be identified according to
telehealth services.

45
their level of risk, which is also attached Catalonia, as in many other counties and
to the electronic medical record. This regions within these, is the sharing of
means that any healthcare professional information between health and social
accessing the record can be made aware care. This kind of sharing does not operate
of each patient’s level of risk. This helps in many places in Spain. Currently it
physicians to make treatment decisions.” only exists in Barcelona, and it has taken
three years just to achieve that. Financing
The initial driver for the integration of services is also an issue, as money comes from
was a policy commitment towards a patient- different places for health and social care.
centric model. This has led to a reorganisation Pooling funding in this way is very tricky.
of services that are specifically designed to You have to be very resilient and patient to
promote co-operation between tiers of care encourage health and social care sectors
and between health and social care.93 A case to work together over long periods of time.
management nurse plays a pivotal role in this There are many cultural barriers.”
process. Mr Contel further explains:
There have been some steps in the right
“In Catalonia, we have attached the direction, including integrated health
chronic care programme into the health and social care plans, and the “Spanish
plan of Catalonia. The chronic care Dependency Law”, which introduces universal
programme lays out the care for complex coverage for moderate to severely dependent
patients, which includes patients with people.93 However, since the 2008-2014
singular chronic diseases, multiple economic crisis a tight budget and severe cuts
chronic conditions and a further variation in healthcare have stalled progress. Despite
which is one chronic condition with social this, creative funding schemes for integrated
problems.” care such as per capita payments for primary
Despite the various successes of the SELFIE care services are being introduced by the
project in the Catalan region, there remains Catalan government called “adjusted multi-
limited integration of health and social care, morbidity groups”. Catalan policy makers push
with the health and welfare departments in forward by reviewing and tailoring health
Catalonia organised separately. “Of course, plans every five years, adapting to the financial
there are barriers to this system,” says environment and making sure goals set for the
Mr Contel, “The problem we have in region are realistic.

46
UK: Guy’s and St Thomas’ Charity Clinical Commissioning Groups, corporates,

Programme on Multiple Long-term community organisations and local health
Conditions services.
Guy’s and St Thomas’ Charity is running a The reasons some people develop multiple
ten-year programme to explore how people health conditions sooner than others is not
living in urban environments develop multiple well understood. While it’s not yet clear
long-term conditions and what works to which factors contribute more than others,
help slow down progression from one to the Charity’s research and work to date
many conditions. This multi-million pound show significant variation in the length of
programme which started in 2017 is running time between people developing one and
across the diverse London boroughs of subsequent conditions. For example, in
Lambeth and Southwark.94, 95 Lambeth, people living in the areas with the
highest levels of deprivation are developing
As an independent urban health foundation, long-term conditions on average 10 years
the Charity tackles key health challenges that earlier than those living in the most affluent.
affect inner-cities. It takes a whole-systems
and place-based approach, running focused The programme focuses on people, of working
programmes that come at a small number of age, living with one condition who are most
complex health issues from different angles. at risk of developing many conditions. It aims
To do this, the Charity works in partnership to reduce the variation in progression seen in
and at different scales to drive impact in their Lambeth and Southwark, and share learning of
place. Through its programme on multiple what does and doesn’t work with others.
long-term conditions the Charity collaborated According to Barbara Reichwein, Programme
with a range of partners on small and large Director, Multiple long-term conditions
projects including the NHS, the Richmond at Guy’s and St Thomas’ Charity, they are
Group of Charities, the Royal College of focussing on two main areas, “intervening
General Practitioners, local governments, upstream to fill the gap in early intervention
The evidence base on what works is small,

so in this ‘exploratory programme’ we are
assembling a broad portfolio of interventions
and activities aiming to reduce people’s
progression from one to many conditions
Barbara Reichwein, Programme Director, Multiple long-term
conditions, Guy’s and St Thomas’ Charity

47
and preventative healthcare and social risk a higher prevalence of people living with
factors of health that we think influence the three or more long-term conditions in black
variance in people’s progression to multiple and Asian ethnic groups, and that people
long-term conditions”. from these communities are often diagnosed
years earlier than their white neighbours.
Research published by the Charity in July 2018 Similarly, the research suggests that levels
in partnership with Kings College London has of deprivation also seem to play a part in
helped hone the programme strategy – for the burden of multiple long-term conditions
example by focussing on working age adults experienced by a community. People living in
and on social risk factors. It’s From one to many areas with the highest levels of deprivation are
report showed that in Lambeth, around a third diagnosed with multiple long-term conditions
of people with multiple long-term conditions earlier than their more affluent neighbours.
are diagnosed under the age of 65. Whilst
age is a significant factor in predicting the risk Ms Reichwein explains that this research has
of multiple long-term conditions, it is by no highlighted “postcode inequalities with
means the only one. A closer look at age shows stark contrasts in opportunities for good
a breakdown of patients living with multiple health”. She goes on to say that “multiple
long-term conditions in the borough by age: long-term conditions are a relatively new
concept with a variety of definitions.
• 34.6% of people under the age of 65 Our strategy has a strong focus on early
• 22.8% of people aged 65 to 75 secondary prevention because we see
• 42.6% of people 75 or more years old there is a gap here. A minority of the NHS
budget is spent on prevention”. The charity
People living with long-term health conditions has several areas of focus for an improved
are also significantly more likely to be living with approach:
health risk factors including obesity (60%) and
• The programme must target the working
hypertension (50%). In Lambeth, 96% of people
population who have one long-term
living with multiple long-term conditions have
condition such as type 2 diabetes or chronic
more than one associated risk factor.
pain and aim to arrest the development
The research explored common patterns of other conditions through reducing risk
of progression from one to multiple chronic factors and increasing protective factors.
illnesses in the borough using GP records over • The charity will focus on 32 conditions that
time in order to better understand prevalence effect people in the most deprived areas
and target prevention. The variability and (lowest two quintiles in the Index of Multiple
compounding effect of conditions, as well Deprivation).
as the time between diagnoses makes this a
• It plans a multi-pronged approach to
complex issue. However, some patterns were
address social risk factors, for example
clear. For example, diabetes was the starting
by working with local employers on
point for the majority of the most common
making workplaces healthier or with local
sequences of conditions and chronic pain is a
community groups to co-locate social and
common feature in more than half of recorded
healthcare support. Reaching out through
sequences in Lambeth, followed by chronic
different channels will hopefully capture
kidney disease and depression.
some of the same people at risk in a local
People’s social context also appears to neighbourhood.
influence risk. In Lambeth, the report found • A range of interventions and activities will

48
be put in place to optimise management disproportionate number of Portuguese

of the primary condition and reduce risk speakers in the borough live with multiple
factors including stress, hypertension, long-term conditions, including cardiovascular
obesity and anxiety. disease, hypertension and diabetes. The
• The programme aims to track the effect of charity is supporting the Lambeth Portuguese
interventions on health outcomes over time. Wellbeing Partnership (LPWP). This is an
One of the metrics they are aiming for is to emerging grassroots network of over 40
“level the median age of onset” of multiple local groups and community members built
chronic conditions. around a shared goal of supporting the health
and wellbeing of local Portuguese-speaking
From its work on the ground, the Charity is residents. Since December 2017 the charity
finding that multiple long-term conditions are and LPWP have worked to identify people with
a complex health issue and that the answers or at risk of multiple long-term conditions, such
aren’t just medical. They must also encompass as those who are socially isolated or suffering
wider social risk factors, like people’s from domestic violence. They also work
employment, housing and financial health. In with families of people living with long-term
line with the NHS long-term plan, the charity conditions. Community workers help:
is planning to support social prescribing. The
programme’s staff are also looking at non- • reduce barriers to accessing GPs (e.g.
traditional ways of “reaching out through through language difficulties)
different channels to augment and speed up • address unhealthy lifestyle behaviours
support” to people in their Boroughs, such as:
• connect isolated people with community
• Supporting employers to create health- groups
promoting environments
• engage people with mental health problems
• Help people with long term conditions find with appropriate services
appropriate work and progress at work
• with finances and welfare support
• Invest in building partner relationships,
• negotiate home improvements with
capacity and capability which allow people
landlords for healthier homes so that they
in our Boroughs to protect their health,
can manage their long-term conditions most
including looking at housing issues.
effectively.
• Improving contract conditions, money
advice and financial health interventions to 2. Walworth Neighbourhood Scheme
try and stabilise people’s money The charity has partnered with Pembroke
The charity is also testing “whole-system House, a local “community anchor” which
solutions” in the form of three specific has been providing community services for
projects: over 100 years. Ms Reichwein describes the
charity’s involvement as “finding, activating
1. North Lambeth Neighbourhood Scheme and growing local energy” in order to provide
a number of projects including:
One in six Lambeth residents is a Portuguese
speaker (around 35,000 people). They have • Walworth Living Room, a shared public
a higher than average prevalence of long- building to bring professionals from
term conditions and are 20% more likely to different disciplines together and combine
have three or more long-term conditions community, social, work and health
than the general Lambeth population. A

49
activities so that people with multiple long- 3. Neighbourhood Based Care,

term conditions can access more integrated Coordination and Wellbeing Networks
care. This opened in the summer of 2019
In both Boroughs, the programme co-
with nearly £500,000 funding.
funds partnerships between primary care,
• Supporting social prescribing - such as the secondary care, social care, community
Safe and Independent Living (SAIL) organisations patients and carers. The aim of
Navigators, who assist people with health these partnerships is to re-group care around
and/or social care needs to get access and neighbourhoods and to achieve the following
referrals to the relevant local agencies. In objectives:
particular, SAIL Navigators help with social
• Identifying people with multiple long-term
isolation and poor housing.
conditions earlier
The charity also aims to better support people
• Addressing health and social risk factors
newly diagnosed and people living with a
through holistic, preventative care
combination of social risk factors and long-
term conditions. There is a lot of investment • Mapping out available services in each area
within the NHS in earlier diagnosis and on- to raise awareness and improve access.
going management of long-term conditions,
Key insights
however this support offer tends to focus on
single conditions, clinical risk and short-term One of the strengths of this partnership
patient education and self-management is that Guy’s and St Thomas’ Charity is an
courses. Within its programme strategy, independent health foundation, which Ms
the charity also seeks out opportunities to Reichwein says, enables it “to invest differently”.
augment and improve this offer for groups at As the charity is a funder, it does not provide
risk of rapid progression to multiple long-term direct services. “But at arm’s length,” says Ms
conditions such as co-funding neighbourhood Reichwein, “we are an enabler to nudge the
based care and wellbeing networks. system to shift”. There were loose networks
in the boroughs before, but the involvement
of Guy’s and St Thomas’ Charity has helped to
bring organisations together. The charity is also
able to fund and support these organisations,
providing business skills, evaluation,
governance and safeguarding expertise.

50
UK: Multi-morbidity guidelines and been—and largely still are—organised around

integrated care in the UK single disease management systems.5 This has
resulted in healthcare services being designed
Consultant pharmacist Nina Barnett works according to clinical guidelines that, on the
in older people’s care in the UK National whole, recommend treatment protocols that
Health Service (NHS). Dr Barnett provides are irrelevant to a person with multiple chronic
practical insights on how healthcare conditions. The evidence base is also largely
professionals manage people with multiple dominated by research into single conditions,
chronic conditions through the prism of providing very little basis for developing new
clinical guidelines that empower co-ordinated, guidelines for people with multiple chronic
person-centred care. In 2016 the National conditions.97 Dr Barnett states:
Institute for Clinical Excellence (NICE),
which has a strong influence on both service “There is limited evidence on managing
provision and clinical practice in the UK, multiple chronic conditions in practice
published a guideline specifically on how through personalised approaches, as it
to manage patients with more than one is very difficult to quantify outcomes in
long term conditions. Dr Barnett provides trials. However, even with evidence, it is
insights into how this guideline is being used not possible to expect change to happen
to implement change in pharmacy practice in healthcare practice with evidence only.
in the NHS to effectively manage a growing For the management of multi-morbidity,
population of people with multiple chronic looking at evidence in the form of the
conditions. outcomes of conversations with different
people and recording their quality of life,
Although multiple chronic conditions are you might determine quality of care for
familiar to some healthcare professionals, people for multi-morbidity. Looking for
mainly geriatricians, who treat frail older evidence or trying to do research in the
people often living with more than one chronic field of multi-morbidity and managing
condition, the rest of modern medicine has patients with multi-morbidity is very
not adapted quickly enough to address the difficult. This is because success is
consequences of multiple chronic conditions.96 measured by having conversations with
Both primary and secondary care for long- patients about what matters to them.
term conditions in the UK have traditionally Changes to practice should be focussed
A simple way to start the

conversation with a patient with
multi-morbidity is to ask: ‘If
you can get one thing from this
consultation what would it be?’
Nina Barnett, consultant pharmacist

51
on quality of life and be about what

the patient wants to achieve by taking Some of the key recommendations
medicines.” from the NICE multi-morbidity
guideline include:
Previous policy in the UK has made steps
towards improving MCC care, such as the 2014 • responsibility for co-ordination of
NHS Five Year Forward View which set out a care should be assigned, ensuring
plan for developing “expert generalists” in GP that this is communicated to other
practices.96 This policy highlighted the need healthcare professionals and services,
to target services at patients with complex especially if care has become
ongoing needs, such as the frail elderly or fragmented;
people with chronic conditions. However, • responsibility for co-ordination of
implementation of the NHS Five Year Forward care could be assigned to a case
Review has remained varied in the UK.96 manager or a GP;
NICE used the lack of evidence base and the
• benefits from existing treatments
lack of an appropriate healthcare approach
must be maximised and treatments
for people with MCCs as the spring board
of limited benefit stopped;
for developing a multi-morbidity guideline.98
This guideline lays out the care procedures • treatment and follow-ups with high
of people with two or more long-term health burden must be optimised;
conditions. All NICE guidelines are developed
• ensure that higher-risk medications
with a multi-disciplinary group consisting
are appropriately given and
of clinical experts from across all sectors to
take consideration of non-
ensure that they are applicable to healthcare
pharmacological alternatives;
practice.98 The opinions and experiences
of clinical experts, as well as their clinical • optimise appointments.98
judgement, are used to piece these guidelines
together, promoting shared decision making
and holistic planning.97
with or without multi-morbidity, management
Translating the holistic approach to care laid of conditions might be more about extending
out in this multi-morbidity guideline into life expectancy whilst also taking into
applied changes to the healthcare system account quality of life, so it’s a combination of
requires a cultural shift for both patients and quality and quantity of life. For older people,
clinicians.97 Dr Barnett elaborates from a sometimes the focus is more about quality
pharmaceutical perspective: over quantity or, to put it another way, what
can we do to improve quality of life in the later
The broad definition of multi-morbidity
phase of life.
is a person with more than one long-term
conditions, as it’s is very rare to see an older Although the NICE multi-morbidity guideline
person with only one long-term condition. So does not provide specific advice on how to
what this means is changing the focus of what manage multi-morbidity, it recommends
you are trying to do with medicines in the first that local providers have an action plan and
place. The principle of the NICE guideline on a project group, including staff, associated
multi-morbidity is to optimise people’s overall services, and financial and information
quality of life, rather than manage conditions professionals. One of the strengths of the
specifically and individually. In younger people NICE guideline is that is lays out a pragmatic

52
approach to treating people with MCCs.98 It the process is reliant on people wanting and
highlights how to identify the kind of people accepting help. Indeed, two-thirds of eligible
who may benefit from an approach to care patients either did not respond to the study
that takes into account multi-morbidity before opportunity or declined to take part.
a person requires emergency hospitalisation,
both during routine health encounters and As Dr Barnett explains, when embarking on
also by searching electronic medical records.97 a project that involves making changes to
It has the potential to re-empower healthcare healthcare practice for people with MCCs,
professionals as holistic physicians and relying on medical research alone will not
remove the constraints of contemporary result in effective change:
protocol-based medicine.5 The guideline “In order to effect a change in practice
also highlights areas where research and around management of medicines in
knowledge on people with multi-morbidity people with multimorbidity, change
is lacking. For example, there is still a lack of needs to come from a variety of sources.
information and guidance on how to manage This may include the evidence base but
frailty in younger people and vulnerable also can be supported by individual
populations, such as those with learning and organisational role models, case
difficulties, serious mental health problems or examples, NHS policy and political will
addiction issues, or migrants.99 for change. It’s a coalescence of a lot of
There have been some efforts to conduct different factors, not one on its own.”
research into multiple chronic conditions, Another UK initiative, which mirrors the
although the results have been mixed. The approach laid out in the NICE multi-morbidity
National Institutes for Healthcare Research guideline, is the Comprehensive Geriatric
conducted a randomised controlled trial Assessment (CGA). This assessment aims to
(RCT) of a three-dimensional review of care reduce frailty (thereby decreasing the risk of
conducted for individual patients every six hospitalisation or rehospitalisation) and try to
months.100 This was performed by a nurse, GP enable people to live independently at home
and pharmacist. The trial was conducted in for as long as possible. GPs or community
33 general practices in England and Scotland, geriatricians are expected to perform most
and included 1,546 people with at least three CGAs with the help of multi-disciplinary teams.
long-term conditions. Those having the three-
dimensional review scored slightly higher on Studies measuring the impact of the CGA
the Patient Assessment of Care for Chronic have been mixed.101 A recent review of the
Conditions score, which ranges from 1 to 5 CGA as applied in care homes found that it is
(adjusted mean difference 0.29, 96% CI 0.16 to not effective unless all three components—
0.41). These patients were also more likely to standardised assessment, communication of
be satisfied with their care (56% versus 39%) the plan within a multidisciplinary team and
and report that they were able to talk with co-ordination of the delivery—are performed
a healthcare professional about their most adequately. A feasibility study of 186 people
important issues (42% versus 26%). However, on eight or more medications found that
there was no difference in patient quality of having a CGA with a geriatrician resulted in an
life or burden of illness and treatment after 15 average of four changes to those medications,
months. The study was hampered by only 49% predominantly stopping some or reducing
of the intervention group having both review the dose.102 However, a trial of 433 older
sessions. This highlights one of the difficulties adults found that conducting the CGA prior
in managing people with multi-morbidity— to discharge from hospital had no effect on

53
readmission rates or transference of patients

into care homes.103
Dr Barnett has helped to transform
Medication reviews and streamlining patient pharmacy practice by empowering staff
treatments may seem like a beneficial result of to place person-centred conversations
the CGA, but, as Dr Barnett explains, without with patients at the heart of
a person-centred approach, treatment pharmacists’ everyday responsibilities.
reviews such as this can be quite destructive For people with MCCs, Dr Barnett’s
and may not improve quality of life: ethos is to conduct pharmacy
consultations with quality of life at
As pharmacists, if performing a medication the heart, making sure that what the
review, we need to think carefully before patient wants to achieve from taking
broaching the subject of reducing the amount medicines is understood and respected.
of medications the patient is taking. People “This line of questioning encourages
have very different views about stopping the patient to take the lead in terms of
medicines: some are very pleased to take less what they want out of a consultation,
medicines, and for others this can be quite rather than assuming you know what
distressing, confusing and possibly destructive the person wants”, she says.
for the patient-clinician relationship. For
example, if you are thinking about a review
of pain medication, the patient might be
thinking “I am in a lot of pain already; stopping
medicines will make me worse”. Introducing example of how a guideline can have a
the idea of reducing or stopping these trickledown effect into healthcare practice.
medicines will be doomed to failure unless The NICE guideline on multi-morbidity is one
effective person-centred consultations, of a kind in terms of writing and publishing
which include shared decision making, are a guideline specifically related to organising
undertaken to ensure that any changes are services and the care approach for people
acceptable, agreed and followed up. with multi-morbidity, meaning that the UK
serves as global leader in this topic. Although
Dr Barnett has developed training modules NICE technically only has authority in the UK,
for pharmacists to encourage person-centred it is generally seen as providing high-quality
consultations in hospitals, a successful evidence that is highly influential worldwide.5

54
US: The AGING Initiative: devising a Although the HHS provided ground breaking
new paradigm of medical education work in the realm of addressing MCCs in
in the US the US, it is difficult to find examples of the
educational and training materials in practice.
In 2010 the Health and Human Services (HHS) Although knowledge exists about the need for
Initiative on Multiple Chronic Conditions change in medical schools and treatment of
published guidelines and a framework on MCCs, the educational reforms still need to be
multiple chronic conditions (MCCs) in the fully implemented on a larger scale.
US. The HHS Assistant Secretary for Health
convened a working group on the topic, in The AGING Initiative’s Role in MCC care
order to get a clear picture of the problem Other smaller-scale initiatives have since
and develop a roadmap for ways to handle emerged that seek to shape the next
the growing disease burden.1 The materials generation of physicians into medical
produced were partly based on input from professionals who understand the vastly
various community stakeholders and were different treatment modalities and
intended for internal use within the HHS and preferences for patients with MCCs. One
correlating government entities. This was one such programme is the Advancing Geriatrics
of the first national efforts by the US to take Infrastructure & Network Growth (AGING)
steps in combating the rise of MCCs. Following Initiative. This initiative was originally formed
the publication of the framework, additional to connect and improve communication
measures were taken by HHS to halt the rise between the Healthcare Systems Research
of MCCs. These measures included forming Network (HCSRN) and The Claude D Pepper
a research network, creating a measurement Older Americans Independence Centres
framework, and developing an inventory of (referred to as Pepper Centres or OAIC).5
existing programmes, tools and research
initiatives already focussed on addressing The HCSRN was founded in 1994 and is
MCCs in the US.1 comprised of 20 non-profit healthcare
delivery systems. One thousand nine hundred
Three years after the launch of the initial faculty members and staff work at HCSRN
framework, HHS published the Education member centres to provide research for over
and Training Resources on Multiple Chronic 28m patients. 4 Research is conducted using
Conditions for the Healthcare Workforce. electronic medical records from each of the
These are a set of educational tools, member organisations. The Pepper Centres,
curriculum guides and a training repository for which are funded by the National Institute on
the purpose of improving outcomes across the Ageing (NIA), serve as centres of excellence
care continuum.2 The educational component that focus on geriatrics research and
is an important contributor to MCC care, education for medical students on maintaining
because so much of the US healthcare system and restoring functional independence for the
is currently based on a more traditional geriatric population. 4 Currently there are 15
single-disease paradigm.3 “The system we Pepper Centres in the US, each one operated
practice […] works well for a single-disease by its own advisory committee and the NIA.
approach to medicine,” says Dr Heather The OAICs also provide important datasets
Whitson of the Duke Centre for Ageing. “[It and biospecimens for research.
is based on] a paradigm by which the
purpose of the system is to provide the The idea to unite the two research
most aggressive and thorough care to a powerhouses into the AGING Initiative came
particular diagnosis or an acute event.” from Dr Jerry Gurwitz, a geriatrician at the

55
University of Massachusetts. According The AGING Initiative Scholars Programme

to Dr Whitson, who currently serves as is designed to train physicians in the patient
the director for the AGING Initiative MCC engagement, methodology and study design,
Scholars Programme, Dr Gurwitz saw the and burden of the problem (in terms of
two organisations as being complementary to economic impacts, consequences to the
one another but with little contact occurring healthcare system, and so on). The curriculum
between them, as research was often was not explicitly guided by the original HHS
conducted in siloes with little concept of team guidelines previously mentioned, but the
science. (Although there are many definitions Scholars Programme did utilise principles
of team science, it can be summarised produced by the American Geriatric
as a “means of attending to complex Society, which are derivatives of the HHS
clinical problems by applying conceptual work. These are not guidelines, but rather
and methodological approaches from recommendations from an expert panel for
multiple scientific disciplines and health the clinical management of older patients who
professions”.6) have MCCs.7
The Future of MCCs in the US
The AGING Initiative was designed When asked about the wider state of medical
as a way to bridge the two distinct education for MCCs in the US, Dr Whitson
organisations in order to create a notes that it is improving, but concedes
national resource to “nurture and that the healthcare system continues to fall
advance an interdisciplinary research back on the single disease paradigm. She
agenda focused on older adults with also notes that establishing quality metrics
multiple chronic conditions”.5 has been difficult for patients with MCCs,
because disease guidelines currently focus on
treatment of a single disease. In thinking about
the future of medical education for MCCs in
The AGING Initiative has three core strands: the US, Dr Whitson envisions that “maybe
methods and measures, career development tomorrow’s clinicians will be trained to
and knowledge dissemination, and patient- understand that it’s often not completely
priority alignment. These are used as the black and white, but it’s a spectrum. Being
guiding facets of research for the partnership. mindful of where it is appropriate to be on
Recently, the initiative has expanded into the that spectrum from disease-driven care to
realm of education, through the establishment preference-driven care is something that
of the MCC Scholars Programme. Leaders of [new doctors] will think about with every
the programme (including Dr Whitson) select patient.”
a cohort of students on a yearly basis, who
then receive training and career development The structure of medical education and
in the field of MCCs. In addition to receiving research for MCCs is also posed with
this training, students become part of a difficulties from within the publishing realm,
community of physicians around the country where study sections of the National Institutes
who remain connected as they work to better of Health and academic journals are still
understand MCCs. This, as Dr Whitson sees organised on the basis of the single-disease
it, is one of the most powerful parts of the system. This reflects the disparate nature
programme. of work that is being done around MCCs

56
currently, in that no single body is responsible Although the programme is fairly new, the
for providing resources or training the medical personnel overseeing it have observed
workforce to care for patients with MCCs. notable improvements for patients with MCCs
around the country. An expansion of this type
Ultimately, MCC care necessitates team
of training and research is needed on a large
science because of the diversity of every
scale in order to prepare medical professionals
patient. The purpose of the larger AGING
for the increasing numbers of patients with
Initiative is to foster research that is founded
MCCs and their differing care needs.
on team science in order to improve outcomes
for patients with MCCs. Putting in place a “There are these other patients that are
holistic approach to improving MCC care in living with—not dying from—they are
the US has always been at the forefront of living with multiple chronic conditions,
the AGING Initiative’s purpose, which is why and that merits a different approach to
the leadership seeks to address all aspects, their care,” says Dr Whitson. With this in
from research, to point of care, to economic mind, it is clear that efforts surrounding MCC
burdens. 4 care need to be unified and strategic in order
to achieve better outcomes for patients.

57
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Assessing health system

preparedness for multiple

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About this report

International advisory panel Alan Lopez, Professor of Global and Public

© The Economist Intelligence Unit Limited 2020

Project objectives As well as discussing the results of the index

© The Economist Intelligence Unit Limited 2020

© The Economist Intelligence Unit Limited 2020

Index methods alignment with best practice (as measured

© The Economist Intelligence Unit Limited 2020

© The Economist Intelligence Unit Limited 2020

Figure 1: Country scores by domain

Australia Australia Australia Australia Australia Australia

Brazil Brazil Brazil Brazil Brazil Brazil

Canada Canada Canada Canada Canada Canada

Chile Chile Chile Chile Chile Chile

China China China China China China

Croatia Croatia Croatia Croatia Croatia Croatia

Denmark Denmark Denmark Denmark Denmark Denmark

France France France France France France

Germany Germany Germany Germany Germany Germany

Indonesia Indonesia Indonesia Indonesia Indonesia Indonesia

Israel Israel Israel Israel Israel Israel

Italy Italy Italy Italy Italy Italy

Japan Japan Japan Japan Japan Japan

Mexico Mexico Mexico Mexico Mexico Mexico

Netherlands Netherlands Netherlands Netherlands Netherlands Netherlands

Peru Peru Peru Peru Peru Peru

Russia Russia Russia Russia Russia Russia

Spain Spain Spain Spain Spain Spain

Thailand Thailand Thailand Thailand Thailand Thailand

Turkey Turkey Turkey Turkey Turkey Turkey

Ukraine Ukraine Ukraine Ukraine Ukraine Ukraine

 PREPARED  FAIRLY PREPARED  LESS PREPARED  NOT VERY PREPARED

© The Economist Intelligence Unit Limited 2020

Key takeaways 30% and 81%—in this instance, the former

Source: The Economist Intelligence Unit

© The Economist Intelligence Unit Limited 2020

Source: The Economist Intelligence Unit

© The Economist Intelligence Unit Limited 2020

© The Economist Intelligence Unit Limited 2020

© The Economist Intelligence Unit Limited 2020

© The Economist Intelligence Unit Limited 2020

© The Economist Intelligence Unit Limited 2020

Discussion of findings by country to encourage people to self-­‐manage their

© The Economist Intelligence Unit Limited 2020

© The Economist Intelligence Unit Limited 2020

© The Economist Intelligence Unit Limited 2020

© The Economist Intelligence Unit Limited 2020

The Netherlands, does particularly well

© The Economist Intelligence Unit Limited 2020

© The Economist Intelligence Unit Limited 2020

© The Economist Intelligence Unit Limited 2020

© The Economist Intelligence Unit Limited 2020

© The Economist Intelligence Unit Limited 2020

© The Economist Intelligence Unit Limited 2020

© The Economist Intelligence Unit Limited 2020

Opportunities for action

• Strong political leadership is essential. • Gaps in healthcare coverage. These increase

Discussion of findings by country to encourage people to self-‐manage their