Health » Overview

Salzburg Global Seminar has long been a leading forum for the exchange of ideas on issues in health and health care affecting countries throughout the world. At these meetings agendas have been re-set affecting policy and practice in crucial areas, such as patient safety and the engagement of patients in medical decision making. In 2010, Salzburg Global Seminar launched a multi-year series of seminars to crystallize new approaches to global health and health care in the face of emerging challenges affecting us now and set to continue on through the coming generation.


Interviews and coverage from our Health programs

Healthcare Session - Day 5: Preaching to the unconverted
Healthcare Session - Day 5: Preaching to the unconverted
Louise Hallman 
Senior IHI Fellow, Enrique Ruelas presented his ‘10 Commandments to deal with politicians’ during Pierre Barker’s ‘Sustaining Execution’ session. On the penultimate day of the Salzburg Global Seminar on ‘Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?’, participants were given a new set of commandments to consider: ‘Ten Commandments for Dealing with Politicians’. Enrique Ruelas, Senior Fellow at the Institute for Healthcare Improvement, Mexico, shared his commandments with the group as part of the Thursday morning session on ‘Sustaining Execution’ covering introducing QI systems to countries unfamiliar with the methodology and designing sustainability into healthcare initiatives from the start. Mr. Ruelas’ commandments offered an insight into the psyche of politicians and included selling the concept of QI in healthcare to politicians, not arguing with them, and also aligning your position with existing initiatives. The full list can be seen overleaf. Reflecting on the morning’s session, Bruce Agins, chair of the previous day’s session on leadership said: “There clearly is no one way to communicate the benefits or importance of QI... One has to know and read your audience to adapt your message appropriately, i.e. scanning and reading the environment effectively to tailor and craft your message.” As with previous sessions, all key suggestions made by the group were collated by the session chair to be included in the final session to be held on Friday morning entitled ‘Next Steps’. Participants will not only reflect on the outcomes of the week-long Session but also produce a Salzburg Statement to be shared with key stakeholder groups.
Talking Point: What positive outcome will you take back to your colleagues from this session at Salzburg Global Seminar? “That the patient matters and quality improvement is all about the patient.”
Natalia Largaespada Beer, Maternal and Child Health Technical Advisor, Ministry of Health, Belize “Quality isn’t really my field...I was confused, and I guess I didn’t really grasp the importance of quality or the huge impact it has [until now].”
Michelle Vanzie, Director of Policy Analysis and Planning Unit, Ministry of Health, Belize “From this meeting I will have a lot of friends! [I will have] a lot of challenges. We have discussed a lot of issues on quality so when I go back, I think my vision will be different.”
Babacar Ndoye, Co-ordinator, National Program Against Nosocomial Infections, Ministry of Health, Senegal “This meeting has brought great light to ideas on what we can share with our country, not to show that QI is a program but a science. I think we can present, we can advocate to leadership that this is the QI methodology.”
Januario Reis, Clinical Site Monitoring Specialist, USAID, Mozambique “The one this is the validation of the enthusiasm around using quality improvement to enhance the healthcare of poor around the world and create a quality movement to really make great progress very quickly in healthcare.”
Sheila Leatherman, Research Professor, Gillings School of Public Health, UNC, USA
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Dr. M. Rashad F. Massoud - Let's Take Healthcare Improvement to a Whole Other Level
Rashad Massoud at the Salzburg Global Seminar
Dr. M. Rashad F. Massoud - Let's Take Healthcare Improvement to a Whole Other Level
Louise Hallman 
Trying to pin Dr. M. Rashad Massoud down long enough for an interview is no mean feat. The smiling American-based, British and Russian-educated Palestinian doctor is seemingly always on the go. The morning sessions start at 9am and he might have been up until 1am, perfecting the next day’s line-up, updating the e-conferencing website, or discussing the improvement of quality improvement with other participants into the small hours, but the tiring schedule never shows. Dr. Massoud is no stranger to the Salzburg Global Seminar. Now chairing the session ‘Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?’, Dr. Massoud first came to Salzburg as a fellow in 2001. A student of Don Berwick, the outgoing Administrator of the Centers for Medicare and Medicaid Services and the former president and CEO of Institute for Healthcare Improvement in the USA, Dr. Rashad attended a session on Patient Safety and Medical Error. This first visit to Schloss Leopoldskron convinced Dr. Rashad of the value of the Seminar. “The first seminar I came to,” Dr. Massoud explains over a hastily poured coffee, “followed the Institute of Medicine’s report ‘To Err is Human’ in which medical errors were described as between 48,000 and 98,000 errors per year, half of which are easily preventable. And what [Don Berwick, session chair] did, because safety was a poorly developed area generally speaking in healthcare, he brought in experts from aviation, from space, from road traffic accidents, from psychologists to meet with people who are in the area of improvement and that was the beginning of a major thrust in patient safety today. In fact some of the people who were here in 2000 are today some of the leaders in safety and healthcare. That was an amazing experience... “The whole patient safety movement – a lot of them were here and that’s how the work started. The meeting here was certainly a significant milestone in the development of the safety effort in healthcare and it really moved things forward.” Dr. Massoud agrees he has similar high hopes for his session this week. “I’d really like us to take the opportunity of this magnificent setting,” he says turning to look out of the Meierhof, across the lake and to the Untersberg mountain. “The environment we have, the focus that we get out of having 60 people in the same place – not just for the session but for all the interactions outside of the sessions. Having been here already – these interactions were even more valuable than the formal sessions themselves.” Indeed – Dr. Massoud is almost as great an advocate of late night discussions in the Schloss’ Bierstube as he is of improving healthcare. “So if we can put all this together,” he continues, “what I’d like to come out with is a thoughtful way that all of us who are representing different groups – host country national governments, improvement efforts, representing implementers in the field, donor agencies, other stakeholders – all of us should think through how do we maximise and leverage everything we have that would enable us to improve healthcare in a different way, take the healthcare improvement effort, which has so far been very successful, to a whole other level.” The session itself has been two years and dozens of hours of Skype conference calls in the making and brings together over 60 healthcare professionals, from physicians, donors, improvement advocates, government officials to civil society leaders, from over 35 countries. “When John Lotherington [SGS Program Director for Health] approached me with the idea of a seminar on improvement science…my idea was that we probably don’t need just another conference or meeting to talk about it, however what we could do is a strategy conversation – something that would enable us to think through what have we accomplished to date, what are the challenges ahead and design an agenda that would take us through the next five to ten years. Everything followed from there. I invited partner organisations, colleagues to join the planning committee. We started to think through what would that agenda look like, what are the themes we have to discuss, who are the people we need to have in the room?” Much of this week’s session has focussed on ‘Quality Improvement’, and although the physician-cum-Director of USAID’s Health Care Improvement Project is a strong advocate of the school of thought (that more isn’t always better – more resources, more money, more hospitals – and that healthcare professionals should strive to deliver the best level of care from the resources they have and constantly improve upon that level of care) he is not overly keen on the term. “If there was one thing I could do here it would be remove the word ‘quality’,” he laughs. “Everything we’re talking about here is how can we ensure the patients get the best outcomes possible. What is the best medicine that we know? Can we deliver it to them correctly so that they benefit maximally from this? Can we do this in ways that are not wasteful and inefficient? Can we be mindful about meeting patients’ needs and expectations? Improvement is what we should be doing in the first place; good quality care is what we should be providing patients anyway.” His enthusiasm for the topic is clear from the outset, driving conversations from the breakfast table first thing in the morning, through the day’s sessions, right up to in the Bierstube – the Seminar’s own on-site bar – last thing at night. “He’s like this all the time,” says his research assistant, Nana Mensah Abrampah. Dr. Massoud just laughs, shrugs, and hurries off for another meeting.
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Healthcare Session - Day 4: “Leaders must never give up”
Healthcare Session - Day 4: “Leaders must never give up”
Louise Hallman 
Participants at the Salzburg Global Seminar were urged on Wednesday to continue to strive for quality improvement in healthcare by the Minister of Health for Rwanda, Dr. Agnes Binagwaho. Dr. Binagwaho joined the Seminar to speak on ‘Strengthening Leadership and Policy for Improving Care in Low and Middle Income Economies’ via video link from Kigali. She spoke on her own personal experiences of leading quality improvement, particularly highlighting the importance of engaging all stakeholders, including the population, in improving healthcare, as politicians like herself rarely stay in office for more than two years. The session also saw an international panel - from Namibia, Thailand, the UK, Uganda and the US, as well as Rwanda - convene to share their views and successful experiences of leading healthcare improvements. Community level engagement was brought up repeatedly through out the session, with participants during their breakout workshops yet again drawing attention to the limitations in traditional thinking. One of the key suggestions to be made by Salzburg participants addressed the need to lead change through all levels of healthcare systems, not just national, but regional, district and community. Another suggestion was that leaders must establish clear direction and set priorities that are then communicated to the public, championing transparency in performance and displaying integrity in addressing those promised priorities. Session chair, Bruce Agins, highlighted in his report: “As they stay attuned to their environment and changing landscape, leaders in particular need to stay attuned to the care provided to those most vulnerable in their nations and drive improvement to meet their needs which may often require specific efforts to ascertain.” All suggestions made by the groups will be incorporated into the Salzburg Statement.
Talking Point:  What is the number one most important attribute for a good leader to have? “Sensitivity to the needs of his staff.”
Rob Palkovitz, Professor, Human Development & Family Studies, University of Delaware, USA “Puts the client first.”
Jean Nguessan, Country Director, URC, Cote d’Ivoire “To be able to visualize, five, ten years ahead.”
Amit Pawal, Consultant, USAID & GTZ, India “Effective communication.”
Nana Mensah-Abrampah, Quality Improvement Fellow, URC, USA “Communication and compassion.”
Sylvia Sax, Lecturer, Institute of Health, University of Heidelberg, Germany “Be inspiring to the people they lead.”
Sarah Byakika, Assistant Commissioner for Quality Assurance, Ministry of Health, Uganda “A good team that can point out the real priorities and ensure the strategic ones are being taken and put into the agenda.”
Tatiana Paduraru, National Consultant on Foreign Assistant, Ministry of Health, Moldova “Tolerance...they have to work with different donors and organizations... It is important for leaders to understand what other people would like and try to choose key issues.”
Aigul Kalieva, Chief of Neonatal Services, Ministry of Health, Kyrgyzstan “A vision, along with empathy to others.”
Shirin Kazimov, Health Project Management Specialist, USAID, Azerbaijan “Trust his team.”
Anna Korotkova, Deputy Director for International Affairs, Federal Institute for Health Care Organization, Russian Federation “Ability to see different sides to an issue.”
Carlo Irwin Panelo, Chief of Party, Health Policy Development Program, USAID, Philippines “Integrity...straightforward, accountable, be visionary.”
Baile Moagi, Director, Health Inspectorate, Ministry of Health, Botswana “A vision...chart out a path and all other things will fall into place.”
Charles Nde Awasom, Medical Director, Ministry of Health, Cameroon “Insight...if a leader isn’t able to learn from mistakes and to support people when mistakes are made, they will never reach their potential for delivery.”
Tracey Cooper, President, ISQua, Ireland “Unflagging dedication and commitment to the goal of improvement.”
Bruce Agins, Medical Director, AIDS Institute, New York State Department of Health, USA
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Healthcare Session - Day Three: Seventh and eighth blocks
Participants vote on matters of confusion in healthcare improvement
Healthcare Session - Day Three: Seventh and eighth blocks
Louise Hallman 
Presented by Ed Kelley, Head of Strategic Programs and Coordinator, WHO Patient Safety, Geneva, Switzerland, the session considered the existing building blocks inadequate in improving the healthcare systems of lower and middle income countries. Published in 2010, the WHO “six building blocks of health systems” cover:
  1. Service delivery
  2. Health workforce
  3. Information
  4. Medical products, vaccines and technologies
  5. Financing
  6. Leadership and governance (stewardship)
In his summary, Kelley said, “It is clear that the ‘six building blocks’…include major action areas where the application of improvement methods can achieve significant results.” However, common concern amongst the Seminar contested that community mobilization and patient perspective should also be added to the existing list. Reflecting on all the comments and suggestions made through the group work of the afternoon, Kelley added in his summary: “Though [its] a broad set of areas to address, key lessons emerged that may form the beginnings of an overarching strategy to more explicitly link quality and safety improvement to the larger health systems strengthening effort.” These key lessons included mobilizing clients and reforming financing systems, strengthening quality in health information systems and building the healthcare workforce.
Talking Point: What role does consumer choice have in improving healthcare in lower and middle income countries? “Consumers’ choice is not really only related to the individual’s choice but it relates to the collective’s choice. If the choice for the collective consumer is limited then an individual’s right to choice ends where the rest of the collective’s start. ”  Jorge Hermida, Director, HCI Programs - Latin American Region, URC, Ecuador “I think it is fundamental if you want to improve healthcare, the quality of healthcare, consumers’ choice is a key element. That implies that first you have to recognize that, and second you have to give elements to the people so that they can make choices - giving information, allowing them to participants, empowerment. This is not an easy thing to do... If they have a choice in selecting a physician for their care, there are some areas with only one physician so they have no choice! ...But you have to it. I see it as a key element for pressing the system to provide quality health services. If that doesn’t happen, the health system won’t be as responsive as it should be.” Enrique Ruelas, Senior Fellow, Institute for Healthcare Improvement, Mexico “Consumers in most circumstances have less opportunities to make choices about their healthcare. The bulk of the population live below the poverty line and in the remote areas. It is not a matter of choice for them but rather a matter of access to the nearest health facility... In cities people have health facilities but then again the poorer tend to be going for public hospitals and they have limited choices. Those with better socioeconomic status and can afford better and higher quality prices for healthcare services, they will go for private hospitals because the perception is the quality is better... And then we have a small percentage of people who really can afford health services outside the country.” Mirwais Amiri, Senior Quality Improvement Advisor, URC, Afghanistan “The primary consumer in healthcare is the patient. So when we are talking about low and middle income countries, the only way consumers’ choice can even be an issue is when affordability and access to services are there. And before there is affordability and access, the only choice the consumers have will be to either live or die.” Ayman Sabae, Master’s Student, International Healthcare Management, Innsbruck, Austria/Egypt Click here to download the full daily newsletter (4 pages, PDF)
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Healthcare Session - Day 2: HR voted greatest challenge, Community involvement close second
Healthcare Session - Day 2: HR voted greatest challenge, Community involvement close second
Louise Hallman 
Heated debates arose as participants reported back to the full room. Should “patients’ needs” be added to “patients’ preferences”? Could the issue of staff competency be considered in the same human resources issue bracket as the inadequate numbers of staff? Once the participants – from such wide-ranging backgrounds as physicians, academics, government officials and donors – had negotiated and agreed upon the nuances of the challenges, they were then asked to vote on what they believed were the two greatest challenges they faced in improving healthcare. Coming out resoundingly on top with 17 votes was human resources, including but not limited to inadequate numbers of health care workers, high turnover, maldistribution geographically, staff morale and unfilled training needs. Community and civil society involvement followed with 16 votes; this issue called for more civil society engagement and client-focus in advocacy, feedback, public protection and responsiveness. In third place was poor planning, encompassing lack of comprehensive operational plans, vertical programs that lack integration and inadequate harmonization of donor programs. Designing a system to meet patient preferences and needs and facilitating the process of addressing different perceptions of quality among providers, policymakers and the public both garnered 12 votes. Lagging behind were limited capacity and capability to implement QI strategies – 7; leadership behavior – 6; involvement of patients and staff in the process of improving care – 6; absence of QI skills in the head of frontline managers – 6; inadequate information and poor communication – 6; interface of strategy and implementation – 4; optimization of technical skills – 3; poorly articulated arguments to donors and decision makers about the value of improvement and the costs of poor health – 2; and finally inadequate leadership with just one vote.
Talking Point: Donors in Healthcare One issue that was raised in the day’s sessions was that of the role of donors in healthcare improvements. Several participants shared their views with Planning Committee Member Sylvia Sax. “I don’t want donor money because it has strings attached.”
 “Donors want short term solutions. When the money is gone after two years, we cannot continue the programs put in place.”
 “Donors come with their own solutions and expect them to be implemented. ”
 “Donors put in parallel initiatives and reporting systems.” SGS editor Louise Hallman asked donor representatives for their response.  “An intrinsic part of what donors are trying to do is support the governments, not to impose a specific agenda. Intrinsically, improvement has got to be owned by the government, by the country itself. And the solution is a product of dialogue between the donor and the country. ”
Jim Heiby, Medical Officer and Contracting Officer’s Technical Representative, USAID Health Care Improvement Project, Washington, DC, USA “Anything we do needs to be something that’s needed by the government and that they would like...
 The role of the donor is several fold: we can provide resources, in the form of money or in the form of technical inputs. But we can also use voice, often at a global level to try and move an entire sector a specific way...
 I think the best way we can have an affect and have impact is to support a country’s leadership and to try and leverage each other. We shouldn’t be independently investing here, there or wherever. The whole needs to be greater than the sum of its parts...
 So it’s about integrated work, led by governments.”
Mary Taylor, Senior Program Officer, The Bill and Melinda Gates Foundation, Seattle, USA “One of the important things for donors is to know the real situation of the governments, or what is going on in healthcare, what priorities there are, what exact problems there are, what the priorities of the ministry of health are. And then it’s very important to communicate with them and involve them in the process from the beginning...to help get them on your side while you are implementing something you know will be good for them and it will be easier to transfer to them after you leave.”
Shirin Kazimov, Health Project Management Specialist, USAID, Azerbaijan Monday afternoon’s session, led by Sheila Leatherman, Research Professor at Gillings School of Global Public Health, University of North Carolina, USA, saw participants to split into groups to identify challenges in two categories: how to improve quality and how to improve healthcare system delivery.
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Improving Health Care in Low Income Economies
Rashad Massoud speaking at the Salzburg Global Seminar
Improving Health Care in Low Income Economies
Louise Hallman 
Welcoming over 60 international healthcare professionals from more than 35 countries, Dr. M. Rashad Massoud expressed his excitement at the “wonderful journey” the participants would take over the next six days at Schloss Leopoldskron for the Salzburg Global Seminar session ‘Health and Healthcare Series IV: Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?’ The session has been two years in the making, and will follow on from previous sessions’ discussions to debate the progress made so far in meeting such targets as the Millennium Development Goals and the role of quality improvement in meeting such public health targets. Whilst improvements in health care have clearly been made in the past number of years, this progress has since “plateaued”, making it necessary for health care professionals to address the issues and challenges that still lie ahead. Joining the “crucially important meeting” via a pre-recorded video, Don Berwick, former president and CEO of the Institute for Healthcare Improvement, USA, highlighted the great opportunity such a global gathering of healthcare experts would experience over the coming week. “In developed healthcare systems in the Western developed world, we have a crust to drill through,” he said. “We have an existing legacy production system that for complex reasons has not been orientated around those six aims [safety, effectiveness, patient-centeredness, timeliness, efficiency and equity] for the continual improvement of performance as its primary driver… “I have the feeling that low and middle income countries have a thinner crust. There’s more opportunity there because in some senses you’re building on a relatively less developed platform of management and process thinking. The opportunity in lower and middle income countries is to do it right the first time. “I think the potential is enormous.” The Salzburg Statement: How to Improve Health in Low and Middle Income Economies, was produced at the end of the week-long intensive discussions. Click here to read Louise Hallman's daily newsletters for the session
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Healthcare Session - Day 1: Journey's Beginning
Healthcare Session - Day 1: Journey's Beginning
Ezequiel García-Elorrio 
The history of the Schloss Leopoldskron and the Salzburg Global Seminar are very impressive; since after World War II this organization has promoted the gathering of people around the world to provide solutions to global problems. The ambience is fantastic – it will surely make participants to give the most of themselves. During the opening remarks goals were set. The clearest one is to “set an agenda of coming years”. Reviewing where we are and how we got here. Constructing then the action plan for the times to come. Participants represented a wide variety of settings and realities from around the world. So far just listening to everyone’s introductions you can perceive the amount of experience and knowledge in the room. Surely clear objectives and a goal will come from this week-long discussion. This week-long seminar is described as the “beginning of a journey where we all will go together” confirming that we are “not sitting on plateau but moving ahead”. The audience is quite diverse, comprising government, patient representatives, international organizations, researchers and improvers. Almost every point of view is represented. Just to give a sense on the importance of our participation, the questions/debates posted before the seminar were presented to all participants to start the discussion. Hopefully conversations from Salzburg will reverberate around the world and feedback could be provided. Ezequiel García-Elorrio’s blog for the ISQua Knowledge Portal can be found online: isquaknowledge.org
Talking Point - Do We Need More Data? By Louise Hallman "Work that is not documented is not done, so definitely documentation would help to improve quality - at then end the day you have to be able to see what you have done. There are two issues: crediable documentation and also making documentation easier... If we have this system where you can plug in the information at the time the activity was going on, or at worst at the close of the day, then you cannot go back at the end of month and change the information for that day.”
Charles Nde Awasom, Medical Director, Ministry of Health, Cameroon “There’s data for public reporting purposes and there’s data for actual clinical management application. If you connect the two, you have a data source that serves two purposes and is essentially incredibly important to the clinicians themselves... You can’t improve something that you know nothing about. The vast majority of the time [in my research] the data element is collected and sent somewhere on a district level or a regional healthcare system or government’s national health system and the clinic never learns how it’s represented in public health records.”
Kedar Mate, Director for Developing Countries Programs, Institute for Healthcare Improvement, USA “It is helpful [to have more data], but you can do a lot without it, by sampling, by rigorous independent monitoring, particularly of vaccination programs, and having extensive documentation, like a lot of high income countries do, doesn’t necessarily mean that you use data more intelligently. ”
Sir Liam Donaldson, former Chief Medical Officer, UK “It is true that in developing country settings you do have a lack of data...so for sure documentation needs to be improved, but it’s really about what you do with it. In a lot of countries there is tons of data but it’s not developed with clinicians in mind so it’s not relevant and it’s not given to them even if it were relevant so they can do something with it.”
Ed Kelley, Head of Strategic Programs, WHO Patient Safety, Switzerland “A lot of our problems stem from inadequate documentation but more importantly, I think we generate a lot of data that is definitely not used optimally. We don’t have adequate information systems to connect information at community level. If you don’t have a health information system that works well across all levels, you are losing out a lot of vital information that will enable you to put interventions in place that are going to target the community best. ”
Nanthalile Mugala, Director for Technical Support, Integrated Systems Strengthening Program, Zambia
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