rolex yacht master 40 rubber

Rolex Yachtmaster 116655 Full Review

Behold the  new rose gold Rolex Yachtmaster with the Rolex Oysterflex Bracelet: Rolex's 1st Rubber Strap

With the new rose gold Rolex Yachtmaster, Rolex watchmakers held no punches and put in nearly every great idea they ever had into one amazing watch. The Rolex Yachtmaster has been around since the early '90s and came in an assortment of materials from gold and steel all the way up to platinum. They are known for being shiny and luxurious from one end to the next. So it comes as no surprise that the world was taken by a storm when they decided to use rubber to introduce the new Rolex Yachtmaster watch reference #116655 . Was it a step up or a step down for the series? PrestigeTime.com bloggers believe that pictures speak much louder than words.

The new men's Yachtmaster from Rolex is a 40mm 18k rose gold case watch with a black dial and accented in Rolex's very own Everose gold. Just like their proprietary 18kt rose gold alloy, Rolex will always prefer to create the status quo and not have to rise to meet it because of anyone else.

In the new rose gold Rolex Yachtmaster, they held no punches and put in nearly every great idea they ever had into one amazing watch.

At the core lies their in-house Rolex movement, the automatic caliber 3135 which resonates at 28,800 vph containing 31 jewels and has a whopping 50-hour power reserve. Of course, it would not be complete without their "Cyclops" magnifier. The new rose gold Rolex Yachtmaster is also known as the m116655-0001.

Rolex is also no stranger to trending luxury watches. They tend to be the first in doing and introducing many things. While rubber has been around for a long time and has been used on many watches over the years, both high-end luxury watches and everything else. Rubber had no place on a Rolex watch until now. Rolex waited this long to introduce this material into their products not because they were hesitant to be part of the trend, on the contrary, 

they wanted to revolutionize the rubber watch band before using it on their first-ever rubber strapped watch. Creating the best rubber bracelet was something Rolex obsessed about until its perfection. Enter the new Rolex  Oysterflex bracelet which we hope to see on more of their men's watches. A rubber-coated two-piece titanium bracelet with a patented cushioning system. The black elastomer coating is a similar substance to what you see on the Apple Watch. The bracelet has an Oysterlock clasp in solid 18k Everose gold which seals the deal. Rolex held nothing back in reinventing and over-engineering the perfect rubber bracelet that has the same elasticity as a metal bracelet without the initial cold feeling of a metal bracelet when first placed on a wrist. Now it's just a matter of time before a platinum Rolex comes with a rubber Oysterflex bracelet.

In 2015 Rolex introduces the Rolex Yachtmaster watch model #116655, the first Rolex watch with the all-new rubber Oysterflex band with an 18k rose gold clasp. After its creation, they saw all that they have made …and it was good.

Most recently this watch has been upgraded with a new movement and new reference number that we sell new, in its original box, with a warranty, and with free shipping to the United States. The new Rolex 126655 Yachtmaster 40mm is essentially the same watch with a few improvements. Specifically, the caliber inside has been replaced with the Rolex in-house caliber 3235, a Superlative Chronometer with exceptional precision, 31 watch jewels, Paraflex shock absorbers, and a substantially longer power reserve duration of approximately 70 hours.

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There is big news, and there is Rolex big news, and in some ways, ne'er the twain shall meet. At Baselworld this year, Rolex debuted a first for the company: the very first, ever, Rolex delivered on a rubber strap. Now, for most companies this would have little effect on watch enthusiasts other than to evoke (very) tepid interest at best, and boredom at worst – but this is not an ordinary rubber strap, this is an official, designed-and-tested-and-thoroughly-obsessed-over-by-Rolex rubber strap. And thereby hangs a tale.

The Yachtmaster, as we have mentioned in some of our previous coverage , occupies a somewhat particular place in Rolex’s lineup of sports watches; it shares water-resistance and a turning bezel with the Submariner (the latter is water resistant to 300 m while the Yachtmaster standard model is water resistant to 100 m). It is certainly not a tool watch; the Yachtmaster is offered in either platinum and steel, or gold and steel (that’s Rolesium and Rolesor, lest we forget) and is either quietly or unequivocally luxurious depending on what size and metal you go for (Rolex makes the Yachtmaster in both 35 mm and 40 mm sizes). 

The Yachtmaster’s history goes back to the first introduction of the watch in 1992, although the name, interestingly enough, appears on the dial of a prototype Yachtmaster Chronograph from the late 1960s (a watch so legendary I am actually forced to use the word; one of three known is in the collection of Mr. John Goldberger; we covered it – and a host of other remarkable ultra-rare watches from his collection – in a very memorable episode of Talking Watches ).

The term “Yachtmaster” is also, incidentally, used for a certificate of competency in yachting which is issued by the Royal Yachting Association, although we’re unaware of any specific association between the RYA and the Yachtmaster watch.

Now, this newest version of the Yachtmaster does take a few pages from the existing Yachtmaster playbook: 100-meter water resistance, a bidirectional turning bezel, and a dial and hands that echo the Submariner. There are also a couple of features that may make vintage Sub enthusiasts wonder if Rolex mightn’t have an exceedingly subtle sense of humor; the gilt coronet and “Rolex,” and the red lettering, both features which according to HODINKEE founder Ben Clymer would have, had they appeared on a Rolex dive watch, made it instantly the single most popular watch in the modern Rolex inventory. The case is rose gold – Rolex famously makes their own, called Everose, in their own foundry, with a bit of platinum mixed in to prevent discoloration – and the bezel, rather than being some other precious metal (as is the case in the “standard” Yachtmasters) is in black Cerachrom – a very technical-looking matte black that contrasts sharply with the gold case. Somehow, between the rose gold, the Cerachrom bezel, and the new Oysterflex bracelet this manages to be the most luxurious and at the same time most technical Yachtmaster yet (leaving aside the Yachtmaster II, which we recently reviewed right here , but that is a watch that marches to the beat of a different drummer entirely).

The two different versions of the Everose Yachtmaster (40 mm and 37 mm) sport different movements; the larger uses the caliber 3135 and the smaller, the newer 2236, which sports the “Syloxi” silicon balance spring (first used by Rolex in 2014).

The Oysterflex bracelet is, in a nutshell, quite a piece of work. One of the most endearing traits of Rolex as a company is that it tends to demonstrate what we can only describe as a laudable degree of corporate obsessive-compulsive disorder when it comes to research and development, and it does so, often, without making any sort of fanfare about it at all. In this case we do know a little bit about the Oysterflex, however – it is basically designed to have the hypoallergenic and comfort properties of a rubber strap and the durability and shape-retention properties of a bracelet. 

At the core of the Oysterflex bracelet are metal inserts made of titanium and nickel, which are used to affix the bracelet to the clasp and watch case; over those is a sheathing of “high-performance black elastomer.” “Elastomer” is a portmanteau word, formed from “elastic” and “polymer” and is a general term for natural and synthetic rubbers. In addition to the materials complexity of the Oysterflex bracelet, it is also shaped in a rather unusual fashion – there are ridges molded into the the wristward face of the bracelet, which are intended to allow the bracelet when worn to better approximate the natural curvature of the wrist.

They might look a bit odd but in practice, the design works out quite wonderfully; this is easily the most downright comfortable and organic-feeling rubber strap I have ever worn, and like the entire watch manages to be both extremely technical in feel, and very luxurious at the same time; I doubt whether any company has ever taken so much trouble over the design of a strap (for all that Rolex prefers the term “bracelet” in describing the Oysterflex, habit dies hard and you’ll probably find yourself calling it a strap, just as we did). On the wrist, the two stabilizing ridges do exactly what they are supposed to: keep the watch from shifting, as heavier watches on rubber straps are wont to do, without requiring you to have the strap uncomfortably tight. The Everose Oysterlock clasp does a superb job mechanically and also looks fabulous into the bargain; the quality of finish on the clasp and case may not seem terribly elaborate at first, but it is as technically flawless as anything I have ever seen at any price, on any watch.

What we have here, in other words, is a very Rolex interpretation of luxury. Yes, this is a gold watch, and a gold Rolex, and wearing a gold Rolex always carries with it, shall we say, certain semiotic complexities. However there is also another side to the watch, and to the Rolex approach to luxury in general: the taking of such pains to produce technical perfection that technical perfection becomes a luxury in itself.

The Everose Rolex Yachtmaster, in Rolex Everose, with Everose Oysterclasp and Oysterflex bracelet, as shown, $22,000 in 37 mm, and $24,950 in 40 mm. For more info, check out Rolex.com.

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Curved End Rubber Strap for Rolex Yacht-Master with Tang Buckle

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Installing your new Everest Band can be done easily at home using one of Everest's tool kits and by following the instructions in this video. While Everest always recommend that a professional installs your watch bands, most Rolex wearers can install the strap at home with the appropriate tools.  Everest is not responsible for injury or damage to one's self or watch.

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Check out this video to see how to size and assemble your Everest deployant style watch band. Everest offers deployant straps in any combination of 4 links, 5 links or 6 links. Please see the sizing guides below.

HOW TO COUNT THE LINKS FOR EVEREST DEPLOYANT STRAPS

Step 1: Count how many links you have on the 6 o'clock side. 

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Step 3: Compare which size is correct to correlate with the sizes. 

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Everest Curved End Rubber straps are intentionally and meticulously designed to create a flawless case connection to your Rolex Yacht-Master. The easy-to-install, curved end rubber strap comes equipped with Rolex grade spring bars. At the connection point, there is a hardened plastic insert. This ensures a strengthened case connection.

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The Everest curved end rubber strap is the perfect addition to your Rolex Yacht-Master. It allows your watch to have a more casual, sporty look while also looking classy and upscale. Everest straps are designed to be so comfortable, you may never want to put your Rolex Yacht-Master bracelet back on.

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Volume 20 Supplement 2

The Physician and Professionalism Today: Challenges to and strategies for ethical professional medical practice

• Open access
• Published: 09 December 2020

Objectives, methods, and results in critical health systems and policy research: evaluating the healthcare market

• Jean-Pierre Unger 1 ,
• Ingrid Morales 2 &
• Pierre De Paepe 1  

BMC Health Services Research volume  20 , Article number:  1072 ( 2020 ) Cite this article

7930 Accesses

3 Citations

Metrics details

Since the 1980s, markets have turned increasingly to intangible goods – healthcare, education, the arts, and justice. Over 40 years, the authors investigated healthcare commoditisation to produce policy knowledge relevant to patients, physicians, health professionals, and taxpayers. This paper revisits their objectives, methods, and results to enlighten healthcare policy design and research.

This paper meta-analyses the authors’ research that evaluated the markets impact on healthcare and professional culture and investigated how they influenced patients’ timely access to quality care and physicians’ working conditions. Based on these findings, they explored the political economic of healthcare.

In low-income countries the analysed research showed that, through loans and cooperation, multilateral agencies restricted the function of public services to disease control, with subsequent catastrophic reductions in access to care, health de-medicalisation, increased avoidable mortality, and failure to attain the narrow MDGs in Africa.

The pro-market reforms enacted in middle-income countries entailed the purchaser-provider split, privatisation of healthcare pre-financing, and government contracting of health finance management to private insurance companies. To establish the materiality of a cause-and-effect relationship, the authors compared the efficiency of Latin American national health systems according to whether or not they were pro-market and complied with international policy standards.

While pro-market health economists acknowledge that no market can offer equitable access to healthcare without effective regulation and control, the authors showed that both regulation and control were severely constrained in Asia by governance and medical secrecy issues.

In high-income countries they questioned the interest for population health of healthcare insurance companies, whilst comparing access to care and health expenditures in the European Union vs. the U.S., the Netherlands, and Switzerland. They demonstrated that commoditising healthcare increases mortality and suffering amenable to care considerably and carries professional, cultural, and ethical risks for doctors and health professionals. Pro-market policies systems cause health systems inefficiency, inequity in access to care and strain professionals’ ethics.

Policy research methodologies benefit from being inductive, as health services and systems evaluations, and population health studies are prerequisites to challenge official discourse and to explore the historical, economic, sociocultural, and political determinants of public policies.

Since the 1980s, markets have turned increasingly to intangible goods – health care, education, arts, and justice. Political changes have accompanied the transformation of health systems. After World War II, the WHO was founded to counter the health effects of devastating destruction, but over the last decades its funding by the World Health Assembly dropped to 25% of its budget. Foundations and industrial countries funded the rest, that is, their preferred programmes. The 1978 Alma Ata Declaration establishing the Primary Health Care policy had resulted from able WHO leadership and a growing social movement demanding health for all. One year later, the Selective Primary Health Care movement promoted by the Rockefeller Foundation undermined its foundations. It led the international policy exclusively to support disease control programmes in LMICs and to turn their first-line health services into epidemiological units allegedly because comprehensive primary health care was costly.

After the collapse of the “socialist” camp in 1989, the Washington Consensus, WB, and IMF conditioned low-interest loans on moves to market economy and government withdrawal from health care provision and financing. Since the 2000s, governments in industrialized countries and their private sector set up international disease control programmes called Global Health Initiatives. These were actually epidemiological public-private partnerships that replaced international cooperation in the health sector.

With the Millennium Development Goals (MDGs) and subsequent Sustainable Development Goals (SDGs), the United Nations set quite unambitious global health goals. They assigned donor-driven targets to LMIC governments, that is, controlling a limited number of pathologies, first transmissible and then increasingly chronic ones.

Over this period the authors evaluated pro-market reforms and policies and identified their determinants through the lenses of patients, physicians and health professionals, and taxpayers. Patients are concerned about accessibility to healthcare services and the price and quality of care. Physicians’ interests are, or should also be, their problem-solving capacity, professional freedom, intellectual progress, medical ethics, work environment, and income. These were the authors’ yardsticks to assess health systems and conduct policy research. These studies thus covered curative medicine, preventive medical care, and medical education but not the important field of inter-sectoral public health policies.

It all started in 1982, when J.-P. Unger discovered in Boston the Rockefeller Foundation’s long-term strategy to commoditise healthcare financing worldwide. In investigating the health marketisation motives of the “Selective Primary Healthcare” strategy in low- and middle-income countries (LMICs), he interviewed J. Walsh and K. Warren, the authors of a publication released just 1 year after the Alma Ata conference that advocated an alternative to the Primary Healthcare strategy called “selective primary healthcare” [ 1 ]. Their message was that the Primary Healthcare Strategy endorsed by the World Health Assembly in Alma Ata in 1978 was unaffordable. Instead, the Rockefeller Foundation promoted a policy that would turn low-income countries’ (LICs) public health systems into structures fit to host disease control programmes – “like Christmas ornaments festooning a Christmas tree” – rather than delivering individual health care. A field experiment in Deschapelles, Haiti [ 2 ], was a central piece of evidence supporting this strategy to make LIC health centres in public services mere disease control structures. The scenario pushed by the Rockefeller Foundation eventually came to be in LICs in the 1980s, albeit with major variants.

In 1986, we invalidated the efficiency alibi of this strategy. As an answer to the Rockefeller strategy, an action research project covering 180,000 persons in Kasongo, Congo [ 3 ] (then Zaire), enabled us to show that the cost of delivering individual health care and a few disease control and other public health interventions under a single administration could be similar to those of first-line services providing just five disease control programmes, because the former solution made it possible to keep its administration simple [ 4 ]. That prompted us to study the economic motives and public health consequences of healthcare insurance commercialisation, healthcare commoditisation, and health service privatisation and to build a case with coordinated studies. This paper meta-analyses the objectives, methods, and results of evaluations and research into market based health systems and policies spanning over 35 years ( https://pure.itg.be/en/persons/jeanpierre-unger(92d91a56-f267-4b85-82e7-9e4f8a8cffed).html ). Specifically, it aims to make sense of an array of policy studies that all relied on the same medical and public health ethical criteria already formulated in 1972 [ 5 ]; and to delineate health policy research standards relevant to physicians, health professionals, and patients’ representatives committed to the human right to health, i.e., the right to access professional care in universal health systems [ 6 ].

Research strategy

On the grounds of the Kasongo experience and aforementioned Walsh and Warren interview, we formulated in 1983 the overarching hypothesis of our decades-long policy research: Pro-market reforms of healthcare financing and management expand the healthcare delivery and disease control market to the detriment of patients, populations, doctors, health professionals, and taxpayers.

To confirm or overturn this hypothesis, we tested four secondary hypotheses and tried to show a causal relationship between pro-market policies’ characteristics and the following phenomena:

Regarding the access of patients and persons with health risks to professionally delivered healthcare, we tried to verify whether the market tended to allocate individual, “discretional” health care to the rich and public health interventions to the poor, thereby reducing the general population’s access to care significantly.

Regarding disease control, we checked whether public health programmes often failed because the market assigned them a vertical structure to be better suited to absorbing medical equipment and pharmaceuticals with public financing.

Regarding fiscal justice, we strove to determine whether health markets ran counter to social justice in health as they precluded the efficient and equitable use of taxes in the care sector.

About professionals’ ethics and personal development, we aimed to verify if care commoditisation was compatible with the physician’s reliance on professional ethics and investments in medical equipment and pharmaceuticals might antagonise the conditions of doctors’ and teams professional development.

This paper meta-analyses the authors’ research evaluating the impact of markets on health care and professional culture and investigating how they influenced patients’ timely access to quality care and physicians’ working conditions. Based on these findings, they explored the political economy of health care. However, there was no early design of a long-term research strategy. They conducted the studies according to opportunities, although some principles were adopted from the start:

Interdisciplinarity

Testing the above hypotheses required ad hoc, interdisciplinary research methods in order to build a good case for a causal relationship.

Heterogeneous research setting

The hypotheses had to be tested in a large array of health systems, from low- to high-income countries. To allow generalisations about the healthcare environment, countries and regions would be key policy analysis units.

Inductive reasoning

Historical studies would be based on public health evaluation of healthcare systems. Interpreting policy decisions critically required previous ex-post demonstration of ill-functioning services.

The authors approached qualitative research in medical care and public health policies by making use of the concept of praxeology that Bourdieu developed and adapted to sociology in his “Outline of a Theory of Practice.” [ 7 ] They took this approach because both medicine and public health, like sociology research, are combinations of practice and theory [ 8 ]. They believed that the failure to connect them was a frequent weakness of contemporary medical and public health research. An important aspect of praxeology is inductive reasoning. It builds on and evaluates propositions that are abstractions of observations of individual instances of members of the same class. In this regard, the policy evaluations were problem-based and relied on paradoxical observations of care delivery and health service management. They were the raw material of the research and prerequisites for assessing health systems and policies and then exploring the social, political, and economic determinants of faulty ones. Figure 1 depicts the inductive chain generally used in these policy analyses.

Sequencing the authors’ research on (inter-)national health policies

Deconstruction of the policy discourse

Deconstruction is a form of critical analysis concerned with the relationship between text and meaning. Jacques Derrida’s 1967 work on grammatology introduced the majority of its influential concepts. The authors set out to deconstruct public policies with qualitative, interpretative research and nested probabilistic studies. Their goal in this respect was to verify the evidence sustaining pro-market reforms in LMIC and high-income country (HIC) settings; based on these findings, expose their practical, political economy rationale; and then tentatively deconstruct the pro-market discourse of multilateral agencies and commercial organisations. Case studies of national healthcare policies and disease control programmes would provide the material required to analyse international policies and national health sector reforms [ 9 ].

Explicit research values

The authors made explicit their ethical values of social justice and medical professionalism because research methodology, policy evaluation, and interpretation depend on social, economic, and professional standards. These values, published elsewhere, were conceived of for healthcare delivery, management, planning, financing, and disease control. In particular, the authors relied on three healthcare standards with policy implications formulated in 1971, namely, holistic (biopsychosocial and patient-centred), continuous, and integrated care [ 5 ]. In Belgium, they served as an ideology to cement alliances of professionals concerned about quality and equitable access to care for more than 40 years [ 10 , 11 ]. The authors also relied on another key standard of medical practice, the Hippocratic “self-effacement” tenet (“Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm”) that is expected to deter physicians from making self-interested clinical decisions and maximising their profits with ad hoc clinical decisions, i.e., practising commercial medicine.

Evaluating disease control programmes, the hub of international and national health policies in LICs

By 2015, Africa still had not attained the modest MDGs in health. In 2007, we reviewed the grey literature issued by the main multilateral agencies active in the LIC health sector. Under the aegis of the MDGs, disease control was the conceptual and operational hub of health system reform in LICs. Our review revealed that over the preceding 25 years, virtually all the multilateral agencies active in the health sector had adopted policies restricting the function of LICs’ public services to disease control, thereby allocating individual healthcare delivery to commercial services (and private, non-profit facilities where they existed) [ 12 ].

To convince physicians and policy makers in LICs to adhere to sectoral reforms and to replace individual care delivery by disease control in public services, the Bretton Wood agencies attached conditions to their loans and projects and financed a host of local experts to produce the “scientific” justifications of this policy.

For LIC populations, the avoidable mortality, suffering, and anxiety that followed the loss of access to individual care proved immense. In Africa, virtually none of the MDGs were attained, regardless of their limited scope, precisely because in failing to deliver individual healthcare, African public services could no longer implement disease control initiatives satisfactorily.

To explain why a huge financial effort (AIDS control funds, for instance, were multiplied twentyfold between 1997 and 2007) could not achieve the MDGs in Africa, the authors

showed mathematically that successful disease control programmes required health facilities to be used by patients with various symptoms, as they represented the pool of users that these programmes needed for early case detection and follow-up [ 15 ].

studied the mechanisms whereby integrated disease control interventions hampered access to care in the services in which they were integrated and so undermined public services. Although a few AIDS and under-five programmes had been known to deliver bio-psychosocial care, disease control programmes in Africa have reduced the problem-solving capacities of health services; shrunk the professional identity and skills of physicians and nurses; reduced access to drugs to those managed by Global Health Initiatives; and limited in-service training to collective care delivery [ 16 ].

showed this to be a “catch 22” situation, with disease control programmes drastically reducing the number of users in the (public service) facilities where such programmes were implemented [ 17 ].

analysed the evidence of pro-market policies for other characteristics, such as equitable access to quality health care; mismatch of commercial healthcare delivery with medical ethics [ 18 ]; the inability of public services focusing on disease control to respond to people’s demands for individual care, thus preventing community participation; and undue restrictions on professional autonomy in health services designed as “machine bureaucracies.” [ 19 ]

The authors concluded that Hypothesis 2 was plausible because of the following:

Disease control-based reforms strained access to care in LICs without achieving their alleged epidemiological goals.

Replacing individual health care by disease control interventions in LIC public services could be the real motive of the related (inter-)national policies. This was because these reforms practically, albeit tacitly, ushered in a situation in which competition between public and private providers in delivering individual care was made impossible. Multinationals linked to charities that were focusing LMIC public services on disease control took advantage of the disappearance of publicly delivered health care to sell medical care to LMIC middle and upper classes without having to face public sector competition. International disease control programmes not only permitted the use of cooperation funds to purchase drugs and medical equipment manufactured by HIC industries, so fomenting aid-dependent pharmaceutical markets in LICs, but were also structured to foster the healthcare market in urban settings.

How do health-financing markets perform in middle-income countries? Comparing Latin American national healthcare policies and evaluating healthcare regulation in Asia

In MICs, pro-market health system reforms focused on national health care financing. Starting in Chile in the 1980s (under a military government) and in Colombia in 1993 (under an authoritarian government), the privatisation of health financing in Latin America occurred in virtually every country, even those with “socialist” governments. The two exceptions that did not undergo market reforms, Costa Rica [ 20 ] and Cuba [ 21 ], were performance outliers. However, the reform scenarios and organisation of health systems were not identical across the continent. Schematically, Insurance companies made profits whilst managing government funds, capturing the health expenditures of the healthy and wealthy middle class, and employing or contracting physicians. The political economics of health sector reforms in MICs consisted of variable combinations of

under-financing public services;

unduly favouring investments in public services over their recurrent operating costs;

putting the physicians working for publicly-oriented institutions under economic and workload stress;

separating purchasers and providers by law so as to create a niche for commercial insurance banks;

allowing commercial entities to manage public funds and possibly making this scheme mandatory;

privatising public hospitals or imposing commercial competition rules on them (the so-called “management property split”) and on contracted, self-employed physicians, too;

stimulating private financing of public hospitals (“private finance initiatives”);

limiting public services’ activities to unprofitable care, e.g., for the poor (Medicaid) and the elderly (Medicare) in HICs, and to disease control programmes in LMICs; and

liberalising investments in health care under the aegis of international trade treaties.

Given the many cultural and political similarities across Latin American countries, their health systems offered a good setting to explore strategic variants of care commoditisation. The authors assessed primarily the effects of pro-market reforms in Latin America by comparing the performance of systems abiding by international (World Bank, International Monetary Fund, Inter-American Development Bank, etc.) health policies with those that did not [ 9 ]. They thus studied the histories and functioning of some national health systems and the impact of financing options on their management, care quality, and access to care. To study health systems’ productivity, they relied on aggregated production data, population-based care accessibility and continuity rates and ratios; direct observations in healthcare services and administration; and interviews of patients, physicians, health professionals, policy makers, and public health experts.

They studied the health care and outcomes of large-scale, nationwide, in vivo experiments of care commoditisation. The ones they studied did not show any benefits for patients, physicians, health professionals, and/or public finances:

Colombia, which had been a good student, by international standards, since 1993, had a deplorable health record [ 22 ]. In our interviews we studied and compared the barriers to access to care erected in Colombia by a managed competition model with the barriers in north-eastern Brazil, where public services were severely under-financed [ 23 , 24 ]. As expected, both had very poor results.

In 2006, Chile’s public services [ 25 ], which had survived the dictatorship, covered 84% of the population with half of the country’s health expenditure. However, with just 50% of the country’s health expenditures, the public services managed to make the country a positive outlier in Latin America on many health indicators. The technical challenge of this study was to relate health system features to indicators of output (utilisation and coverage rates, for instance) and outcome (maternal mortality, for instance).

Finally, in 2001, Costa Rica, with its publicly-oriented healthcare services and financing, had about the same demographic and epidemiological features as the United States, although it spent nine times less per capita on health than the U.S. [ 20 ]

To fuel the legal and institutional dynamics of health insurance privatisation, the WHO and other UN agencies promoted a strategy called “Universal Health Coverage” (UHC) [ 26 ], that is, universal access to health insurance. Its pro-market discourse endorsed the idea that only insured populations could access health care [ 27 ], despite evidence that expanding insurance coverage might reduce service utilisation, e.g., when public-private insurance mixes were supposed to achieve universal coverage of health risks [ 28 , 29 , 30 ] and evidence of the superior effectiveness, fairness, and efficiency of Latin American off-market health systems [ 20 , 21 ].

The findings of these international comparisons led the authors to question the UHC strategy as a way to secure universal access to care. This was not only because public-private mixes in healthcare financing give rise to severe inefficiency in health systems, but because access to care was shown to be highly dependent on non-financial factors (geographical and psychological accessibility of health services, for instance) [ 31 ] otherwise neglected by the UHC strategy and possibly even undermined by it. In the absence of performance-based evidence supporting health-financing marketisation, the hypothesised centrality of an economic agenda in Latin American health reforms became plausible.

In sum, these comparisons of the Chilean, Colombian, Costa Rican, and Brazilian health systems and historical studies of Bolivia and Ecuador support Hypothesis 1 regarding the negative impact of pro-market policies on access to care and quality of care and Hypothesis 3 regarding fiscal injustice and inefficient use of public funds by commercial health services and insurance companies.

In addition, the authors’ studies of Asian health systems showed that the health care market was structurally flawed by the impossibility of regulating and controlling the activities of the private but also public health care sector in MICs properly. Whilst the Rockefeller Foundation had tacitly admitted that without regulation and control, privatising health services could not produce equitable access to care [ 32 ], the authors showed through their observations in nine (maternal health) case studies of regulations in China, India, and Vietnam [ 33 ] and theoretical discussion [ 34 ] that regulation and control of for-profit care delivery were most likely to be ineffectual in the MIC care sector.

In Vietnam, for instance, sex-selective abortion was responsible for a serious gender imbalance in spite of a decade of State regulation and control. Although a regulation against the practice had been passed in 2003 and implemented since 2006, regional disparities in gender-specific birth rates increased between 2006 and 2011. As a “critical incident”, the number of ultrasound violations detected in 2011 had been 1 positive out of 83,192 controls done in the health districts under study. And in 2016, the gender ratio still was 112 females/100 males in Vietnam. Against a background of strong social demand for sex-selective abortion in the middle class, selective abortions remained undetected in spite of the regulation and inspections because of the policy-makers’ failure to allocate sufficient resources to this exercise, weak governance, medical secrecy, conflicts of interests, dual physicians’ employment (in public and private healthcare services), the opacity of the medical market, and difficulties specifying contingency in clinical situations [ 33 ].

This set of nine studies in China, India, and Vietnam thus supports the plausibility of Hypothesis 4, as they confirm the vulnerability of medical ethics to care commoditisation policies when regulation and control of medical practice are ineffectual, which actually they are because of the socio-political and technical characteristics of middle income countries.

Assessing the impact of health markets on access to care in Europe

At the end of World War II, unionised blue-collar workers imposed social protection schemes in health. In a bipolar world, the workers’ organisations took advantage of progressive ideologies that were gathering strong followings in Europe. Whilst the weakened employers’ organisations prevailed upon the Social Democrats and Social Christians to join them in the anti-Communist struggle, they conceded the pillarization of European States. Workers’ trade unions, mutual societies, and political parties entered the parliaments (as was the case before Word War II), but also the State’s executive branches, judiciary, and social and health services, education, the police, and the army. That is how workers’ representatives limited the impact of corruption in State constituencies, i.e., preventing those who had the will and resources from buying the State’s policy and administrative decisions. They locked the sustainability of social security into government structures and secured access to professional health care in universal health systems as a human right. Admittedly, the users of healthcare services paid for this State pillarization with a dose of nepotism and its consequences. Still, European States had acquired key democratic features. Heated negotiations between representatives of social classes with opposing interests produced sectoral priorities within the overarching framework of national health budgets. In Belgium, for instance, this debate was institutionalised in the national social security organisation. Footnote 1

The macroeconomic result of this pillarization of the State can be seen in two inversely proportional numbers that show the importance of risk-pooling and solidarity in European health care financing, namely:

a government share in total health spending that long exceeded 80% and

total health expenditures that were high enough (about US$4000 per capita in 2014, of which approximately 10% was for the commercial sector) to make the publicly-oriented healthcare services Footnote 2 effective but sufficiently modest (10% of European GDP versus 17.1% of U.S. GDP in 2014) to favour economic growth outside the health sector.

That is how employees’ and employers’ taxes and social contributions made it possible to limit household expenditures on health care whilst securing one of the best geographically, financially, psychologically, and technically accessible forms of professional health care. Importantly, these schemes gave physicians sufficient professional autonomy. Access to professional care was equitable thanks to cost-redistributing, non-profit, non-actuarial health care financing and a sufficiently large proportion of non-material investments in the health sector.

With government social security schemes that included fairly comprehensive universal health insurance, Europeans enjoyed a high degree of social protection from 1945 to 1989 in Eastern Europe, until the 2008 financial crisis in Southern Europe, and even later in other countries.

Unfortunately, the institutional pillarization did not prevail at the European Union and Commission level. Rather, European politicians, civil servants, and political parties were the targets of more than 30,000 commercial lobbyists (1.4 per European Commission (EC) civil servant) [ 35 ] working to foster the interests of the international insurance banks that were investing in health, amongst other things. In contradiction to the provisions of the Treaty of Rome [ 36 ], the EC intervened in the Member States’ health care systems by negotiating international trade treaties involving investments in health care that could make healthcare management and medical practice subject to a commercial rationale. In addition, the 3% budget deficit rule that the Maastricht Treaty imposed on Member States gave political parties an opportunity and a plausible reason to cut public expenditures on health until healthcare financing would be sufficiently privatised, as the WB and IMF had done earlier in Latin America.

Public expenditure on health care was severely constrained but once health laws and regulations had been modified, as shown by the history of Dutch, Swiss, and Colombian health systems, insurance banks strove to maximise public and private expenditures on health care and governments found the needed resources through inter-branch arbitration.

In the U.S., where the health market was mature, the wealthy faced more problems accessing health care than the poor in most OECD countries, whilst the U.S. government alone spent more on health per capita than the total (public and private) per capita spending of most European countries [ 37 ]. Nevertheless, over the last 10 years, the number of uninsured Americans varied between 35 and 50 million. Many more were poorly insured. If the U.S. insurance coverage rate were applied to Europe, the number of uninsured Europeans would reach about 75 million. If the European ratio of mortality amenable to care became that of the United States, avoidable mortality would increase by up to 100,000 deaths per year.

In Latin American countries, the same financial structure yielded the same health effects as in the U.S. but, admittedly, not in the Netherlands and Switzerland. The sustainable performance of these two health systems is central to policy debates in Europe and, expectedly, insurance banks praise their functioning, except for one small detail: Since health care financing has been marketed (respectively in 1996 and 2006), the Swiss and Dutch health expenditures have skyrocketed [ 38 ].

What are the reasons to believe that health insurance markets are environments hostile to the universal right to care? The authors evaluated [ 39 ] the performances of the U.S., the Netherlands, and Switzerland, three industrial nations that pursued market-based financing models, with a focus on equity in access to care, care quality, health status, and efficiency. They then assessed the consistency of their findings with those of various research teams. Using secondary data obtained from a semi-structured review of articles from 2000 to 2017, inter alia, they discussed the hypothesis that commercial health care insurance was detrimental to access to professional health care and population health status.

The findings can be summarised as follows:

In 2010, poor Americans had twice the unmet care needs of Americans with above-average incomes and ten times more than the UK poor. The unmet care needs of the rich in the U.S. exceeded those of the poor in several industrial countries [ 40 ]. The number of Dutchmen and -women experiencing financial obstacles to health care quadrupled between 2007 and 2013 [ 41 ]. Switzerland ranked second worst in a 2016 survey of 11 countries, just ahead of the USA, with 22% of Swiss adults likely to skip needed care [ 42 ].

The most negative impacts of “managed care” on care quality were its tight constraints on physicians’ professional autonomy, large reliance on the physicians’ material motivation, the fragmentation of health services, and a tendency to apply evidence-based medicine too rigidly. In requiring strict application of clinical protocols, commercially managed care was less likely to be favourable to care quality than systems giving physicians sufficient freedom to rely on professional decision-making and medical ethics.

The prevalence of burnout amongst MDs made medical practice the riskiest occupation in the United States and one of the riskiest occupations in Europe [ 43 ]. This burnout was not related to insufficient income but to excessive workloads and to perceiving existential threats to their professional identity, ethics, and autonomy in the way health care was organised. This observation supports Hypothesis 4 because these psychological and professional status threats actually result from the commoditisation of care [ 44 ].

Countries with a commercial insurance monopoly generally remained above the maternal, infant, and neonatal mortality rates v. the health-spending regression line [ 45 ]. And the growth rates of health expenditure were the highest in the U.S. and Switzerland, with the Netherlands not far behind [ 46 ].

Controlling for the impact of the obesity confounding factor, these studies reveal that the industrialisation of care contributes to the comparatively poor performance of the U.S., Dutch, and Swiss health systems, with the Dutch first-line services being an exception made possible by the GPs’ medical culture and the low cost to patient.

International trade treaties may further worsen the mortality rates of cardiovascular and cerebrovascular conditions, diabetes, and cancers in Europe, since they favour the food industry’s market penetration [ 47 ].

These findings admittedly conflict with recent influential health system rankings, perhaps because of the ways their health indicators are constructed and a bias towards assessing first-line healthcare services.

In conclusion, the comparison of US, Dutch, and Swiss health systems with the others in Europe supports the validity of Hypotheses 1 and 3. The most inefficient system is where the insurance market has achieved its maximal development, that is, in the U.S. In general, healthcare expenditures rose faster where health insurance was commoditised. The Netherlands and Switzerland reveal that increasing expenditure on health care enables health systems based on commercial insurance to maintain decent access to professionally-delivered health care for a few years.

The sizeably better, much more equitable access to health care in Western Europe (and its demographic and epidemiological superiority over the U.S.) and its much lower cost is generally explained by redistributive laws and regulations (tax-based or mandatory social security) channelled through health care public services or mutual societies that permit solidarity in health care financing.

The analysis of the U.S. health system’s disappointing performance reveals that actuarial management of health finances and the commercial management of health services are responsible for deficient accessibility to care and services. In particular, actuarial management of health care reduces risk pooling and solidarity in health financing between men and women, the young and the elderly, the sick and the well, high and low risks, and rich and poor.

Methodological lessons for descriptive, policy studies

Identifying health services productivity shortfalls and dysfunctional structures

The authors tried to provide patients’ and physicians’ organisations with the evidence and clues about policies from the angle of the human right to care and professional endeavour. Their research assessed the influence of policies on health services’ productivity in defined historical contexts from various standpoints: those of patients (e.g., care quality and accessibility); physicians (e.g., continuing medical education and teamwork); taxpayers (efficiency and equity in use of public monies); and public health specialists (health care and disease control management).

From an inductive study perspective, documenting health services’ structural and functional deficiencies provided the raw material for assessing health systems and possibly challenging policy decisions and official discourse.

To gauge the quality of health care, the authors used medical knowledge to observe clinical practice (sometimes as mock patients) [ 48 ]. For instance, to assess the impact of managed care techniques on care quality in Costa Rica, they sat in on consultations. The research hypotheses had been formulated by the Limon region’s GPs, who suggested that there was a relationship between managed care ( compromisos de gestión ) and the lack of time available for interpersonal communication and deficient care accessibility [ 49 ]. In addition, they collected data on disease-specific indicators to explore the extent to which managed care techniques were responsible for decreasing care quality and data reliability.

To assess care accessibility, they often used the services’ routine production data, with indicators such as population-based utilisation rates of curative care in first-line services and hospital admission rates [ 31 ], referral completion rates, and preventive (vaccination, antenatal clinics, etc.) coverage rates, and then they validated them by triangulation when possible. As a proxy for the financial accessibility of health care, they used “catastrophic health expenditures.” [ 50 ] Routine data proved cheaper, readily available, and a good reflection of the services’ operations in large geographical areas, but the method had limits even when it was combined with data triangulation and controls:

In Colombia, semi-structured interviews of patients and professionals proved indispensable to gauge care accessibility [ 51 , 52 , 53 ] because networks of “sentinel physicians” were not organised to collect service utilisation and epidemiological data; population-based statistics were not available and the denominators would have consisted of populations affiliated with a myriad of health insurers and care providers; and private insurance companies were reluctant to provide data that could undermine their reputations.

The routine data were sometimes biased, such as in the case of a state administration in charge of determining regional maternal mortality rates in Asia. Aside from the technical difficulties of establishing the maternal mortality rate (MMR), middle line managers were likely to be penalised when this indicator was too high but also too low, because in the latter case the administration did not trust the data’s validity [ 33 ]. Hence a regression to the mean …

In general, the authors relied on output indicators rather than on population outcome. However, two demographic indicators proved particularly interesting for critical assessment of healthcare systems:

The Maternal Mortality Rate (MMR) reflects access to the entire healthcare system pyramid [ 54 ], particularly in LMICs [ 55 ] and probably in any situation where it exceeds 40 per thousand. This is in contrast to the Infant Mortality Rate (IMR), which in LICs often mirrors low-cost interventions that may reduce access to care (such as immunisation campaigns) [ 56 ] and biomedical/sociocultural health determinants (such as the availability of food and clean water and women’s education, respectively). Since the lower the per capita GDP, the cheaper and less reliable the demographic indicators used [ 57 ], the authors retained in practice only the gross differences when comparing the health systems’ performances in terms of MMR. In 2010, for instance, Moldova, the poorest country in Europe, had the same MMR as the U.S., despite spending 1/20 as much on health per capita.

In HICs, life expectancy and population mortality rates mirror obesity-associated pathologies but, just as importantly, access to quality health care. Up to 80% of premature deaths in Poland were explained by unsatisfactory access to health care [ 58 ]. According to Kruk and co-workers, 15.6 million excess deaths from 61 conditions occurred in LMIC in 2016. This research compared case fatality between each LMIC with corresponding numbers from 23 high-income reference countries with strong health systems. After excluding deaths that were preventable by public health measures, the authors found that 55% of excess deaths were amenable to health care and could be put down to either the receipt of poor-quality care or the non-utilisation of health care [ 59 ].

To evaluate health systems by the design and performance of their disease control programmes, the authors relied on two models:

An all-purpose disease control model (“ vertical analysis” ), designed by P. Mercenier [ 60 ] to provide standards for the design of disease-specific control programmes. It was based on the systemic representation of the disease-specific syndromes and vector development stages and biomedical and socio-cultural interventions to interrupt the disease chain in the field, from aetiology to patient death.

M. Piot’s model [ 61 ] to assess care continuity for any defined disease. It establishes the disease-specific cure rate as the product of coefficients measuring detection, diagnosis, and treatment activities. As the model reveals the health system characteristics needed to secure, say, early detection and care continuity, they used it to contrast the performances of public and private sectors in tuberculosis control in India [ 62 ] and to evaluate malaria control programmes in Mali and Sub-Saharan Africa in general [ 15 ].

Once health system productivity had been studied, the authors analysed the organisation of health services and systems. For this they relied on managerial models and standards specific to

publicly-minded care management (e.g., concerned with access to professional health care, professional autonomy and well-being, professional ethics, and public health) [ 63 ];

the systemic management of hospital(s) and first-line facilities networks [ 18 ]; and

“divisionalised adhocracy”, an organisation pattern that favours knowledge management and teamwork [ 19 ] and is suited to systems whose end-line producers are highly skilled and sufficiently autonomous professionals (as are physicians) rather than workers and technicians, as assumed by the classic generic management theories.

Studies of health financing and systems characteristics that cause low services productivity

Health system case studies and the existence of large databases in the health sector provided the opportunity to single out natural, quasi-experimental study designs – time series and non-equivalent comparisons – to contrast health systems with and without or before and after pro-market health reforms:

For non-equivalent groups (countries, regions, etc.), the authors compared the performances of national/regional health systems in Latin America compliant with the international policy standards with those of “disobedient” ones [ 9 ] and established a typology of reforms.

With time series, we showed long-standing, substandard performances in the quality, accessibility, and financing of health care (for instance, after the privatisation of health insurance in Colombia).

Time series of health services’ routine data also proved useful to reveal contradictory interactions of health activities in populations. For instance, in the late 1980s, the utilisation of medical consultations decreased steadily in Senegal whilst immunisation campaigns were implemented in health care services [ 64 ]. The challenge of the study consisted in demonstrating a causal relationship between these campaigns and the subsequent sustained deterioration of care accessibility in public services.

Beyond substandard care performances: political economics

Inductive research made it possible to deconstruct official self-apologetic discourses. The authors were then able to seek the real motives for ill-conceived policies whose results belied the stated objectives. Their entry point in the complex socio-cultural and political determinants of health policies was political economics because of the huge weight of health expenditures in the global economy (up to 17% of U.S. GDP and 11.3% of Germany’s GDP) and the political leverage acquired by the economic players. The economic determinism of health care policies was so powerful that these players did not even need to be coordinated to gear health systems towards care markets [ 65 ].

From corruption [ 66 ], political leverage, and lobbying to trade, it takes time for relationships between commercial organisations and public institutions to result in health systems’ structures and new professional practice. Some studies thus adopted an historical viewpoint [ 12 , 65 , 67 , 68 ] to probe the care commoditisation mechanisms. Even in non-profit organisations, the main determinant of poor healthcare accessibility proved to be the business mission of health financing, management, and medical practice.

However, correlations between events, sequences, sociological observations, and relationships between historical times enabled us to identify professional, cultural, and geostrategic determinants of health policies alongside economic ones. The prevailing order was reflected in professional culture thanks to education, information, scientific ideology, and advertising. The resulting personal characteristics, identity, and knowledge of physicians and professionals were the conditions of health systems’ reproducibility. Bourdieu calls these internal features “habitus,” i.e., ways of doing and being, and “representations”.

Since 1985, the trend has been towards the privatisation of health financing, public subsidies for private health care providers, commercial management of health services, and for-profit medical practice, in spite of the wealth of evidence pointing to the risks of large-scale mortality and morbidity and threats to professional ethics associated with the commoditisation of care.

Governments and multilateral agencies ought to be held accountable when health policies cause avoidable mortality and suffering and thus human rights violations, or at least “be shamed”, as Sir Michael Marmot once said. Therefore, with States being fields “structured according to oppositions linked to specific forms of capital” [ 69 ], health system and policy research should not so much address the knowledge needs of policy makers directly as those of physicians, socially-minded professionals, and patients’ organisations that could leverage them. Political indictments on the impact of health policies require these organisations to access the relevant scientific and professional information in order to question and challenge public policies in the health sector.

The studies analysed here stemmed from the human right to access professional care in universal health systems and the knowledge they produced was directed at physicians, health professionals, and patients’ organisations sharing moral values and interested in lobbying health policies. The present meta-analysis sheds light on the requirements of this type of research:

Inductive, multidisciplinary policy research is time-consuming but often a condition to study health policies independently:

International health policies assessments benefit from analysing national healthcare policies and disease control programmes.

National health policies should be studied with political economy and medical concepts, and through the lenses of political science and history, but importantly on the grounds of health systems and services productivity assessment.

Medical concepts, public health models, and indicators of professional care delivery and non-profit health management make it possible to evaluate health systems from a professionally- and socially-driven, problem-based perspective.

Health systems and policy researchers need scientific and professional knowledge. Academics should engage in medical, managerial, and policy-making work alongside their research and teaching activities. Therefore, medical and public health schools should learn to assess the academic’s professional proficiency and ability to derive validated theory from their practice.

Professional ethics should be a criterion for evaluating care quality:

Although values are an obstacle to Weberian axiological neutrality in medical, public health, and education policy studies, they are indispensable to assess care quality, health services, and healthcare systems. From a phenomenological perspective, they ought to be made available to the reader.

Health systems have evolved rapidly over the last three decades. Long-term reliance on the same set of explicit ethical and technical criteria applicable to medical practice and health services organisation is what allows valid conclusions to be drawn from time series and comparative or historical studies of health systems that belong to different eras.

Such studies ought not to be only descriptive and critical but also designed as proposals to improve health systems and policies. Those analysed here reveal many nationwide experiences to improve access to professional care. Some countries (Costa Rica, Cuba, Spain, Sri Lanka, Thailand, and Italy), states (e.g. , Kerala), regions or cities (e.g. Rosario, Argentina), and health systems (Chilean public services) acquired collective knowledge to develop non-commercial care delivery and promote ethical, medical practice. There is no doubt that decades of neoliberal policy have compromised their professional achievements, to the point that they are often no longer perceptible.

Medical journals ought to be devoted to professional practice and not only to science, and be independent and publicly financed. Given the undeclared conflict of interest created by the presence of insurance banks in the shareholding of top impact-factor medical journals, physicians’ and patients’ organisations should lobby public universities to stop relying on the researcher’s bibliometrics and the impact factor to decide on scientists’ careers.

The hypothesis that the authors formulated in 1983 can reasonably be accepted. Health markets most likely undermine patients’ health, physicians and professionals’ status and morale, and taxpayers’ interests. The key function of health sector reforms is not public health but economic: they aim to privatise the profitable part of health care financing; maximise the return on health care with commercial healthcare management of services and for-profit care delivery; prevent public services from being involved in a competition with the private sector for health care delivery, management, and financing; and open markets in LMICs with public aid funds to medical and pharmaceutical goods preferably manufactured in industrialised countries.

The studies analysed here show physicians and their organisations that commercial healthcare financing is incompatible with ethical, medical practice because, with or without vertical integration (in HMOs or PPOs), whether through contracts or wages, it imposes the goal of maximising shareholders’ profits on physicians and health professionals, whereas this commercial mission goes against the grain of Hippocratic ethics.

To patients’ organisations, the studies analysed here prove worldwide that care commercialisation prevents solidarity in healthcare financing and obstructs equal access to care. Markets segment health systems, they foment competition between physicians, whilst cooperation among them is essential to peoples’ health [ 13 ]. Moreover, they use public expenditure on healthcare inefficiently.

This research thus opens avenues for joint political action by patients’ and physicians’ organisations to defend and promote social protection in health because it shows that both doctors and patients benefit from professional care delivery and publicly-oriented care financing and management; the major contemporary threat to care accessibility and quality, namely, the privatisation of health care financing, also jeopardises the physicians’ autonomy, ethics, and incomes.

Finally, this research shows that competition prevails between not only commercial entities but also sectors. The interests of insurance banks investing in health and those of all the other economic actors are contradictory: Inter-country comparisons of total health expenditures reveal that the commodisation of care is accompanied by broad inter-sectoral, macro-economic redistribution. Economic agents that do not invest in health insurances would do better to learn from this.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Whilst these schemes had been forced upon employers, they unexpectedly proved to be highly favourable to economic growth.

Referring to health services and systems, we use the terms “publicly oriented”, “publicly minded”, “socially driven”, “non commercial”, and “not for profit” interchangeably

Abbreviations

Disability-adjusted life years

European Commission

Global health initiatives

General practitioner

High income countries

Infant mortality rate

Low and middle income countries

Medical doctor

Millennium development goals

Maternal mortality rate

Quality-adjusted life years

Sustainable development goals

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Acknowledgements

We are indebted to Professors Charlene Harrington (Department of Social & Behavioral Sciences, University of California San Francisco), Antonio Ugalde (University of Texas at Austin, College of Liberal Arts), and Matt Anderson (Albert Einstein College of Medicine, New York) for their indispensable comments. Gaby Leyden edited the manuscript thoroughly. No error can be attributed to them.

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Unger, JP., Morales, I. & De Paepe, P. Objectives, methods, and results in critical health systems and policy research: evaluating the healthcare market. BMC Health Serv Res 20 (Suppl 2), 1072 (2020). https://doi.org/10.1186/s12913-020-05889-w

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The importance of human resources management in health care: a global context

• Stefane M Kabene 1 , 3 ,
• Carole Orchard 3 ,
• John M Howard 2 ,
• Mark A Soriano 1 &
• Raymond Leduc 1  

Human Resources for Health volume  4 , Article number:  20 ( 2006 ) Cite this article

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This paper addresses the health care system from a global perspective and the importance of human resources management (HRM) in improving overall patient health outcomes and delivery of health care services.

We explored the published literature and collected data through secondary sources.

Various key success factors emerge that clearly affect health care practices and human resources management. This paper will reveal how human resources management is essential to any health care system and how it can improve health care models. Challenges in the health care systems in Canada, the United States of America and various developing countries are examined, with suggestions for ways to overcome these problems through the proper implementation of human resources management practices. Comparing and contrasting selected countries allowed a deeper understanding of the practical and crucial role of human resources management in health care.

Proper management of human resources is critical in providing a high quality of health care. A refocus on human resources management in health care and more research are needed to develop new policies. Effective human resources management strategies are greatly needed to achieve better outcomes from and access to health care around the world.

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Defining human resources in health care

Within many health care systems worldwide, increased attention is being focused on human resources management (HRM). Specifically, human resources are one of three principle health system inputs, with the other two major inputs being physical capital and consumables [ 1 ]. Figure 1 depicts the relationship between health system inputs, budget elements and expenditure categories.

Relationship between health system inputs, budget elements and expenditure categories . Source: World Health Report 2000 Figure 4.1 pg.75. http://www.who.int.proxy.lib.uwo.ca:2048/whr/2000/en/whr00_ch4_en.pdf Figure 1 identifies three principal health system inputs: human resources, physical capital and consumables. It also shows how the financial resources to purchase these inputs are of both a capital investment and a recurrent character. As in other industries, investment decisions in health are critical because they are generally irreversible: they commit large amounts of money to places and activities that are difficult, even impossible, to cancel, close or scale down [1].

Human resources, when pertaining to health care, can be defined as the different kinds of clinical and non-clinical staff responsible for public and individual health intervention [ 1 ]. As arguably the most important of the health system inputs, the performance and the benefits the system can deliver depend largely upon the knowledge, skills and motivation of those individuals responsible for delivering health services [ 1 ].

As well as the balance between the human and physical resources, it is also essential to maintain an appropriate mix between the different types of health promoters and caregivers to ensure the system's success [ 1 ]. Due to their obvious and important differences, it is imperative that human capital is handled and managed very differently from physical capital [ 1 ]. The relationship between human resources and health care is very complex, and it merits further examination and study.

Both the number and cost of health care consumables (drugs, prostheses and disposable equipment) are rising astronomically, which in turn can drastically increase the costs of health care. In publicly-funded systems, expenditures in this area can affect the ability to hire and sustain effective practitioners. In both government-funded and employer-paid systems, HRM practices must be developed in order to find the appropriate balance of workforce supply and the ability of those practitioners to practise effectively and efficiently. A practitioner without adequate tools is as inefficient as having the tools without the practitioner.

Key questions and issues pertaining to human resources in health care

When examining health care systems in a global context, many general human resources issues and questions arise. Some of the issues of greatest relevance that will be discussed in further detail include the size, composition and distribution of the health care workforce, workforce training issues, the migration of health workers, the level of economic development in a particular country and sociodemographic, geographical and cultural factors.

The variation of size, distribution and composition within a county's health care workforce is of great concern. For example, the number of health workers available in a country is a key indicator of that country's capacity to provide delivery and interventions [ 2 ]. Factors to consider when determining the demand for health services in a particular country include cultural characteristics, sociodemographic characteristics and economic factors [ 3 ].

Workforce training is another important issue. It is essential that human resources personnel consider the composition of the health workforce in terms of both skill categories and training levels [ 2 ]. New options for the education and in-service training of health care workers are required to ensure that the workforce is aware of and prepared to meet a particular country's present and future needs [ 2 ]. A properly trained and competent workforce is essential to any successful health care system.

The migration of health care workers is an issue that arises when examining global health care systems. Research suggests that the movement of health care professionals closely follows the migration pattern of all professionals in that the internal movement of the workforce to urban areas is common to all countries [ 2 ]. Workforce mobility can create additional imbalances that require better workforce planning, attention to issues of pay and other rewards and improved overall management of the workforce [ 2 ]. In addition to salary incentives, developing countries use other strategies such as housing, infrastructure and opportunities for job rotation to recruit and retain health professionals [ 2 ], since many health workers in developing countries are underpaid, poorly motivated and very dissatisfied [ 3 ]. The migration of health workers is an important human resources issue that must be carefully measured and monitored.

Another issue that arises when examining global health care systems is a country's level of economic development. There is evidence of a significant positive correlation between the level of economic development in a country and its number of human resources for health [ 3 ]. Countries with higher gross domestic product (GDP) per capita spend more on health care than countries with lower GDP and they tend to have larger health workforces [ 3 ]. This is an important factor to consider when examining and attempting to implement solutions to problems in health care systems in developing countries.

Socio-demographic elements such as age distribution of the population also play a key role in a country's health care system. An ageing population leads to an increase in demand for health services and health personnel [ 3 ]. An ageing population within the health care system itself also has important implications: additional training of younger workers will be required to fill the positions of the large number of health care workers that will be retiring.

It is also essential that cultural and geographical factors be considered when examining global health care systems. Geographical factors such as climate or topography influence the ability to deliver health services; the cultural and political values of a particular nation can also affect the demand and supply of human resources for health [ 3 ]. The above are just some of the many issues that must be addressed when examining global health care and human resources that merit further consideration and study.

The impact of human resources on health sector reform

When examining global health care systems, it is both useful and important to explore the impact of human resources on health sector reform. While the specific health care reform process varies by country, some trends can be identified. Three of the main trends include efficiency, equity and quality objectives [ 3 ].

Various human resources initiatives have been employed in an attempt to increase efficiency. Outsourcing of services has been used to convert fixed labor expenditures into variable costs as a means of improving efficiency. Contracting-out, performance contracts and internal contracting are also examples of measures employed [ 3 ].

Many human resources initiatives for health sector reform also include attempts to increase equity or fairness. Strategies aimed at promoting equity in relation to needs require more systematic planning of health services [ 3 ]. Some of these strategies include the introduction of financial protection mechanisms, the targeting of specific needs and groups, and re-deployment services [ 3 ]. One of the goals of human resource professionals must be to use these and other measures to increase equity in their countries.

Human resources in health sector reform also seek to improve the quality of services and patients' satisfaction. Health care quality is generally defined in two ways: technical quality and sociocultural quality. Technical quality refers to the impact that the health services available can have on the health conditions of a population [ 3 ]. Sociocultural quality measures the degree of acceptability of services and the ability to satisfy patients' expectations [ 3 ].

Human resource professionals face many obstacles in their attempt to deliver high-quality health care to citizens. Some of these constraints include budgets, lack of congruence between different stakeholders' values, absenteeism rates, high rates of turnover and low morale of health personnel [ 3 ].

Better use of the spectrum of health care providers and better coordination of patient services through interdisciplinary teamwork have been recommended as part of health sector reform [ 4 ]. Since all health care is ultimately delivered by people, effective human resources management will play a vital role in the success of health sector reform.

In order to have a more global context, we examined the health care systems of Canada, the United States of America, Germany and various developing countries. The data collection was achieved through secondary sources such as the Canadian Health Coalition, the National Coalition on Health Care and the World Health Organization Regional Office for Europe. We were able to examine the main human resources issues and questions, along with the analysis of the impact of human resources on the health care system, as well as the identification of the trends in health sector reform. These trends include efficiency, equity and quality objectives.

Health care systems

The Canadian health care system is publicly funded and consists of five general groups: the provincial and territorial governments, the federal government, physicians, nurses and allied health care professionals. The roles of these groups differ in numerous aspects. See Figure 2 for an overview of the major stakeholders in the Canadian health care system.

Overview of the major stakeholders in the Canadian health care system . Figure 2 depicts the major stakeholders in the Canadian health care system and how they relate.

Provincial and territorial governments are responsible for managing and delivering health services, including some aspects of prescription care, as well as planning, financing, and evaluating hospital care provision and health care services [ 5 ]. For example, British Columbia has shown its commitment to its health care program by implementing an increase in funding of CAD 6.7 million in September 2003, in order to strengthen recruitment, retention and education of nurses province-wide [ 6 ]. In May 2003, it was also announced that 30 new seats would be funded to prepared nurse practitioners at the University of British Columbia and at the University of Victoria [ 6 ]. Recently the Ontario Ministry of Health and Long Term Care announced funding for additional nurse practitioner positions within communities. Furthermore, most provinces and territories in Canada have moved the academic entry requirement for registered nurses to the baccalaureate level, while increasing the length of programmes for Licensed Practice Nurses to meet the increasing complexity of patient-care needs. Several provinces and territories have also increased seats in medical schools aimed towards those students wishing to become family physicians [ 7 ].

The federal government has other responsibilities, including setting national health care standards and ensuring that standards are enforced by legislative acts such as the Canada Health Act (CHA) [ 5 ]. Constitutionally the provinces are responsible for the delivery of health care under the British North America (BNA) Act; the provinces and territories must abide by these standards if they wish to receive federal funding for their health care programs [ 8 ]. The federal government also provides direct care to certain groups, including veterans and First Nation's peoples, through the First Nationals and Inuit Health Branch (FNIHB). Another role of the federal government is to ensure disease protection and to promote health issues [ 5 ].

The federal government demonstrates its financial commitment to Canada's human resources in health care by pledging transfer funds to the provinces and direct funding for various areas. For example, in the 2003 Health Care Renewal Accord, the federal government provided provinces and territories with a three-year CAD 1.5 billion Diagnostic/Medical Equipment Fund. This was used to support specialized staff training and equipment that improved access to publicly funded services [ 6 ].

The third group – private physicians – is generally not employed by the government, but rather is self-employed and works in a private practice. They deliver publicly-funded care to Canadian citizens. Physicians will negotiate fee schedules for their services with their provincial governments and then submit their claims to the provincial health insurance plan in order to receive their reimbursement [ 5 ].

The roles of nurses consist of providing care to individuals, groups, families, communities and populations in a variety of settings. Their roles require strong, consistent and knowledgeable leaders, who inspire others and support professional nursing practice. Leadership is an essential element for high-quality professional practice environments in which nurses can provide high-quality nursing care [ 9 ].

In most Canadian health care organizations, nurses manage both patient care and patient care units within the organization. Nurses have long been recognized as the mediators between the patient and the health care organization [ 10 ]. In care situations, they generally perform a coordinating role for all services needed by patients. They must be able to manage and process nursing data, information and knowledge to support patient care delivery in diverse care-delivery settings [ 10 ]. Workplace factors most valued by nurses include autonomy and control over the work environment, ability to initiate and sustain a therapeutic relationship with patients and a collaborative relationship with physicians at the unit level [ 11 ].

In addition to doctors and nurses, there are many more professionals involved in the health care process. Allied health care professionals can consist of pharmacists, dietitians, social workers and case managers, just to name a few. While much of the focus is on doctors and nurses, there are numerous issues that affect other health care providers as well, including workplace issues, scopes of practice and the impact of changing ways of delivering services [ 12 ]. Furthermore, with health care becoming so technologically advanced, the health care system needs an increasing supply of highly specialized and skilled technicians [ 12 ]. Thus we can see the various roles played by these five groups and how they work together to form the Canadian health care system.

Canada differs from other nations such as the United States of America for numerous reasons, one of the most important being the CHA. As previously mentioned, the CHA sets national standards for health care in Canada. The CHA ensures that all Canadian citizens, regardless of their ability to pay, will have access to health care services in Canada. "The aim of the CHA is to ensure that all eligible residents of Canada have reasonable access to insured health services on a prepaid basis, without direct charges at the point of service" [ 6 ].

Two of the most significant stipulations of the CHA read: "reasonable access to medically necessary hospital and physician services by insured persons must be unimpeded by financial or other barriers" and "health services may not be withheld on the basis of income, age, health status, or gender" [ 5 ]. These two statements identify the notable differences between the Canadian and American health care systems. That is, coverage for the Canadian population is much more extensive.

Furthermore in Canada, there has been a push towards a more collaborative, interdisciplinary team approach to delivering health care; this raises many new issues, one of which will involve successful knowledge transfer within these teams [ 13 ]. Effective knowledge management, which includes knowledge transfer, is increasingly being recognized as a crucial aspect of an organization's basis for long-term, sustainable, competitive advantage [ 34 ]. Even though health care in Canada is largely not for profit, there will still be the need for effective knowledge management practices to be developed and instituted. The introduction of interdisciplinary health teams in Canadian hospitals is a relatively new phenomenon and their connection to the knowledge management policies and agendas of governments and hospital administrations raises important questions about how such teams will work and to what extent they can succeed in dealing with the more difficult aspects of knowledge management, such as the transfer of tacit knowledge.

The multidisciplinary approach tends to be focused around specific professional disciplines, with health care planning being mainly top-down and dominated by medical professionals. Typically there is a lead professional (usually a physician) who determines the care and, if necessary, directs the patient to other health care specialists and allied professionals (aides, support workers). There is generally little involvement by the patient in the direction and nature of the care. Interdisciplinary health care is a patient-centred approach in which all those involved, including the patient, have input into the decisions being made.

The literature on teamwork and research on the practices in hospitals relating to multidisciplinary teams suggests that interdisciplinary teams face enormous challenges [ 13 ], therefore multidisciplinary teamwork will continue to be a vital part of the health care system. However, the goal of this teamwork should not be to displace one health care provider with another, but rather to look at the unique skills each one brings to the team and to coordinate the deployment of these skills. Clients need to see the health worker most appropriate to deal with their problem [ 14 ].

Some of the issues regarding the Canadian public system of health have been identified in the Mazankowski Report, which was initiated by Alberta's Premier Ralph Klein in 2000. Many issues have arisen since this time and have been debated among Canadians. One of the most contentious, for example, is the possibility of introducing a two-tier medical system. One tier of the proposed new system would be entirely government-funded through tax dollars and would serve the same purpose as the current publicly-funded system. The second tier would be a private system and funded by consumers [ 5 ].

However, the CHA and the Canadian Nurses Association (CNA) are critical of any reforms that pose a threat to the public health care system. It should be noted that although Canada purports to have a one-tier system, the close proximity of private, fee-for-service health care in the United States really creates a pay-as-you-go second tier for wealthy Canadians. In addition, many health care services such as most prescriptions and dental work are largely funded by individuals and/or private or employer paid insurance plans.

It is important to realize the differences between the proposed two-tier system and the current health care system. Presently, the public health care system covers all medically necessary procedures and the private sector provides 30% for areas such as dental care. With the new system, both public and private care would offer all services and Canadians would have the option of choosing between the two.

The proposal of the two-tier system is important because it highlights several important issues that concern many Canadians, mainly access to the system and cost reduction. Many Canadians believe the current public system is not sustainable and that a two-tiered system would force the public system to become more efficient and effective, given the competition of the private sector. However, the two-tiered system is not within the realm of consideration, since the majority of Canadians are opposed to the idea of a privatized system [ 5 ]. No proposals have come forward that show how a privately funded system would provide an equal quality of services for the same cost as the current publicly funded system.

United States of America

The health care system in the United States is currently plagued by three major challenges. These include: rapidly escalating health care costs, a large and growing number of Americans without health coverage and an epidemic of substandard care [ 15 ].

Health insurance premiums in the United States have been rising at accelerating rates. The premiums themselves, as well as the rate of increase in premiums, have increased every year since 1998; independent studies and surveys indicate that this trend is likely to continue over the next several years [ 15 ]. As a result of these increases, it is more difficult for businesses to provide health coverage to employees, with individuals and families finding it more difficult to pay their share of the cost of employer-sponsored coverage [ 15 ]. The rising trend in the cost of employer-sponsored family health coverage is illustrated in Figure 3 .

The trend of the cost of employer-sponsored family health care coverage in the United States . Source: National Coalition on Health Care 2004 pg.9. http://www.nchc.org/materials/studies/reform.pdf . Figure 3 illustrates the increase in health insurance premiums since 2001. These increases are making it more difficult for businesses to continue to provide health coverage for their employees and retirees [15].

To help resolve this problem, health maintenance organizations (HMO) have been introduced, with the goal of focusing on keeping people well and out of hospitals in the hope of decreasing employer costs. HMOs are popular alternatives to traditional health care plans offered by insurance companies because they can cover a wide variety of services, usually at a significantly lower cost [ 16 ]. HMOs use "networks" of selected doctors, hospitals, clinics and other health care providers that together provide comprehensive health services to the HMOs members [ 16 ]. The overall trade-off with an HMO is reduced choice in exchange for increased affordability.

Another problem to address regarding the American health care system is the considerable and increasing number of Americans without health coverage. Health care coverage programs such as Medicare offer a fee-for-service plan that covers many health care services and certain drugs. It also provides access to any doctor or hospital that accepts Medicare [ 17 ]. Patients with limited income and resources may qualify for Medicaid, which provide extra help paying for prescription drug costs [ 17 ]. However, according to figures from the United States Census Bureau, the number of Americans without health coverage grew to 43.6 million in 2002; it is predicted that the number of uninsured Americans will increase to between 51.2 and 53.7 million in 2006 [ 15 ].

Those Americans without health care insurance receive less care, receive care later and are, on average, less healthy and less able to function in their daily lives than those who have health care insurance. Additionally, the risk of mortality is 25% higher for the uninsured than for the insured [ 15 ].

Despite excellent care in some areas, the American health care system is experiencing an epidemic of substandard care; the system is not consistently providing high-quality care to its patients [ 15 ]. There appears to be a large discrepancy between the care patients should be receiving and the care they are actually getting. The Institute of Medicine has estimated that between 44 000 and 98 000 Americans die each year from preventable medical errors in hospitals [ 15 ].

It is also useful to examine the demographic characteristics of those Americans more likely to receive substandard care. Research shows that those Americans with little education and low income receive a lower standard of care [ 18 ]. This finding may be explained by the fact that patients who have lower education levels tend to have more difficulty explaining their concerns to physicians, as well as eliciting a response for those concerns because health professionals often do not value their opinions [ 18 ].

Case studies

As shown by the extensive literature, statistics and public opinion, there is a growing need for health care reform in the United States of America. There is a duty and responsibility of human resources professionals to attempt to elicit change and implement policies that will improve the health care system.

It is informative to examine case studies in which human resources professionals have enacted positive change in a health care setting. One such case from 1995 is that of a mid-sized, private hospital in the New York metropolitan area. This case presents a model of how human resources can be an agent for change and can partner with management to build an adaptive culture to maintain strong organizational growth [ 19 ].

One of the initiatives made by human resources professionals in an attempt to improve the overall standard of care in the hospital was to examine and shape the organization's corporate culture. Steps were taken to define the values, behaviors and competences that characterized the current culture, and analyze these against the desired culture [ 19 ]. A climate survey was conducted in the organization; it became the goal of the human resources professionals to empower employees to be more creative and innovative [ 19 ]. To achieve this, a new model of care was designed that emphasized a decentralized nursing staff and a team-based approach to patient care. Nursing stations were redesigned to make them more accessible and approachable [ 19 ].

Human resources management also played an important role in investing in employee development. This was achieved by assisting employees to prepare and market themselves for internal positions and if desired, helping them pursue employment opportunities outside the organization [ 19 ]. This case makes obvious the important roles that human resources management can play in orchestrating organizational change.

Another case study that illustrates the importance of human resources management to the health care system is that of The University of Nebraska Medical Center in 1995. During this period, the hospital administrative staff recognized a variety of new challenges that were necessitating organizational change. Some of these challenges included intense price competition and payment reform in health care, reduced state and federal funding for education and research, and changing workforce and population demographics [ 20 ]. The organizational administrators recognized that a cultural reformation was needed to meet these new challenges. A repositioning process was enacted, resulting in a human resources strategy that supported the organization's continued success [ 20 ]. This strategy consisted of five major objectives, each with a vision statement and series of action steps.

Staffing: Here, the vision was to integrate a series of organization-wide staffing strategies that would anticipate and meet changing workforce requirements pertaining to staff, faculty and students. To achieve this vision, corporate profiles were developed for each position to articulate the core competences and skills required [ 20 ].

Performance management: The vision was to hold all faculty and staff accountable and to reward individual and team performance. With this strategy, managers would be able to provide feedback and coaching to employees in a more effective and timely manner [ 20 ].

Development and learning: The vision was to have all individuals actively engaged in the learning process and responsible for their own development. Various unit-based training functions were merged into a single unit, which defined critical technical and behavioral competencies [ 20 ].

Valuing people: The vision was to have the hospital considered as a favored employer and to be able to attract and retain the best talent. To facilitate this vision, employee services such as child care and wellness were expanded [ 20 ].

Organizational effectiveness. The vision was to create an organization that is flexible, innovative and responsive [ 20 ]. The developments of these human resources strategies were essential to the effectiveness of the organization and to demonstrate the importance of human resources in the health care industry.

Both these case studies illustrate that effective human resources management is crucial to health care in a practical setting and that additional human resources initiatives are required if solutions are to be found for the major problems in the United States health care system.

Approximately 92% of Germany's population receives health care through the country's statutory health care insurance program, Gesetzliche Krankenversicherung (GKV). GKV designed an organizational framework for health care in Germany and has identified and constructed the roles of payers, providers and hospitals. Private, for-profit companies cover slightly less than 8% of the population. This group would include, for example, civil servants and the self-employed. It is estimated that approximately 0.2% of the population does not have health care insurance [ 21 ]. This small fragment may be divided into two categories: either the very rich, who do not require it, or the very poor, who obtain their coverage through social insurance. All Germans, regardless of their coverage, use the same health care facilities. With these policies nearly all citizens are guaranteed access to high-quality medical care [ 22 ].

While the federal government plays a major part in setting the standards for national health care policies, the system is actually run by national and regional autonomous organizations. Rather than being financed solely through taxes, the system is covered mostly by health care premiums [ 22 ]. In 2003, about 11.1% of Germany's gross domestic product (GDP) went into the health care system [ 23 ] versus the United States, with 15% [ 24 ] and Canada at 9.9% [ 25 ]. However, Germany still put about one third of its social budget towards health care [ 22 ].

The supply of physicians in Germany is high, especially compared to the United States, and this is attributed largely to the education system. If one meets the academic requirements in Germany, the possibility to study medicine is legally guaranteed [ 26 ]. This has led to a surplus of physicians and unemployment for physicians has become a serious problem. In 2001, the unemployment rate for German physicians of 2.1% led many German doctors to leave for countries such as Norway, Sweden and the United Kingdom, all of which actively recruit from Germany [ 27 ].

Germany's strong and inexpensive academic system has led the country to educate far more physicians than the United States and Canada. In 2003, Germany had 3.4 practicing physicians per 1000 inhabitants [ 23 ], versus the United States, which had 2.3 practicing physicians per 1000 inhabitants in 2002 [ 24 ] and Canada, which had 2.1 practicing physicians per 1000 inhabitants in 2003 [ 25 ]. It is also remarkable that health spending per capita in Germany (USD 2996) [ 23 ] amounted to about half of health spending per capita in the United States (USD 5635) [ 24 ], and slightly less than Canada's health spending (USD 3003) [ 25 ]. This clearly demonstrates the Germans' strength regarding cost containment.

There are several issues that physicians face in the German health care system. In a 1999 poll, 49.9% of respondents said they were very or fairly satisfied with their health care system, while 47.7% replied they were very or fairly dissatisfied with it [ 28 ]. Furthermore, the degree of competition between physicians is very high in Germany and this could lead to a reduction in physician earnings. Due to this competition, many younger physicians currently face unemployment. The German law also limits the number of specialists in certain geographical areas where there are issues of overrepresentation [ 22 ]. Thus, the oversupply of physicians in Germany leads to many challenges, including human resources management in the health care system.

In Germany a distinction is made between office-based physicians and hospital-based physicians. The income of office-based physicians is based on the number and types of services they provide, while hospital-based physicians are compensated on a salary basis. This division has created a separated workforce that German legislation is now working to eliminate by encouraging the two parties to work together, with the aim of reducing overall medical costs [ 22 ].

Developing countries

Accessing good-quality health care services can be incredibly arduous for those living in developing countries, and more specifically, for those residing in rural areas. For many reasons, medical personnel and resources may not be available or accessible for such residents. As well, the issue of migrant health care workers is critical. Migrant health workers can be defined as professionals who have a desire and the ability to leave the country in which they were educated and migrate to another country. The workers are generally enticed to leave their birth country by generous incentive offers from the recruiting countries [ 29 ].

Developing countries struggle to find means to improve living conditions for their residents; countries such as Ghana, Kenya, South Africa and Zimbabwe are seeking human resources solutions to address their lack of medically trained professionals. Shortages in these countries are prevalent due to the migration of their highly educated and medically trained personnel.

Professionals tend to migrate to areas where they believe their work will be more thoroughly rewarded. The International Journal for Equity in Health (2003) suggested that those who work in the health care profession tend to migrate to areas that are more densely populated and where their services may be better compensated. Health care professionals look to areas that will provide their families with an abundance of amenities, including schools for their children, safe neighborhoods and relatives in close proximity. For medical professionals, the appeal of promotions also serves as an incentive for educating oneself further [ 30 ]. As one becomes more educated, the ability and opportunity to migrate increases and this can lead to a further exodus of needed health care professionals.

These compelling reasons tend to cause medical professionals to leave their less-affluent and less-developed areas and migrate to areas that can provide them with better opportunities. This has caused a surplus in some areas and a huge deficit in others. This epidemic can be seen in nations such as Nicaragua. Its capital city, Managua, holds only one fifth of the country's population, yet it employs almost 50% of the medically trained health care workers. The same situation can be found in other countries, such as Bangladesh, where almost one third of the available health personnel are employed "in four metropolitan districts where less than 15% of the population lives" [ 30 ]. Clearly this presents a problem for those living outside these metropolitan districts.

Other possible explanations put forth by Dussault and Franceschini, both of the Human Development Division of the World Bank Institute, include "management style, incentive and career structures, salary scales, recruitment, posting and retention practices" [ 31 ]. Salary scales can differ quite drastically between originating and destination countries, which are shown in Figures 4 and 5 . They also state that in developing countries the earning potential one would see in more affluent or populated urban areas is much higher than one would expect to earn in rural areas.

Ratio of nurse wages (PPP USD), destination country to source country . Source: Vujicic M, Zurn P, Diallo K, Orvill A, Dal Poz MR 2004. http://www.human-resources-health.com/content/2/1/3 . Figure 4 shows the difference between the wage in the source country and destination country for nurses. This difference is also known as the "wage premium" [29].

Ratio of physician wages (PPP USD), destination country to source country . Source: Vujicic M, Zurn P, Diallo K, Orvill A, Dal Poz MR 2004. http://www.human-resources-health.com/content/2/1/3 . Figure 5 shows the difference between the wage in the source country and destination country for physicians [29].

As more health professionals emigrate to urban areas, the workloads for those in the rural areas greatly increase. This leads to a domino effect, in that those in such dire situations look for areas where they may be able to find more satisfactory and less demanding working conditions [ 31 ]. Vujicic et al. (2004) summarizes numerous variables that influence the migration pattern and has created a formula to express their impact. It is possible to quantify the factors, and human resources professionals need to look at the costs and benefits of altering the factors so that the migration pattern is more favorable. This formula is expressed as the results shown in Table 1 , which shows the different reasons for one to migrate in terms of the popularity of a given reason.

There is a tendency for developed countries faced with decreasing numbers of nationally trained medical personnel to recruit already-trained individuals from other nations by enticing them with incentives. Zimbabwe has been particularly affected by this problem. In 2001, out of approximately 730 nursing graduates, more than one third (237) of them relocated to the United Kingdom [ 29 ]. This was a dramatic increase from 1997, when only 26 (approximately 6.2%) of the 422 nursing program graduates migrated to the United Kingdom [ 29 ]. This leads to the loss of skilled workers in developing countries and can be very damaging, since the education systems in developing countries are training individuals for occupations in the medical profession, yet are not able to retain them [ 29 ].

Countries that have the capacity to educate more people than necessary in order to meet their domestic demand have tried to counterbalance this problem by increasing their training quota. Vujicic et al. (2004) identify that "the Philippines has for many years trained more nurses than are required to replenish the domestic stock, in an effort to encourage migration and increase the level of remittance flowing back into the country" [ 29 ].

Developed countries attract internationally trained medical professionals for many reasons. To begin with, "political factors, concerns for security, domestic birth rates, the state of the economy and war (both at home and abroad)" [ 26 ] influence the number of people that will be allowed or recruited into a country. Also, due to the conditions of the labor market compared to the demand in developed countries, governments may make allowances to their strict policies regarding the type of and number of professionals they will allow into their country [ 29 ]. This can be seen in a Canadian example:

Canada maintains] a list of occupations within which employment vacancies [are] evident. Potential immigrants working in one of these [listed] occupations would have a much higher chance of being granted entry than if they worked in a non-listed occupation [ 29 ].

Though Canada attracts internationally trained medical professionals, those employment vacancies may not always be open. Although there may be up to 10 000 international medical graduates (IMG) in Canada, many are not legally allowed to practice. Many immigrants cannot afford the costs of retraining and may be forced to find a new job in a completely unrelated field, leaving their skills to go to waste [ 32 ]. In 2004, Ontario had between 2000 and 4000 IMGs looking for work in medical fields related to their training and background [ 33 ]. That year, IMG Ontario accepted 165 IMGs into assessment and training positions, which was a 50% increase over the last year, and a 600% increase from the 24 positions in 1999 [ 33 ].

Another appeal for developed countries with regard to foreign trained health care professionals is that they may be less of a financial burden to the host country than those trained domestically. This is because educational costs and the resources necessary for training are already taken care of by the international medical schools and governments [ 29 ]. Though these reasons may make recruiting foreign medical professionals seem appealing, there are still ongoing debates as to whether those trained outside the host country are equally qualified and culturally sensitive to the country to which they migrate. Developing countries are addressing these concerns by establishing health professional training programs similar to those in developed countries [ 29 ]. These practices can be seen in, "the majority of nursing programs in Bangladesh, the Philippines and South Africa [which] are based on curricula from United Kingdom or USA nursing schools" [ 29 ]. Because of these actions, those who are trained may be more likely to leave and use their skills where they will be recognized and more highly rewarded.

There are also ethical considerations when examining the practice of recruiting health care professionals, particularly if they are recruited from regions or countries where health care shortages already exist. The rights of individuals to move as they see fit may need to be balanced against the idea of the greater good of those left behind.

Due to the shortages, it has been found the level of health service in rural or poor areas has decreased, leading to lower quality and productivity of health services, closure of hospital wards, increased waiting times, reduced numbers of available beds for inpatients, diversion of emergency department patients and underuse of remaining personnel or substitution with persons lacking the required skills for performing critical interventions [ 30 ].

The article "Not enough here, too many there: understanding geographical imbalances in the distribution of the health workforce" (2003), states that a reduced number of health care workers in a given area has a direct effect on the life expectancy of its residents. For example, in the rural areas of Mexico, life expectancy is 55 years, compared to 71 years in the urban areas. Additionally, in "the wealthier, northern part of the country, infant mortality is 20/1000 as compared to more than 50/1000 in the poorer southern states" [ 31 ].

Globalization – a common thread

While the issues raised in this article are common to many countries, the approaches taken to address them may not be the same in each country. Factors affecting the approaches that can be taken, some of which have been raised, include demographics, resources and philosophical and political perspectives. However, an overarching issue that affects not only health care but many other areas is that of globalization itself.

Different countries have traditionally had different perspectives on health care that have influenced their approaches to health care delivery. In Canada for example, health care is considered a right; its delivery is defined by the five main principles of the Canada Health Act, which officially precludes a significant role for private delivery of essential services. In the United States, health care is treated more as another service that, while it should be accessible, is not considered a right. Therefore there is a much larger private presence in health care delivery the United States than there is in Canada. In other parts of the world, the approach to health care falls between these perspectives.

As the move towards globalization for many goods and services increases, countries will have to consider how this will affect their approaches to health care delivery. As mentioned earlier, there is already a degree of labor mobility within a country that affects the quality and availability of health care services. There is also already a degree of international mobility of health care workers, as shown by the number of workers recruited developed countries.

While the international mobility of labor is generally not as unencumbered as that for goods and capital, that may be changing as more and more regional free trade agreements are considered. Canada, the United States and Mexico have NAFTA (North American Free Trade Agreement), Europe has the EU (European Union) and talks are under way to consider expanding the NAFTA agreement to include Central and South America, to expand EU membership and to consider an Asian trading bloc including China and India.

If health care becomes a part of these new trade agreements, countries will be obliged to treat health care delivery according to the rules of the agreement. Using the NAFTA as an example, if health care is included, governments could not treat domestic providers more favorably than foreign firms wanting to deliver services. In Canada the concern is that it would mean the end of the Canada Health Act, since NAFTA would allow private, for-profit American or Mexican firms to open.

All five issues raised in this research would be affected by the increase in international trade agreements that included health care. Therefore, governments, health care providers and human resources professionals cannot ignore this important consideration and trend when examining solutions to the issues. Depending upon their relative negotiation strengths and positions, some countries may not benefit as much as others with these agreements.

For example, it is more likely that countries with well-developed private, for-profit, health care expertise, such as the United States, would expand into developing countries rather than the other way around. If there is an increased ability for labor mobility, then it is likely that health care professionals in the poorer, developing countries would move to where the opportunities are better. We already see this internally in the move from rural to urban centers; this would likely continue if the health care professionals had the opportunity to move out of country to where they could have greater financial rewards for their expertise.

When considering the countries examined in this paper, it is likely that Canada and the United States would initially be the two most likely to move towards a more integrated approach to health care delivery. There is already a trade agreement in place, many of the factors influencing health care are similar (demographics, training, level of economic development, geography, cultural factors) and they are currently each other's largest trading partners. While the current agreement, which includes Mexico, does not cover health care, there is pressure to broaden the agreement to include areas not currently covered. If this happens, human resources professionals will have to increase their understanding of what the new health care delivery realities could be. For example, if the move is more towards the Canadian example of a largely not-for-profit, mainly publicly-funded health care delivery system, then it will be more of an adjustment for the American professionals.

However, the likelihood of the Canadian approach to health care's being adopted in the United States is very slim. During the presidency of Bill Clinton, the government attempted to introduce a more universal health care delivery system, which failed completely. Even though there are over 40 million Americans with no health care coverage, the idea of a universal, publicly-funded system went nowhere. Also, within Canada there is increasing pressure to consider a more active role for private health care delivery. Therefore, it is more likely that Canadian health care and human resource professionals will have to adapt to a style more like the American, privately delivered, for-profit approach.

If this is the direction of change, human resources professionals in Canada will need to adjust how they approach the challenges and new realities. For instance, there would likely be an increased role for insurance companies and health maintenance organizations (HMO) as they move towards the managed care model of the United States. With an HMO approach, financial as well as health needs of the patients are considered when making medical decisions. An insured patient would select from the range of services and providers that his/her policy covers and approves. Human resources professionals would need to work with a new level of administration, the HMO, which currently does not exist to any significant degree in Canada.

As mentioned earlier, it is likely that developing countries would be receiving health care models and approaches from developed countries rather than the other way around. In particular, a country such as the United States that has a strong, private, for-profit approach already in place would likely be the source from which the health care models would be drawn. Therefore, health care, as well as human resources professionals in those countries, would also need to adapt to these new realities.

In Germany, where there is currently an oversupply of physicians, a move towards a more global approach to health care delivery, through increased trade agreements, could result in even more German health care professionals' leaving the country. The challenge to be addressed by human resource professionals within the German health care system in this situation would be to prevent, or slow, the loss of the best professionals to other countries. Spending public resources in educating professionals only to have significant numbers of them leave the country is not a financially desirable or sustainable situation for a country.

While examining health care systems in various countries, we have found significant differences pertaining to human resources management and health care practices. It is evident that in Canada, CHA legislation influences human resources management within the health care sector. Furthermore, the result of the debate on Canada's one-tier versus two-tier system may have drastic impacts on the management of human resources in health care. Additionally, due to a lack of Canadian trained health professionals, we have found that Canada and the United States have a tendency to recruit from developing countries such as South Africa and Ghana, in order to meet demand.

Examination of the relationship between health care in the United States and human resources management reveals three major problems: rapidly escalating health care costs, a growing number of Americans without health care coverage and an epidemic regarding the standard of care. These problems each have significant consequences for the well-being of individual Americans and will have devastating affects on the physical and psychological health and well-being of the nation as a whole.

The physical health of many Americans is compromised because these factors make it difficult for individuals to receive proper consultation and treatment from physicians. This can have detrimental effects on the mental state of the patient and can lead to large amounts of undue stress, which may further aggravate the physical situation.

Examining case studies makes it evident that human resources management can and does play an essential role in the health care system. The practices, policies and philosophies of human resources professionals are imperative in developing and improving American health care. The implication is that further research and studies must be conducted in order to determine additional resource practices that can be beneficial to all organizations and patients.

Compared to the United States, Canada and developing countries, Germany is in a special situation, given its surplus of trained physicians. Due to this surplus, the nation has found itself with a high unemployment rate in the physician population group. This is a human resources issue that can be resolved through legislation. Through imposing greater restrictive admissions criteria for medical schools in Germany, they can reduce the number of physicians trained. Accompanying the surplus problem is the legislative restriction limiting the number of specialists allowed to practice in geographical areas. These are two issues that are pushing German-trained physicians out of the country and thus not allowing the country to take full advantage of its national investment in training these professionals.

Developing countries also face the problem of investing in the training of health care professionals, thus using precious national resources, but losing many of their trained professionals to other areas of the world that are able to provide them with more opportunities and benefits. Human resources professionals face the task of attempting to find and/or retain workers in areas that are most severely affected by the loss of valuable workers.

Human resources management plays a significant role in the distribution of health care workers. With those in more developed countries offering amenities otherwise unavailable, chances are that professionals will be more enticed to relocate, thus increasing shortages in all areas of health care. Due to an increase in globalization, resources are now being shared more than ever, though not always distributed equally.

Human resources implications of the factors

While collectively the five main areas addressed in the article represent health care issues affecting and affected by human resources practices, they are not all equal in terms of their influence in each country. For instance, in Canada there are fewer health care issues surrounding the level of economic development or migration of health workers, whereas these issues are much more significant in developing countries. In the United States, the level of economic development is not a significant issue, but the accessibility of health care based upon an individual's financial situation certainly is, as evidenced by the more than 40 million Americans who have no health care coverage. Germany's issues with the size of its health care worker base have to do with too many physicians, whereas in Canada one of the issues is having too few physicians. Table 2 summarizes some of the implications for health care professionals with regard to the five main issues raised in the article. One of the main implications of this paper, as shown in Table 2 , is that HRP will have a vital role in addressing all the factors identified. Solutions to health care issues are not just medical in nature.

Policy approaches in a global approach to health care delivery

As mentioned at the start of this paper, there are three main health system inputs: human resources, physical capital and consumables. Given that with sufficient resources any country can obtain the same physical capital and consumables, it is clear that the main differentiating input is the human resources. This is the input that is the most difficult to develop, manage, motivate, maintain and retain, and this is why the role of the human resources professional is so critical.

The case studies described earlier showed how human resources initiatives aimed at improving organizational culture had a significant and positive effect on the efficiency and effectiveness of the hospitals studied. Ultimately all health care is delivered by people, so health care management can really be considered people management; this is where human resources professionals must make a positive contribution.

Human resource professionals understand the importance of developing a culture that can enable an organization to meet its challenges. They understand how communities of practice can form around common goals and interests, and the importance of aligning these to the goals and interests of the organization.

Given the significant changes that globalization of health care can introduce, it is important that human resources professionals be involved at the highest level of strategic planning, and not merely be positioned at the more functional, managerial levels. By being actively involved at the strategic levels, they can ensure that the HR issues are raised, considered and properly addressed.

Therefore, human resources professionals will also need to have an understanding not only of the HR area, but of all areas of an organization, including strategy, finance, operations, etc. This need will have an impact on the educational preparation as well as the possible need to have work experience in these other functional areas.

We have found that the relationship between human resources management and health care is extremely complex, particularly when examined from a global perspective. Our research and analysis have indicated that several key questions must be addressed and that human resources management can and must play an essential role in health care sector reform.

The various functions of human resources management in health care systems of Canada, the United States of America, Germany and various developing countries have been briefly examined. The goals and motivations of the main stakeholders in the Canadian health care system, including provincial governments, the federal government, physicians, nurses and allied health care professionals, have been reviewed. The possibility of a major change in the structure of Canadian health care was also explored, specifically with regard to the creation of a two-tier system. The American health care system is currently challenged by several issues; various American case studies were examined that displayed the role of human resources management in a practical setting. In Germany, the health care situation also has issues due to a surplus of physicians; some of the human resources implications of this issue were addressed. In developing countries, the migration of health workers to more affluent regions and/or countries is a major problem, resulting in citizens in rural areas of developing countries experiencing difficulties receiving adequate medical care.

Since all health care is ultimately delivered by and to people, a strong understanding of the human resources management issues is required to ensure the success of any health care program. Further human resources initiatives are required in many health care systems, and more extensive research must be conducted to bring about new human resources policies and practices that will benefit individuals around the world.

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The authors are grateful to Valerie Sloby from PCHealthcare for her editorial assistance and helping in reviewing the manuscript.

Management and Organizational Studies, The University of Western Ontario, London, Ontario, Canada

Stefane M Kabene, Mark A Soriano & Raymond Leduc

Schulich School of Medicine, The University of Western Ontario, London, Ontario, Canada

John M Howard

School of Nursing, The University of Western Ontario, London, Ontario, Canada

Stefane M Kabene & Carole Orchard

Correspondence to Stefane M Kabene .

Competing interests.

The author(s) declare that they have no competing interests.

Authors' contributions

SK conceived the paper, worked on research design, did data analysis and led the writing of the paper. CO, JH, MS and RL all actively participated in data analysis, manuscript writing and review. All authors read and approved the final manuscript.

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This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Kabene, S.M., Orchard, C., Howard, J.M. et al. The importance of human resources management in health care: a global context. Hum Resour Health 4 , 20 (2006). https://doi.org/10.1186/1478-4491-4-20

Received : 13 April 2006

Accepted : 27 July 2006

Published : 27 July 2006

DOI : https://doi.org/10.1186/1478-4491-4-20

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5 Critical Priorities for the U.S. Health Care System

by Marc Harrison

Summary .   

The pandemic has starkly revealed the many shortcomings of the U.S. health care system — as well as the changes that must be implemented to make care more affordable, improve access, and do a better job of keeping people healthy. In this article, the CEO of Intermountain Healthcare describes five priorities to fix the system. They include: focus on prevention, not just treating sickness; tackle racial disparities; expand telehealth and in-home services; build integrated systems; and adopt value-based care.

Since early 2020, the dominating presence of the Covid-19 pandemic has redefined the future of health care in America. It has revealed five crucial priorities that together can make U.S. health care accessible, more affordable, and focused on keeping people healthy rather than simply treating them when they are sick.

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Confronting Challenges in the US Health Care System : Potential Opportunity in a Time of Crisis

• 1 Deputy Editor, JAMA Health Forum
• 2 Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
• Editorial The Near-Term Future of Health Care Reform Ezekiel J. Emanuel, MD, PhD JAMA
• Editorial Crucial Questions for US Health Policy in the Next Decade John Z. Ayanian, MD, MPP JAMA

The sheer number of challenges facing the Biden Administration and the 117th Congress in the health policy sphere is staggering, as is the range of potential solutions offered by the authors of the Viewpoints in the JAMA Health Policy series. 1 The most pressing challenges involve addressing the global COVID-19 pandemic. Yet policy makers would be remiss if they did not leverage this opportunity to also address the fundamental problems with the US health system laid bare by the nation’s response to the pandemic. These include major challenges related to health insurance coverage, the solvency of publicly funded programs, the stability of the health care safety net, market power and consolidation, inequities in health care access and outcomes, public health infrastructure, and the failure to effectively use technology to help counteract these problems.

Personal health crises, such as experiencing a myocardial infarction, can spur patients and their care teams to work to improve underlying health habits and conditions that contributed to the health event. Similarly, the havoc wrought by the COVID-19 pandemic is a clarion call to improve US health care coverage, financing, and organization. The status quo practices of the health system in the US—like poor health habits of a patient with heart disease—have left it susceptible to poor outcomes.

The high cost of the US health care system is its biggest weakness. In the US, national expenditures on health care goods and services were approximately $4 trillion in 2020, accounting for an estimated 18% of gross domestic product. 2 High prices for care explain a large part of the difference in spending between the US and other developed countries. Surprise billing is just one aspect of the pricing problem, but one that, as Colla 3 describes, illustrates many troubling trends in medicine. Consolidation of hospitals, insurers, and large and small practices has accelerated during the pandemic and as Dafny 4 explains, can be expected to lead to higher prices in the commercial market in the future. Chernew 5 elegantly discusses how market power and consolidation in the health care industry, exacerbated by the pandemic, could lead to still higher prices and a cycle of harms for individuals, governments, and society as a whole.

Those harms include incomplete insurance coverage, both in terms of numbers of people covered and the generosity of that coverage, due to high prices that lead to high insurance premiums. Higher premiums have meant that many people who are not eligible for subsidies on the health insurance exchanges find insurance unaffordable. The Biden campaign proposals to extend subsidies to higher income groups are designed to help solve this problem but will not address its root causes. High premiums have also contributed to wage stagnation for US workers with employment-based health insurance and to higher cost-sharing, which has been shown to reduce access to necessary care.

In addition, higher health care costs put pressure on state and federal budgets. As Gee et 6 al discuss, 12 states have not chosen to expand Medicaid to date, and a concern that even being responsible for 10% of the increased costs could be burdensome is one of the reasons cited for this choice. Frank and Neuman 7 emphasize that the looming deficits in the Medicare Part A Trust Fund will also put pressure on federal policy makers to find sources of new revenues or to cut benefits or payment rates. Perhaps even more important, as described by Venkataramani and colleagues, 8 high health care prices contribute to limited budgets for other social goods like education and housing that could improve health outcomes, possibly even more than direct spending on health care.

Similarly, it is now clear that the US has spent an increasing amount of resources on health care, but spending on public health has been inadequate. Investments in surveillance officers and systems and in stockpiles of equipment and medications are less appealing ways to spend public resources than covering new drugs or services. The pandemic has revealed the shortcomings of the US public health infrastructure and illustrates that neglecting to reinvest in public health after a pandemic will more severely compromise the ability to respond effectively to the next public health crisis. 9 Although none of the Viewpoints in this series focused on specific public health proposals, they should be part of every discussion of improving health and health care going forward. Public health policy must be central not only to health policy, but to economic policy and national security policy as well.

High health care prices might be less of a problem if the US health care system was uniformly delivering high-quality care and yielding high value. The US does prioritize health as a society and voters are reluctant to endorse solutions that limit access to the latest innovations in health care. However, a fundamental shortcoming in the US health care system is the tendency to create and perpetuate incentives to deliver higher-margin treatments and specialty care instead of primary care, preventive care, and public health. The central need to refine the focus on value was highlighted in many articles in the series.

Several Viewpoints in the Health Policy series provided worthy suggestions and policy recommendations the could help the US health care system recover from the current crises stronger. Berwick and Gilfillan 10 call for speeding the cycle time of demonstrations under the Center for Medicare and Medicaid Innovation, Dafny 4 suggests examining mergers and acquisitions more closely, and Chernew 5 proposes implementing “backstop” prices in commercial markets.

Another important step will be using data and technology strategically. During the pandemic, the health care system rapidly adopted telemedicine in clinical care. Millions of people accessed readily available data dashboards that illustrated the course of the pandemic and the extent of infections in specific areas, and many used the information to demand better and more equal care. As described by Adler-Milstein, 11 a digital transformation in the US health care system could make it possible to continuously monitor and use real-time data to inform preparedness and population-level care planning. Such data systems also could be used to help address and reduce disparities and inequities in care and to improve health system transparency, including around prices. Moreover, these systems could save money and reduce the reporting and patient tracking burdens on health care centers, physicians, and other clinicians participating in value-based care; administrative costs are estimated by Kocher et al 12 at $2500 per person per year.

Can commitments to improving health care coverage, financing, and organization be made in the midst of a pandemic and an affordability crisis? There are reasons to hope the answer is yes. The pandemic has substantially changed care patterns, shown the risks of fee-for-service payment and a reliance on highly reimbursed surgical procedures, and revealed the need for a stronger public health infrastructure and greater preparedness. Health systems will be increasingly held accountable for ensuring delivery of high-value care and for addressing health equity issues in ways that do not rely on outdated models of care. No one could have imagined or would wish the current economic, societal, or health care challenges of the COVID-19 pandemic on a new administration or Congress. But all have hope that leaders can confront these crises as potential opportunities for developing solutions to address the ongoing major challenges in the US health care system.

Correction: This article was updated on June 7, 2021, to correct the spelling of Dr Venkataramani’s name in the fifth paragraph.

Corresponding Author: Melinda B. Buntin, PhD, Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Ave, Ste 1200, Nashville, TN 37203 ( [email protected] ).

Conflict of Interest Disclosures: Dr Buntin reported being an unpaid board member of the Harvard Medical Faculty Practice in Boston, Massachusetts.

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Buntin MB. Confronting Challenges in the US Health Care System : Potential Opportunity in a Time of Crisis . JAMA. 2021;325(14):1399–1400. doi:10.1001/jama.2021.1471

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The role of data science in healthcare advancements: applications, benefits, and future prospects

Sri venkat gunturi subrahmanya.

1 Department of Electrical and Electronics Engineering, Manipal Institute of Technology, Manipal Academy of Higher Education, Manipal, Karnataka India

Dasharathraj K. Shetty

2 Department of Humanities and Management, Manipal Institute of Technology, Manipal Academy of Higher Education, Manipal, Karnataka India

Vathsala Patil

3 Department of Oral Medicine and Radiology, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal Karnataka, India

B. M. Zeeshan Hameed

4 Department of Urology, Father Muller Medical College, Mangalore, Karnataka India

5 Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA USA

Komal Smriti

Nithesh naik.

6 Department of Mechanical and Manufacturing Engineering, Manipal Institute of Technology, Manipal Academy of Higher Education, Manipal, Karnataka India

Bhaskar K. Somani

7 Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK

Data science is an interdisciplinary field that extracts knowledge and insights from many structural and unstructured data, using scientific methods, data mining techniques, machine-learning algorithms, and big data. The healthcare industry generates large datasets of useful information on patient demography, treatment plans, results of medical examinations, insurance, etc. The data collected from the Internet of Things (IoT) devices attract the attention of data scientists. Data science provides aid to process, manage, analyze, and assimilate the large quantities of fragmented, structured, and unstructured data created by healthcare systems. This data requires effective management and analysis to acquire factual results. The process of data cleansing, data mining, data preparation, and data analysis used in healthcare applications is reviewed and discussed in the article. The article provides an insight into the status and prospects of big data analytics in healthcare, highlights the advantages, describes the frameworks and techniques used, briefs about the challenges faced currently, and discusses viable solutions. Data science and big data analytics can provide practical insights and aid in the decision-making of strategic decisions concerning the health system. It helps build a comprehensive view of patients, consumers, and clinicians. Data-driven decision-making opens up new possibilities to boost healthcare quality.

Introduction

The evolution in the digital era has led to the confluence of healthcare and technology resulting in the emergence of newer data-related applications [ 1 ]. Due to the voluminous amounts of clinical data generated from the health care sector like the Electronic Health Records (EHR) of patients, prescriptions, clinical reports, information about the purchase of medicines, medical insurance-related data, investigations, and laboratory reports, there lies an immense opportunity to analyze and study these using recent technologies [ 2 ]. The huge volume of data can be pooled together and analyzed effectively using machine-learning algorithms. Analyzing the details and understanding the patterns in the data can help in better decision-making resulting in a better quality of patient care. It can aid to understand the trends to improvise the outcome of medical care, life expectancy, early detection, and identification of disease at an initial stage and required treatment at an affordable cost [ 3 ]. Health Information Exchange (HIE) can be implemented which will help in extracting clinical information across various distinct repositories and merge it into a single person’s health record allowing all care providers to access it securely. Hence, the organizations associated with healthcare must attempt to procure all the available tools and infrastructure to make use of the big data, which can augment the revenue and profits and can establish better healthcare networks, and stand apart to reap significant benefits [ 4 , 5 ]. Data mining techniques can create a shift from conventional medical databases to a knowledge-rich, evidence-based healthcare environment in the coming decade.

Big data and its utility in healthcare and medical sciences have become more critical with the dawn of the social media era (platforms such as Facebook and Twitter) and smartphone apps that can monitor personal health parameters using sensors and analyzers [ 6 , 7 ]. The role of data mining is to improvise the stored user information to provide superior treatment and care. This review article provides an insight into the advantages and methodologies of big data usage in health care systems. It highlights the voluminous data generated in these systems, their qualities, possible security-related problems, data handling, and how this analytics support gaining significant insight into these data set.

Search strategy

A non-systematic review of all data science, big data in healthcare-related English language literature published in the last decade (2010–2020) was conducted in November 2020 using MEDLINE, Scopus, EMBASE, and Google Scholar. Our search strategy involved creating a search string based on a combination of keywords. They were: “Big Data,” “Big Data Analytics,” “Healthcare,” “Artificial Intelligence,” “AI,” “Machine learning,” “ML,” “ANN,” “Convolutional Networks,” “Electronic Health Records,” “EHR,” “EMR,” “Bioinformatics,” and “Data Science.” We included original articles published in English.

Inclusion criteria

• Articles on big data analytics, data science, and AI.
• Full-text original articles on all aspects of application of data science in medical sciences.

Exclusion criteria

• Commentaries, reviews, and articles with no full-text context and book chapters.
• Animal, laboratory, or cadaveric studies.

The literature review was performed as per the above-mentioned strategy. The evaluation of titles and abstracts, screening, and the full article text was conducted for the chosen articles that satisfied the inclusion criteria. Furthermore, the authors manually reviewed the selected article’s references list to screen for any additional work of interest. The authors resolved the disagreements about eligibility for a consensus decision after discussion.

Knowing more about “big data”

Big data consists of vast volumes of data, which cannot be managed using conventional technologies. Although there are many ways to define big data, we can consider the one defined by Douglas Laney [ 8 ] that represents three dimensions, namely, volume, velocity, and variety (3 Vs). The “big” in big data implies its large volume. Velocity demonstrates the speed or rate at which data is processed. Variety focuses on the various forms of structured and raw data obtained by any method or device, such as transaction-level data, videos, audios, texts, emails, and logs. The 3 Vs became the default description of big data, while many other Vs are added to the definition [ 9 ]. “Veracity” remains the most agreed 4th “V.” Data veracity focuses on the accuracy and reliability of a dataset. It helps to filter through what is important and what is not. The data with high veracity has many records that are valuable to analyze and that contribute in a meaningful way to the overall results. This aspect poses the biggest challenge when it comes to big data. With so much data available, ensuring that it is relevant and of high quality is important. Over recent years, big data has become increasingly popular across all parts of the globe.

Big data needs technologically sophisticated applications that use high-end computing resources and Artificial Intelligence (AI)-based algorithms to understand such huge volumes of data. Machine learning (ML) approaches for automatic decision-making by applying fuzzy logic and neural networks will be added advantage. Innovative and efficient strategies for dealing with data, smart cloud-based applications, effective storage, and user-friendly visualization are required for big data to gain practical insights [ 10 ].

Medical care as a repository for big data

Healthcare is a multilayered system developed specifically for preventing, diagnosing, and treating diseases. The key elements of medical care are health practitioners (physicians and nurses), healthcare facilities (which include clinics, drug delivery centers, and other testing or treatment technologies), and a funding agency that funds the former. Health care practitioners belong to different fields of health such as dentistry, pharmacy, medicine, nursing, psychology, allied health sciences, and many more. Depending on the severity of the cases, health care is provided at many levels. In all these stages, health practitioners need different forms of information such as the medical history of the patient (data related to medication and prescriptions), clinical data (such as data from laboratory assessments), and other personal or private medical data. The usual practice for a clinic, hospital, or patient to retain these medical documents would be maintaining either written notes or in the form of printed reports [ 11 ].

The clinical case records preserve the incidence and outcome of disease in a person’s body as a tale in the family, and the doctor plays an integral role in this tale [ 12 ]. With the emergence of electronic systems and their capacity, digitizing medical exams, health records, and investigations is a common procedure today. In 2003, the Institute of Medicine, a division in the National Academies of Sciences and Engineering coined the term “Electronic Health Records” for representing an electronic portal that saves the records of the patients. Electronic health records (EHRs) are automated medical records of patients related to an individual’s physical/mental health or significant reports that are saved in an electronic system and used to record, send, receive, store, retrieve, and connect the medical personnel and patient with medical services [ 13 ].

Open-source big data platforms

It is an inefficient idea to work with big data or vast volumes of data into storage considering even the most powerful computers. Hence, the only logical approach to process large quantities of big data available in a complex form is by spreading and processing it on several parallel connected nodes. Nevertheless, the volume of the data is typically so high that a large number of computing machines are needed in a reasonable period to distribute and finish processing. Working with thousands of nodes involves coping with issues related to paralleling the computation, spreading of data, and manage failures. Table ​ Table1 1 shows the few open sources of big data platforms and their utilities for data scientists.

source big data platforms and their utilities

Data mining

Data types can be classified based on their nature, source, and data collection methods [ 14 ]. Data mining techniques include data grouping, data clustering, data correlation, and mining of sequential patterns, regression, and data storage. There are several sources to obtain healthcare-related data (Fig.  1 ). The most commonly used type (77%) is the data generated by humans (HG data) which includes Electronic Medical Records (EMR), Electronic Health Records (EHR), and Electronic Patient Records (EPR). Online data through Web Service (WS) is considered as the second largest form of data (11%) due to the increase in the number of people using social media day by day and current digital development in the medical sector [ 15 ]. Recent advances in the Natural Language Processing (NLP)-based methodologies are also making WS simpler to use [ 16 ]. The other data forms such as Sensor Data (SD), Big Transactional Data (BTD), and Biometric Data (BM) make around 12% of overall data use, but wearable personal health monitoring devices’ prominence and market growth [ 17 ] may need SD and BM data.

Sources of big data in healthcare

Applications of analytics in healthcare

There are six areas of applications of analytics in healthcare (Fig.  2 ) including disease surveillance, health care management and administration, privacy protection and fraud detection, mental health, public health, and pharmacovigilance. Researchers have implemented data extraction for data deposition and cloud-based computing, optimizing quality, lowering costs, leveraging resources, handling patients, and other fields.

Various applications of data science in healthcare

Disease surveillance

It involves the perception of the disease, understanding its condition, etiology (the manner of causation of a disease), and prevention (Fig.  3 ).

The disease analysis system

Information obtained with the help of EHRs, and the Internet has a huge prospect for disease analysis. The various surveillance methods would aid the planning of services, evaluation of treatments, priority setting, and the development of health policy and practice.

Image processing of healthcare data from the big data point of view

Image processing on healthcare data offers valuable knowledge about anatomy and organ functioning and identifies the disease and patient health conditions. The technique currently has been used for organ delineation, identification of lung tumors, diagnosis of spinal deformity, detection of arterial stenosis, detection of an aneurysm, etc. [ 18 ]. The wavelets technique is commonly used for image processing techniques such as segmentation, enhancement, and noise reduction. The use of artificial intelligence in image processing will enhance aspects of health care including screening, diagnosis, and prognosis, and integrating medical images with other types of data and genomic data will increase accuracy and facilitate early diagnosis of diseases [ 18 , 19 ]. The exponential increase in the count of medical facilities and patients has led to better use of clinical settings of computer-based healthcare diagnostics and decision-making systems.

Data from wearable technology

Multi-National Companies like Apple and Google are working on health-based apps and wearable technology as part of a broader range of electronic sensors, the so-called IoT, and toolkits for healthcare-related apps. The possibility of collecting accurate medical data on real-time (e.g., mood, diet followed, exercise, and sleep cycles patterns), linked to physiological indicators (e.g., heart rate, calories burned, level of blood glucose, cortisol levels), is perhaps discrete and omnipresent at minimum cost, unrelated to traditional health care. “True Colors” is a wearable designed to collect continuous patient-centric data with the accessibility and acceptability needed to allow for accurate longitudinal follow-up. More importantly, this system is presently being piloted as a daily health-monitoring substitute.

Medical signal analytics

Telemetry and the devices for the monitoring of physiological parameters generate large amounts of data. The data generated generally are retained for a shorter duration, and thus, extensive research into produced data is neglected. However, advancements in data science in the field of healthcare attempt to ensure better management of data and provide enhanced patient care [ 20 – 23 ].

The use of continuous waveform in health records containing information generated through the application of statistical disciplines (e.g., statistical, quantitative, contextual, cognitive, predictive, etc.) can drive comprehensive care decision-making. Data acquisition apart from an ingestion-streaming platform is needed that can control a set of waveforms at various fidelity rates. The integration of this waveform data with the EHR’s static data results in an important component for giving analytics engine situational as well as contextual awareness. Enhancing the data collected by analytics will not just make the method more reliable, but will also help in balancing predictive analytics’ sensitivity and specificity. The signal processing species must mainly rely on the kind of disease population under observation.

Various signal-processing techniques can be used to derive a large number of target properties that are later consumed to provide actionable insight by a pre-trained machine-learning model. Such observations may be analytical, prescriptive, or predictive. Such insights can be furthermore built to activate other techniques such as alarms and physician notifications. Maintaining these continuous waveforms–based data along with specific data obtained from the remaining sources in perfect harmony to find the appropriate patient information to improve diagnosis and treatments of the next generation can be a daunting task [ 24 ]. Several technological criteria and specifications at the framework, analytical, and clinical levels need to be planned and implemented for the bedside implementation of these systems into medical setups.

Healthcare administration

Knowledge obtained from big data analysis gives healthcare providers insights not available otherwise (Fig.  4 ). Researchers have implemented data mining techniques to data warehousing as well as cloud computing, increasing quality, minimizing costs, handling patients, and several other fields of healthcare.

Role of big data in accelerating the treatment process

Data storage and cloud computing

Data warehousing and cloud storage are primarily used for storing the increasing amount of electronic patient-centric data [ 25 , 26 ] safely and cost-effectively to enhance medical outcomes. Besides medical purposes, data storage is utilized for purposes of research, training, education, and quality control. Users can also extract files from a repository containing the radiology results by using keywords following the predefined patient privacy policy.

Cost and quality of healthcare and utilization of resources

The migration of imaging reports to electronic medical recording systems offers tremendous potential for advancing research and practice on radiology through the continuous updating, incorporation, and exchange of a large volume of data. However, the heterogeneity in how these data can be formatted still poses major challenges. The overall objective of NLP is that the natural human language is translated into structured with a standardized set of value choices that are easily manipulated into subsections or searches for the presence or absence of a finding through software, among other things [ 27 ].

Greaves et al. [ 28 ] analyzed sentiment (computationally dividing them into categories such as optimistic, pessimistic, and neutral) based on the online response of patients stating their overall experience to predict healthcare quality. They found an agreement above 80% between online platform sentiment analysis and conventional paper-based quality prediction surveys (e.g., cleanliness, positive conduct, recommendation). The newer solution can be a cost-effective alternative to conventional healthcare surveys and studies. The physician’s overuse of screening and testing often leads to surplus data and excess costs [ 29 ]. The present practice in pathology is restricted by the emphasis on illness. Zhuang et al. [ 29 ] compared the disease-based approach in conjunction with database reasoning and used the data mining technique to build a decision support system based on evidence to minimize the unnecessary testing to reduce the total expense of patient care.

Patient data management

Patient data management involves effective scheduling and the delivery of patient care during the period of a patient’s stay in a hospital. The framework of patient-centric healthcare is shown in Fig.  5 . Daggy et al. [ 30 ] conducted a study on “no shows” or missing appointments that lead to the clinical capability that has been underused. A logistical regression model is developed using electronic medical records to estimate the probabilities of patients to no-show and show the use of estimates for creating clinical schedules that optimize clinical capacity use while retaining limited waiting times and clinical extra-time. The 400-day clinical call-in process was simulated, and two timetables were developed per day: the conventional method, which assigns one patient per appointment slot, and the proposed method, which schedules patients to balance patient waiting time, additional time, and income according to no-show likelihood.

Elemental structure of patient-centric healthcare and ecosystem

If patient no-show models are mixed with advanced programming approaches, more patients can be seen a day thus enhancing clinical performance. The advantages of implementation of planning software, including certain methodologies, should be considered by clinics as regards no-show costs [ 30 ].

A study conducted by Cubillas et al. [ 31 ] pointed out that it takes less time for patients who came for administrative purposes than for patients for health reasons. They also developed a statistical design for estimating the number of administrative visits. With a time saving of 21.73% (660,538 min), their model enhanced the scheduling system. Unlike administrative data/target finding patients, a few come very regularly for their medical treatment and cover a significant amount of medical workload. Koskela et al. [ 32 ] used both supervised and unsupervised learning strategies to identify and cluster records; the supervised strategy performed well in one cluster with 86% accuracy in distinguishing fare documents from the incorrect ones, whereas the unsupervised technique failed. This approach can be applied to the semi-automate EMR entry system [ 32 ].

Privacy of medical data and fraudulency detection

The anonymization of patient data, maintaining the privacy of the medical data and fraudulency detection in healthcare, is crucial. This demands efforts from data scientists to protect the big data from hackers. Mohammed et al. [ 33 ] introduced a unique anonymization algorithm that works for both distributed and centralized anonymization and discussed the problems of privacy security. For maintaining data usefulness without the loss of any data privacy, the researchers further proposed a model that performed far better than the traditional K-anonymization model. In addition to this, their algorithm could also deal with voluminous, multi-dimensional datasets.

A mobile-based cloud-computing framework [ 34 ] of big data has been introduced to overcome the shortcomings of today’s medical records systems. EHR data systems are constrained due to a lack of interoperability, size of data, and privacy. This unique cloud-based system proposed to store EHR data from multiple healthcare providers within the facility of an internet provider to provide authorized restricted access to healthcare providers and patients. They used algorithms for encryption, One Time Password (OTP), or a 2-factor authentication to ensure data security.

The analytics of the big data can be performed using Google’s efficient tools such as big query tools and MapReduce. This approach will reduce costs, improve efficiency, and provide data protection compared to conventional techniques that are used for anonymization. The conventional approach generally leaves data open to re-identification. Li et al. in a case study showed that hacking can make a connection between tiny chunks of information as well as recognize patients [ 35 ]. Fraud detection and abuse (i.e., suspicious care behavior, deliberate act of falsely representing facts, and unwanted repeated visits) make excellent use of big data analytics [ 36 ].

By using data from gynecology-based reports, Yang et al. framed a system that manually distinguishes characteristics of suspicious specimens from a set of medical care plans that any doctor would mostly adopt [ 37 ]. The technique was implemented on the data from Taiwan’s Bureau of National Health Insurance (BNHI), where the proposed technique managed to detect 69% of the total cases as fraudulent, enhancing the current model, which detected only 63% of fraudulent cases. To sum up, the protection of patient data and the detection of fraud are of significant concern due to the growing usage of social media technology and the propensity of people to place personal information on these platforms. The already existing strategies for anonymizing the data may become less successful if they are not implemented because a significant section of the personal details of everyone is now accessible through these platforms.

Mental health

According to National Survey conducted on Drug Use and Health (NSDUH), 52.2% of the total population in the United States (U.S.) was affected by either mental problems or drug addiction/abuse [ 38 ]. In addition, approximately 30 million suffer from panic attacks and anxiety disorders [ 39 ].

Panagiotakopoulos et al. [ 40 ] developed a data analysis–focused treatment technique to help doctors in managing patients with anxiety disorders. The authors used static information that includes personal information such as the age of the individual, sex, body and skin types, and family details and dynamic information like the context of stress, climate, and symptoms to construct static and dynamic information based on user models. For the first three services, relationships between different complex parameters were established, and the remaining one was mainly used to predict stress rates under various scenarios. This model was verified with the help of data collected from twenty-seven volunteers who are selected via the anxiety assessment survey. The applications of data analytics in the disease diagnosis, examination, or treatment of patients with mental wellbeing are very different from using analytics to anticipate cancer or diabetes. In this case, the data context (static, dynamic, or non-observable environment) seems to be more important compared to data volume [ 39 ].

The leading cause of perinatal morbidity and death is premature birth, but an exact mechanism is still unclear. The research carried by Chen et al. [ 41 ] intended to investigate the risk factors of preterm use of neural networks and decision tree C5.0 data mining. The original medical data was obtained by a specialist study group at the National University of Taiwan from a prospective pregnancy cohort. A total of 910 mother–child dyads from 14,551 in the original data have been recruited using the nest case–control design. In this data, thousands of variables are studied, including basic features, medical background, the climate and parents’ occupational factors, and the variables related to children. The findings suggest that the main risk factors for pre-born birth are multiple births, blood pressure during pregnancy, age, disease, prior preterm history, body weight and height of pregnant women, and paternal life risks associated with drinking and smoking. The results of the study are therefore helpful in the attempt to diagnose high-risk pregnant women and to provide intervention early to minimize and avoid early births in parents, healthcare workers, and public health workers [ 41 , 42 ].

Public health

Data analytics have also been applied to the detection of disease during outbreaks. Kostkova et al. [ 43 ] analyzed online records based on behavior patterns and media reporting the factors that affect the public as well as professional patterns of search-related disease outbreaks. They found distinct factors affecting the public health agencies’ skilled and layperson search patterns with indications for targeted communications during emergencies and outbreaks. Rathore et al. [ 44 ] have suggested an emergency tackling response unit using IoT-based wireless network of wearable devices called body area networks (BANs). The device consists of “intelligent construction,” a model that helps in processing and decision making from the data obtained from the sensors. The system was able to process millions of users’ wireless BAN data to provide an emergency response in real-time.

Consultation online is becoming increasingly common and a possible solution to the scarcity of healthcare resources and inefficient delivery of resources. Numerous online consultation sites do however struggle to attract customers who are prepared to pay and maintain them, and health care providers on the site have the additional challenge to stand out from a large number of doctors who can provide similar services [ 45 ]. In this research, Jiang et al. [ 45 ] used ML approaches to mine massive service data, in order (1) to define the important characteristics related to patient payment rather than free trial appointments, (2) explore the relative importance of those features, and (3) understand how these attributes work concerning payment, whether linearly or not. The dataset refers to the largest online medical consultation platform in China, covering 1,582,564 consultation documents among patient pairs between 2009 and 2018. The results showed that compared with features relating to reputation as a physician, service-related features such as quality of service (e.g., intensity of consultation dialogue and response rate), the source of patients (e.g., online vs offline patients), and the involvement of patients (e.g., social returns and previous treatments revealed). To facilitate payment, it is important to promote multiple timely responses in patient-provider interactions.

Pharmacovigilance

Pharmacovigilance requires tracking and identification of adverse drug reactions (ADRs) after launch, to guarantee patient safety. ADR events’ approximate social cost per year reaches a billion dollars, showing it as a significant aspect of the medical care system [ 46 ]. Data mining findings from adverse event reports (AERs) revealed that mild to lethal reactions might be caused in paclitaxel among which docetaxel is linked with the lethal reaction while the remaining 4 drugs were not associated with hypersensitivity [ 47 ] while testing ADR’s “hypersensitivity” to six anticancer agents [ 47 ]. Harpaz et al. [ 46 ] disagreed with the theory that adverse events might be caused not just due to a single medication but also due to a mixture of synthetic drugs. It is found that there is a correlation between a minimum of one drug and two AEs or two drugs and one AE in 84% of AERs studies. Harpaz R et al. [ 47 ] improved precision in the identification of ADRs by jointly considering several data sources. When using EHRs that are available publicly in conjunction with the AER studies of the FDA, they achieved a 31% (on average) increase in detection [ 45 ]. The authors identified dose-dependent ADRs with the help of models built from structured as well as unstructured EHR data [ 48 ]. Of the top 5 ADR-related drugs, 4 were observed to be dose-related [ 49 ]. The use of text data that is unstructured in EHRs [ 50 ]; pharmacovigilance operation was also given priority.

ADRs are uncommon in conventional pharmacovigilance, though it is possible to get false signals while finding a connection between a drug and any potential ADRs. These false alarms can be avoided because there is already a list of potential ADRs that can be of great help in potential pharmacovigilance activities [ 18 ].

Overcoming the language barrier

Having electronic health records shared worldwide can be beneficial in analyzing and comparing disease incidence and treatments in different countries. However, every country would use their language for data recording. This language barrier can be dealt with the help of multilingual language models, which would allow diversified opportunities for Data Science proliferation and to develop a model for personalization of services. These models will be able to understand the semantics — the grammatical structure and rules of the language along with the context — the general understanding of words in different contexts.

For example: “I’ll meet you at the river bank.”

“I have to deposit some money in my bank account.”

The word bank means different things in the two contexts, and a well-trained language model should be able to differentiate between these two. Cross-lingual language model trains on multiple languages simultaneously. Some of the cross lingual language models include:

mBERT — the multilingual BERT which was developed by Google Research team.

XLM — cross lingual model developed by Facebook AI, which is an improvisation over mBERT.

Multifit — a QRNN-based model developed by Fast.Ai that addresses challenges faced by low resource language models.

Millions of data points are accessible for EHR-based phenotyping involving a large number of clinical elements inside the EHRs. Like sequence data, handling and controlling the complete data of millions of individuals would also become a major challenge [ 51 ]. The key challenges faced include:

• The data collected was mostly either unorganized or inaccurate, thus posing a problem to gain insights into it.
• The correct balance between preserving patient-centric information and ensuring the quality and accessibility of this data is difficult to decide.
• Data standardization, maintaining privacy, efficient storage, and transfers require a lot of manpower to constantly monitor and make sure that the needs are met.
• Integrating genomic data into medical studies is critical due to the absence of standards for producing next-generation sequencing (NGS) data, handling bioinformatics, data deposition, and supporting medical decision-making [ 52 ].
• Language barrier when dealing data

Future directions

Healthcare services are constantly on the lookout for better options for improving the quality of treatment. It has embraced technological innovations intending to develop for a better future. Big data is a revolution in the world of health care. The attitude of patients, doctors, and healthcare providers to care delivery has only just begun to transform. The discussed use of big data is just the iceberg edge. With the proliferation of data science and the advent of various data-driven applications, the health sector remains a leading provider of data-driven solutions to a better life and tailored services to its customers. Data scientists can gain meaningful insights into improving the productivity of pharmaceutical and medical services through their broad range of data on the healthcare sector including financial, clinical, R&D, administration, and operational details.

Larger patient datasets can be obtained from medical care organizations that include data from surveillance, laboratory, genomics, imaging, and electronic healthcare records. This data requires proper management and analysis to derive meaningful information. Long-term visions for self-management, improved patient care, and treatment can be realized by utilizing big data. Data Science can bring in instant predictive analytics that can be used to obtain insights into a variety of disease processes and deliver patient-centric treatment. It will help to improvise the ability of researchers in the field of science, epidemiological studies, personalized medicine, etc. Predictive accuracy, however, is highly dependent on efficient data integration obtained from different sources to enable it to be generalized. Modern health organizations can revolutionize medical therapy and personalized medicine by integrating biomedical and health data. Data science can effectively handle, evaluate, and interpret big data by creating new paths in comprehensive medical care.

OOpen access funding provided by Manipal Academy of Higher Education, Manipal.

Declarations

The authors declare no competing interests.

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Blockchain-based healthcare records management framework: enhancing security, privacy, and interoperability.

1. Introduction

1.1. problems in the existing ehr frameworks.

• Information Asymmetry in EHRs: The healthcare industry is impacted by EHR asymmetry because doctors and hospitals have the legal right to access patient information while patients may need to go through a drawn-out and laborious process in order to acquire their EHRs [ 6 ].
• Interoperability in EHRs: Health information exchange (HIE), also known as fact sharing, is a crucial component of EHR architecture [ 7 ]. A generally specified EHR structure is not desirable since several EHR structures used in various institutions have varying levels of vocabulary, technical, and functional capabilities. Technically speaking, the shared clinical information should be interpretable and may be used identically [ 8 ].
• Data Breaches In EHR Systems: The management of EHRs in contemporary EHR management systems has the potential to change. However, blockchain provides immutable and traceable transaction procedures [ 9 ]. Moreover, blockchain can also help people manage their personal EHRs so that they can provide permission for trusted entities, i.e., patients and fitness centers to securely access and update their EHRs [ 10 ].

1.2. Summary of the Proposed Framework

1.3. our contributions.

• We integrate decentralized blockchain technology into the proposed framework to alleviate the single-point-of-failure feature of the existing centralized EHR frameworks.
• A smart contract is developed to improve the management and sharing of patient EHRs while preserving patients’ control over their personal health data.
• It offers improved data privacy and security of EHRs by storing them on the immutable ledger of the blockchain.

2. Background and Related Work

2.1. blockchain technology, 2.2. smart contracts, 2.3. ehr using blockchain technology, 2.4. security and privacy, 3.1. architecture of the proposed framework, 3.2. detailed workflow and data interaction, 3.3. storage and retrieval of patients’ ehr.

• The data are produced by hospitals. The blockchain receives standard data and the patient ID.
• Data are encrypted and stored in cloud storage when the transaction is finished and given a unique ID.
• When other hospitals request a patient’s record, the requested data are decrypted and displayed on the authorized device. The patient’s public key is accessible to the hospital, but only they have access to their own private key.
• The patient’s approval is required if a doctor wants to view the patient’s health records. The patient can approve access by entering their unique key when they receive the queue request on the doctor’s mobile app or website.

3.4. Network Structure of the Proposed Framework

3.5. instantiation of proposed framework, 4. results and discussion, 4.1. experimental setup, 4.2. cost evaluation, 4.2.1. cost per transaction evaluation, 4.2.2. cost analysis of medical record registration, 4.2.3. cost analysis of patient registration, 4.2.4. cost analysis of hospital registration, 4.3. performance evaluation, 4.4. evaluation comparison with existing frameworks, 4.5. security analysis.

• Data privacy and security: The decentralized and immutable nature of blockchain allows for secure and transparent sharing of information among different healthcare providers, while also giving patients control over their personal health data. This ensures that patients’ data are secure and protected from unauthorized access and tampering.
• Interoperability: Blockchain-based EHR systems can facilitate the sharing of patient health information across different healthcare organizations, without the need for a centralized repository. This ensures that patient data can be easily shared and accessed by healthcare providers when needed, regardless of where the patient received care.
• Auditability: The immutable nature of blockchain provides an unchangeable record of all transactions, making it easy to track and verify the authenticity of health records. This helps to ensure that patients’ data are accurate, are up-to-date, and can be trusted by healthcare providers.
• Decentralization: With a decentralized architecture, patients have direct access to their health records, which can help to ensure the accuracy and completeness of the information. This also reduces the risk of data loss or corruption, as there is no central repository that can be compromised.
• Automation: Smart contracts on blockchain can help automate certain processes, such as claims processing, and can reduce administrative costs. This can lead to more efficient and cost-effective healthcare delivery.

5. Conclusions

Future work, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest, appendix a. smart contract code.

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Tahir, N.U.A.; Rashid, U.; Hadi, H.J.; Ahmad, N.; Cao, Y.; Alshara, M.A.; Javed, Y. Blockchain-Based Healthcare Records Management Framework: Enhancing Security, Privacy, and Interoperability. Technologies 2024 , 12 , 168. https://doi.org/10.3390/technologies12090168

Tahir NUA, Rashid U, Hadi HJ, Ahmad N, Cao Y, Alshara MA, Javed Y. Blockchain-Based Healthcare Records Management Framework: Enhancing Security, Privacy, and Interoperability. Technologies . 2024; 12(9):168. https://doi.org/10.3390/technologies12090168

Tahir, Noor Ul Ain, Umer Rashid, Hassan Jalil Hadi, Naveed Ahmad, Yue Cao, Mohammed Ali Alshara, and Yasir Javed. 2024. "Blockchain-Based Healthcare Records Management Framework: Enhancing Security, Privacy, and Interoperability" Technologies 12, no. 9: 168. https://doi.org/10.3390/technologies12090168

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.css-1c7en8u{font-size:clamp(1.375rem, 1.25rem + 0.3125vw, 3.125rem);line-height:1.1;margin-bottom:1rem;} Yacht-Master 40 .css-1g7r01k{font-weight:300;font-size:clamp(0.875rem, 0.9375rem + 0.1563vw, 1.25rem);line-height:1.2;text-wrap:balance;}.css-1g7r01k span{display:block;} Oyster, 40 mm, Everose gold Reference 126655

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Staying on course

The Oyster Perpetual Yacht-Master 40 in 18 kt Everose gold with an Oysterflex bracelet.

Diamond-paved dial, optimal brilliance.

Diamonds, sapphires, rubies, emeralds – the noblest and most precious stones are selected to grace Rolex timepieces. The brand has in-house expertise and equipment enabling it to bejewel any model in its catalogue.

Experienced gemmologists first select gemstones of the highest quality. For this, they can rely on their own seasoned judgement as well as state-of-the-art analysis equipment. The stones are then entrusted to the gem-setters, who skilfully place each precious stone onto the watch by hand, one by one, assuring precision to within hundredths of a millimetre. Such stringent tolerances guarantee that each stone shines with optimal brilliance and is perfectly aligned with those around it. These time-honoured gestures, which may be repeated many hundreds of times, ensure that each gem-set watch produced by Rolex sparkles with exceptional intensity and reflects the standard of excellence required by the brand.

Bidirectional Rotatable Bezel

Timing the distance.

The Yacht-Master’s bidirectional rotatable 60-minute graduated bezel is made entirely from precious metals or fitted with a Cerachrom insert in high-tech ceramic. The raised polished numerals and graduations stand out clearly against a matt, sand-blasted background.

This functional bezel – which allows the wearer to calculate, for example, the sailing time between two buoys – is also a key component in the model’s distinctive visual identity.

The Oysterflex Bracelet

Highly resistant and durable.

The Yacht-Master’s new Oysterflex bracelet, developed by Rolex and patented, offers a sporty alternative to metal bracelets. The bracelet attaches to the watch case and the Oysterlock safety clasp by a flexible titanium and nickel alloy metal blade.

The blade is overmoulded with high-performance black elastomer which is particularly resistant to environmental effects, very durable and perfectly inert for the wearer of the watch. For enhanced comfort, the inside of the Oysterflex bracelet is equipped with a patented longitudinal cushion system that stabilizes the watch on the wrist and fitted with an 18 kt Everose gold Oysterlock safety clasp. It also features the Rolex Glidelock extension system, designed by the brand and patented. This inventive toothed mechanism, integrated beneath the clasp, allows fine adjustment of the bracelet length by some 15 mm in increments of approximately 2.5 mm, without the use of tools.

18 kt Everose gold

An exclusive patent

To preserve the beauty of its pink gold watches, Rolex created and patented an exclusive 18 kt pink gold alloy cast in its own foundry: Everose gold.

Introduced in 2005, 18 kt Everose is used on all Rolex Oyster models in pink gold.

More Yacht-Master technical details

Reference   126655

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Oyster, 40 mm, Everose gold

Oyster architecture

Monobloc middle case, screw-down case back and winding crown

Bidirectional rotatable 60-minute graduated bezel with matt black Cerachrom insert in ceramic, polished raised numerals and graduations

Winding crown

Screw-down, Triplock triple waterproofness system

Scratch-resistant sapphire, Cyclops lens over the date

Water resistance

Waterproof to 100 metres / 330 feet

Perpetual, mechanical, self-winding

3235, Manufacture Rolex

-2/+2 sec/day, after casing

Centre hour, minute and seconds hands. Instantaneous date with rapid setting. Stop-seconds for precise time setting

Paramagnetic blue Parachrom hairspring. High-performance Paraflex shock absorbers

Bidirectional self-winding via Perpetual rotor

Power reserve

Approximately 70 hours

Flexible metal blades overmoulded with high-performance elastomer

Folding Oysterlock safety clasp with Rolex Glidelock extension system

Diamond-paved

Highly legible Chromalight display with long-lasting blue luminescence

Certification

Superlative Chronometer (COSC + Rolex certification after casing)

Learn how to set the time and other functions of your Rolex watch by consulting our user guides.

Yacht-Master 40

Contact an Official Rolex Jeweler

Only official Rolex jewelers are allowed to sell and maintain a Rolex watch. With the necessary skills, technical know-how and special equipment, they guarantee the authenticity of each and every part of your Rolex and help you make the choice that will last a lifetime.

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