Health Sector Transformation Strategy

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· What are the main themes of the transformation?

· What goals and objectives are set to achieve the needed transformation?

· How will the transformation be delivered?

· What are the risks?

· What is the economic impact of the transformation?

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Health Sector Transformation Strategy

V.3

The Custodian of the Two Holy Mosques

Salman bin Abdulaziz Al Saud

His Royal Highness Prince

Mohammad bin Salman bin Abdulaziz Al Saud The Crown Prince, First Deputy Prime Minister and Minister of Defense

Contents

1. Introduction

2. The need for transformation – Why do we want to change?

3. Defining the transformation goals and methods – What do we want to change? Using theory and applying it to our strategy.

4. Delivering the transformation – How and when will things change?

5. Perceived risks and mitigations – What do we want to avoid?

6. The economic case – Do the benefits outweigh the costs?

7. Next steps

8. Annexes

A. Plans by Themes

B. A description and summary analysis of the Harvard and Oxford Value frameworks

C. Bibliography of key documents (with hyperlinks)

D. Endnotes

Introduction

Good health is a gift. Its promotion is amongst the greatest responsibilities of any State. We take that seriously and are now embarking on a fundamental transformation of our health system. Our country needs it. Our people deserve it.

Our population is growing. It’s also growing older. Living longer is a blessing but it also brings challenges – as do our more diversified economy and increasingly urban lifestyles.

Every one of us has a role to play and our attitude towards our physical and mental wellbeing, as well as the system that supports it, must change if we are to achieve our ambition of living fulfilling lives in a vibrant society.

Future success relies on us being smart, sophisticated and less centralized. We must draw on what we’ve achieved in the past but not be held back by it. Healthcare staff need to be empowered to make the right decisions at the right time in the right place. They need the authority to take action, make choices and accept responsibility. They must also be given the chance to make honest, well-intentioned mistakes without undue fear of failure.

The scale and complexity of this transformation cannot be overstated. That is why it has been broken down into themes and will be executed in phases. We have sought to balance ambition and realism.

This paper gives an overview of the transformation, spelling out the underlying goals as clearly and coherently as possible. Delivering the strategy will be more complex and will only work if we can engage and co-ordinate large numbers of highly educated and skilled people effectively.

Context

The Ministry of Health (MoH) has been tasked with delivering this strategy as part of “Vision 2030” for the Kingdom of Saudi Arabia [1]. This document addresses the Level 2 Strategic Objective of raising the standards of our health service, the Level 3 goals of easing access to it, ensuring better value and strengthening prevention against the main threats to our health. The strategy also aims to make a significant contribution to Level 2 Strategic Objective 2.2: Promote a healthy lifestyle.

Though led by the Ministry of Health; this plan has been developed in close collaboration with the National Transformation Program.

The Need for Transformation – Why do we want to change?

The Need for Transformation

Understanding the challenges [2] We have identified eight major challenges in our health system that need to be addressed over the coming decade.

1. The population of the Kingdom continues to grow and age. Our population is expected to rise from 33.5 million in mid 2018 to 39.5 million in mid 2030. The number of elderly (aged 60 to 79) is expected to grow from 1.96 million in mid 2018 to 4.63 million in mid 2030.

In 2015 residents from overseas amounted to 30% of the population of the Kingdom or 10 million people. These are mainly adults but also with some accompanying young people.

We have many overseas visitors too, particularly for the major religious festivals. Two years ago, 537,000 of those attending the Hajj were domestic pilgrims. 1,325,000 came here from abroad and in some years the total number of foreign pilgrims visiting Mecca has been estimated as high as three million people . [3]

The population of the KSA was 83.3% urban in 2016, which is projected to rise to 85.9% in 2030.

2. Rates of avoidable injury and non-communicable disease remain high by regional and international standards. The Kingdom has made notable progress in improving the health of its population over recent decades, particularly in areas of child and maternal mortality and the reduction of communicable disease. For both males and females, life expectancy at birth improved from 64 years in 1970 to 75 years in 2015. There are targets set to ensure it increases to 80 years by 2030. But there is considerable scope to reduce avoidable mortality and avoidable morbidity in both the working and elderly populations. Particular areas of concern include heart disease, stroke, diabetes mellitus, respiratory disease, mental health, road traffic accidents and congenital diseases, all of which are amenable to reduction.

We need to strengthen the prevention of non-communicable disease and injury thereby reducing avoidable illness and death. The risk of major outbreaks of communicable disease also remains substantial, especially at Hajj or following natural or man-made disasters.

The Need for Transformation

When other government departments in the Kingdom develop major policy initiatives, the health and healthcare implications of their actions are not always at the front of their minds. Similarly, it has often proved difficult for the MoH to develop the inter-ministry dialogue necessary to resolve some of its own pressing problems.

3. Primary care remains inadequate and inconsistent. Secondary and tertiary hospitals, and associated resources, are poorly distributed across the Kingdom. [4] There is inadequate capacity in extended care services such as rehabilitation, long-term care and home care. These issues are compounded by low levels of productivity.

4. There are significant gaps in the quality of services provided to patients. Much of this is due to lack of consistent protocols and pathways for treatment, and incomplete measurement of patient processes and outcomes. The Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) Essential Safety Requirements Survey of 2015 has also emphasized key deficits in safety across all categories of hospitals.

5. There is unwarranted variation in provision, access and investment when assessed using the population served rather than the patients treated. This included over-use as well as under-use and leads to significant shortfalls in value as well as quality.

6. The system is currently resource and staff centric rather than patient or person centric in its orientation. It is also institution centric rather than population centric. A health system needs to be both accessible and responsive to patients’ overall welfare.

7. There are significant gaps in workforce capacity and capability, specifically in relation to Saudi employees. The health system also currently lacks robust, consistent and integrated digital information systems to measure and manage resources, activity levels, quality and efficiency and to build a learning health system, in which all involved can contribute, share, and analyze data and in which continuous learning cycles encourage the creation of knowledge that can be used by a variety of health-information systems.

8. The health system also needs to support the containment of public expenditure, and the diversification of the Saudi economy. This is needed to address the risk of long term reductions in the price of crude oil and the impact that will have on public revenues.

The Kingdom therefore needs to:

• Encourage action within and beyond the health system to reduce injuries and the primary and secondary prevention of non-communicable diseases;

• Introduce comprehensive measures of population needs and health system

performance to improve the allocation of resources and delivering the outcomes that people need;

The Need for Transformation

• Create a culture of stewardship, in which all clinicians take responsibility for the use of resources, the prevention of waste and the long term sustainability of universal healthcare.

• Create incentives for staff and the system to be more effective, efficient and to encourage locally generated innovation;

• Facilitate levels of revenue and capital investment in healthcare facilities and systems that are proportionate to the Kingdom’s economic status and are appropriately distributed to reflect population and patient needs;

• Bring transparency into the provision of care through systematic collection and internal reporting of clinical data, costs and outcomes at episode level, to understand and achieve better value;

• Ensure the quality and safety of clinical investigations and treatments, through system and process and the rigorous use of standards, protocols and clinical pathways and clinical practice guideline together with the continuous professional development of clinical and non-clinical staff;

• Ensure a broad-based, highly educated, skilled and highly productive healthcare workforce, staffed increasingly by Saudi citizens;

• Harness technology, the internet and mobile telephony, computational power and interoperability, big data and analysis to improve patient access, education and involvement in protecting and promoting their health, to drive quality and efficiency gains and to build a learning health system; and

• Develop the information systems, distributed governance systems, accounting systems, and the professional, employment and communication practices that will enable the MoH and the health system to be more responsive to current and future pressures.

Defining the Transformation Goals and Methods

– What do we want to change? Using theory and applying it to our strategy.

Defining the Transformation Goals and Methods

Our goals The proposed goals of the Transformation are to:

1. Improve health: Increase the length, wellbeing and quality of life of Saudi citizens, which includes the Vision 2030 goal of increasing the life expectancy of citizens to 80 years by 2030;

2. Improve healthcare: By improving the quality and consistency of services and the

performance and accountability of healthcare organizations and staff to deliver care that is safe, effective, patient-centered, timely and equitable; and

3. Improve value: by containing costs, improving outcomes, controlling public healthcare expenditure and guiding new investment.

All three transformation goals conform with, and are enablers of, the Vision 2030 strategic objectives for health: access, value and public health.

These goals are also informed by international frameworks for the enhancement of health systems including:

• The World Health Organization health systems framework [5];

• The World Bank Group health systems framework [6];

• The Institute for Healthcare Improvement “Triple Aim” framework [7];

• National Academy of Medicine, “Vital Directions for Health and Healthcare [8] : and

• The NHS England “Five Year Forward View” strategic plan. [9]

Introducing value based healthcare

The transformation goals are consistent with the related, but distinct, frameworks for value based healthcare. These frameworks have been articulated by researchers at Harvard Business School. They are also closely associated with work by The World Economic Forum [10] which focuses on the implications for associated health industries and the somewhat distinct work at Oxford University, which has now been adopted in England, Scotland Wales and Italy. [11]

Defining the Transformation Goals and Methods

This transformation strategy is deliberately formulated to utilize and combine aspects of all three value frameworks.

The financial, economic and institutional imperatives, together with the policy intentions of the KSA Government, that were expressed through Vision 2030, require a high level of overall control over health services expenditure and use of other resources. These factors also require a close interest in the health of the whole population. These considerations are distinctive features of the Oxford framework.

A description and summary analysis of the Harvard and Oxford Value frameworks can be found at Annex B.

From theory to strategy The Vision Realization Office (VRO) has organized its work into seven themes:

• The New Models of Care;

• Provider reforms;

• Financing reforms;

• Governance development;

• Private and third sector participation;

• Workforce development; and

• eHealth development.

The first three themes can be understood as enablers of three levels of value:

• The “New Models of Care” theme as a focal point for enhancing personal value through the improvement of treatment and care modalities at an individual level.

• The provider theme as a focal point for enhancing utilization value at an intermediate level, whether that is at the clinical micro-system, hospital or local health system level. (The important principle in a country committed to universal healthcare is that the definition of the population captures everyone in a particular jurisdiction such as a region.)

Defining the Transformation Goals and Methods

• The financing theme as a focal point for enhancing allocative value through ensuring those intermediate levels get “optimum” levels of resource, based on patients’ needs and their ability to benefit.

It can be argued that financing plays a direct role in securing all three types of value. In addition, patients’ needs are often qualified by other criteria including patients’ merits, economic objectives to protect the health of the working population, or patients’ ability and willingness to pay.

Past experience of health transformation strategies [12] suggests that organizational and financial changes are unlikely to lead to any major improvements in outcomes unless they are accompanied with supply side improvements, specifically, improvements in the efficiency, effectiveness, equity and responsiveness of the public health and health services provided. It is essential to recognize that the three value dimensions are interdependent and mutually reinforcing. Simply put, successful delivery of all the seven work themes will be essential to the overall success of our transformation strategy.

Outlining the transformation strategy Through 2017 the MoH made progress in developing the principal elements of its strategy. The following section outlines key policies and links these to the challenges they seek to address. There is a particular emphasis on the first three themes. The subsequent parts of the paper examine in more detail how the key policies will be realized in practice.

The New Models of Care [13] There are many challenges within the existing models of care for key patient pathways within the Kingdom. There are growing hazards within healthcare facilities due to inadequate medical quality and low safety standards. Waiting times are prolonged and they vary considerably across healthcare facilities, causing inevitable dissatisfaction. There are a number of high priority pathways with specific challenges including the maternity pathway, chronic conditions, planned care, urgent care, and last phase of life.

There are also challenges common to all pathways, including:

● Shortage of medications and available medicines are dispensed inconsistently;

● Lack of standardized clinical guidelines and variations in the quality and delivery of care;

● Poor pathway management, with inappropriate referrals, and inappropriate presentation by ill-informed patients disrupting patient flow;

Defining the Transformation Goals and Methods

● Lack of out-of-hospital services for diagnostic, preventative, proactive or follow-up care;

● Poorly coordinated care, particularly between MoH providers and non-governmental organizations; and

● Poor communication between providers, and between clinicians and patients.

To address these challenges, the MoH has developed a program to design, pilot, and implement a patient centric New Models of Care Program.

The program has been designed to answer six key questions:

1. How will the system help to keep me well?

2. How will the system support me when I have an urgent problem?

3. How will the system support me to have a great outcome for my planned procedure?

4. How will the system support me to safely deliver a healthy baby?

5. How will the system support me with my chronic conditions?

6. How will the system support me with compassionate care during the last phase of my life?

The New Models of Care is designed to support people with their health and wellness needs: physical wellbeing, mental wellbeing and social wellbeing. This aligns with the principles set out in the Constitution of the World Health Organization: “health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity”.

Virtual care will be a powerful source of health advice. Virtual care in most instances will serve as people’s first point of contact with medical care providers, improving people’s access to medical advice and guiding them to navigate the healthcare system and seek appropriate care.

The New Models of Care program has been designed based on the following principles:

● Empowering people and their families to take control of their health;

● Providing knowledge to people as part of their treatment, and enabling them to be well-informed and in control of their health;

● Fully integrating the health system from the people’s perspective;

Defining the Transformation Goals and Methods

● Keeping people healthy and focusing on the whole population through a preventive approach, rather than a solely curative approach to health provision; and

● Providing treatment in a patient-friendly and outcome-focused way, without over- treating or under-treating patients.

Accordingly, it has been developed with patient needs and asks at the center of the whole system.

The New Models of Care Program will deliver 42 coordinated interventions, across six ‘systems’ of care by the end of 2020.

The prioritized systems of care are: Keep Well, Safe Birth, Planned Care, Urgent Care, Chronic Conditions and Last Phase.

The 42 initiatives will include defined patient pathways and key performance indicators (KPIs) including measurement of: safety and quality process metrics, clinical and patient reported outcomes, and financial performance. These New Models of Care KPIs will be incorporated into the KPIs for the Essential Benefits Package (EPB) (see Financing below) to ensure that they are monitored and maintained when achieved. (A full list of the 42 interventions, progress to date and next steps is contained in Annex A).

Defining the Transformation Goals and Methods

Provider reform [14] Key policies include:

• Developing all existing MoH providers, through an initial “cluster” phase, into approximately 20 geographically defined, vertically integrated “Accountable Care Organizations (ACOs);”

• Making increased use of private healthcare provision; and

• Developing third sector provision to cover gaps arising from either government or market failure.

The ACOs will be established as “corporatized” public bodies, with substantial and clearly defined “decision rights”. Responsibility and accountability for the successful management and clinical governance of the ACOs will be vested in Boards which will be established in each ACO. The Chairman of each ACO Board will be appointed by the Minister of Health.

The NHS in England has had a policy of corporatizing public healthcare providers since at least 2004. This builds on a key textbook on reforming public hospitals published by The World Bank in 2003. [15] This Strategy is drawing widely on the English experience including its guidance on board led governance. [16]

ACO Boards will become the focal point for the successful realization of utilization value in the system. Each ACO will also have to take responsibility for the allocation of resources for their population.

The precise decision rights of the Saudi ACOs are still being determined. The more extensive the rights, the more scope that ACOs Board will have to improve use and personal value within their geographies and institutions.

Confirmed decision rights of ACO Boards include:

• Salaries and salary structures (clinical and non-clinical); and

• Employment rights over staff, including monitoring and evaluation of clinical and managerial performance.

Defining the Transformation Goals and Methods

Other issues that should be considered include:

• Rights to acquire, dispose of, and invest in physical assets;

• Rights to generate income (adjacent to core activities);

• Rights to set up educational courses and establishments (particularly nursing schools); and

• Financial rights and responsibilities (e.g. handling of surpluses, ability to take on debt).

Well performing ACO Boards, with appropriate decision rights, will be central to addressing the identified challenges within their geographies:

• Insufficient and poorly distributed capacity and capabilities in the provision of public health, primary care, secondary, tertiary care and extended care services;

• Key deficits in the appropriateness, quality, safety, effectiveness and efficiency of services provided, including workforce productivity;

• Gaps in workforce capacity and capability, and specifically in relation to Saudi employees; and

• Unwarranted variation either in comparison with other population based ACOs or within the ACO.

ACO Boards will also play a vital role in the robust local adoption of digital information systems. These will measure and manage resources, activity levels, quality and efficiency and build a learning health system.

Finally, ACO Boards will have an important responsibility for ensuring that ACO staff and institutions become patient or person centric in their orientation. They will do that both by personal example and through their behavior and decisions as a Board.

Defining the Transformation Goals and Methods

Financing reform [17,18]

Key policies, to be achieved in incremental steps, include:

· Confirmed commitment to universal healthcare coverage which will ensure that all citizens, residents and visitors to the Kingdom can obtain timely access to healthcare services, via insurance, without the risk of impoverishment; · Establishing the program for health assurance and purchasing to be a national payor to ensure free care to beneficiaries through the newly MOH corporatized providers and other governmental providers. · Definition of an Essential Benefits Package (EBP) which clearly defines a core package of treatment and care (with defined quality standards) that all insured patients will ultimately become entitled to; · Creating a system of supplementary health insurance (SHI) which will allow most citizens and residents to add additional benefits to their EBP. This SHI could be used to enhance the scope, timeliness or comfort of their treatment and care; · Creating a wider role for private health insurers as the transformation matures, through the creation of a market of licensed and regulated insurers who will offer SHI products. · Payment mechanisms that will support the implementation of the New Models of Care and ensure value at all levels. · Analyzing spend by major program budget at a national and regional level to optimize the allocation process;

The definition of an EBP will improve the allocation of resources and ultimately ensure that the whole population receive a guaranteed level of timely and accessible treatment and care. This will include services that that can achieve primary and secondary prevention of disease.

Defining the Transformation Goals and Methods

Governance development The policy goals of the governance theme are:

1. To define, design and support the establishment of the regulatory and improvement functions and institutions necessary to secure and sustain value based healthcare.

2. To embed strong, delegated and devolved leadership and governance throughout the health system. The Kingdom is too large, and the challenges are too many, complex, dynamic and inter-connected to be addressed successfully solely by a centralized bureaucracy, however competent.

A detailed description of the development approach of this work theme can be found in Annex A.

Capacity and capability building The other three themes of the strategy are all related to aspects of capacity and capability building:

The policy goals of private sector participation on the supply/service provision side are:

• To reduce pressures on public funds;

• To provide performance benchmarks for corporatized providers; and

• To potentially facilitate partnership opportunities for corporatized providers to divest and re-invest to enhance service quality or efficiency.

The policy goal of associated third sector participation is:

• To fill any residual gaps in treatment, care or support services, highly valued by patients and their families, that would otherwise persist in the presence of government and market failures. (e.g. hospice services).

The policy goal of the eHealth program is:

• To support the information requirements of the other work themes and, in particular, to enable a value based healthcare approach and build a learning health system.

Defining the Transformation Goals and Methods

A value based healthcare information architecture includes the following minimum components [19] :

• Standardized outcome metrics and accurate measurement of resource costs by population segment (segmenting the population by need as well as by geography);

• A universal data taxonomy across diseases and population groups (e.g. a consistent methodology and scale for measuring pain or patient quality of life);

• Inter-operability that allows databases to efficiently communicate with each other;

• Integration of outcomes data into the systems clinicians use in their daily work (e.g. electronic medical records [EMRs]) with a user-friendly interface that minimizes the effort required for entering data;

• Mechanisms to link individual patient data across multiple databases (e.g. a unique personal identifier); and

• Robust governance processes, with comprehensive rules for data access, agreements about data sharing and guidelines for managing privacy.

The policy goal of the workforce development program is:

• to support the transformation of the workforce necessary to enable a value based healthcare approach. This will require major increases in workforce capability and some increase, re-distribution and diversification of workforce capacity.

Delivering the Transformation – How and when will things change?

Timeline and scope of the transformation The reforms will be implemented in three broad phases, of increasing scope and complexity:

Phase 1 – Building capabilities

Phase 1 is underway. It commenced at the beginning of 2018 and will finish at the end of 2020. This phase is primarily concerned with clinical systems improvement, capacity and capability building and preliminary institution building.

From a financing perspective, Phase 1 envisages the establishment of a government mandated, Purchasing Program (PP), managed by new department, initially based within the Ministry of Health. The PP will initially cover persons already covered by MoH services, who will be offered entitlements defined in the Essential Benefits Package (EBP).

From a delivery perspective, Phase 1 envisages the establishment of a corporatized public Holding Company with a number of associated regional Corporates. The Holding Company will be responsible for the creation of approximately 20, vertically integrated, geographically defined, clusters of providers.

The present plan is that the clusters will be established in “waves.” Wave 1, comprising five clusters will be initiated during 2018. The first cluster will be in the Eastern Region, the second and third in Riyadh, the fourth in Makkah. The location of the fifth cluster will be Qasim. Subsequent waves of clusters will be initiated by the Corporates, at a pace that they will determine.

The Phase 1 reforms, from both financing and delivery perspectives, will be heavily informed by ongoing work coordinated by, the MoH-Vision Realization Office (VRO) on New Models of Care. This includes the 42 initiatives proposed by the MoH during the latest round of revisions (July to October 2017) to the National Transformation Plan.

Phase 2 – Developing autonomy and value

Phase 2 will start at the beginning of 2021 and finish at the end of 2025. This phase is primarily concerned with the secure and robust corporatization of key public entities. These include the ACOs (developed from the clusters), PHAP in Phase 2, and a range of regulatory and improvement agencies.

Phase 2 will also include the re-purposing of the MoH; the implementation of Health in All policies; and the implementation of system wide enabling reforms regarding workforce, digital and systems governance.

Delivering the Transformation

From a financing perspective, Phase 2 envisages the possible extension of the PHAP to persons presently funded by all other government departments including Other Government Services (OGS).

During Phase 2 most persons covered by the PP will be given the opportunity to purchase supplementary health insurance (SHI).

From a delivery perspective, clusters will be developed into approximately 20 corporatized ACOs across the Kingdom. The ACOs will primarily be resourced from existing MoH services and facilities. However, the ACOs will also be able to sub-contract services for patients covered by the PHAP (and SHI) from the private sector. It is also envisaged that healthcare facilities and staff presently directly managed by other government departments may be fully or partly integrated into emerging ACOs during Phase 2.

Phase 3 – Strengthening value and choice

Phase 3 will start at the beginning of 2026 and finish at the end of 2030.

From a financing perspective, Phase 3 envisages the extension of the NHI to all citizens, residents and visitors to the Kingdom. It envisages the simultaneous push of licensed private health insurance providers to embrace and implemented the principles of value based healthcare.

Delivering the Transformation

Change management The change proposed in this strategy is transformational. It involves altering the overall orientation of the MoH a

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