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Sun 1 Apr 2007 09:42 AM

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Prevention is better than cure

Dr Oliver Harrison, head of public health at the newly renamed Abu Dhabi Health Authority, reveals his plans for revamping the region's health.

Abu Dhabi's switch to compulsory private healthcare has won mixed reviews from the emirate's physicians. While backing the idea of emirate-wide access to healthcare in principle, a closer look at insurance plans for low-income workers have sparked protests from clinicians aghast at the number of exclusions and accompanying lack of preventive care. Dr Oliver Harrison, head of public health for Abu Dhabi, answers the critics and tells
Medical Times

how he intends to put care back in the community.

What is your background?

I'm a medical doctor. I qualified in 1999 from Cambridge and University College London, and my postgraduate training is in psychiatry. I left clinical medicine after four years and then worked for McKinsey (a management consultancy company) for about four years. Most of my work was in system design for governments but also operational improvement for individual hospitals. I've been in my current role now for five months.

Can you tell me about Abu Dhabi's current public health projects?

We have a total of twelve priority areas that we're focusing on. The approach we're taking is to use all the data that we collect to identify the biggest killers and causes of disease in the population; and that's for nationals and non-nationals. Then we put all of those on to a prioritisation matrix and we come up with a rolling list of diseases that become our priority areas for a six-month period. And then, for each disease area, we pick specific projects and initiatives that are really going to change the level of disease or death caused by those diseases in our population.

What are these priority areas?

Our current areas are: diabetes, road death, breast cancer, cervical cancer, congenital abnormalities, tobacco smoking, hypertension, osteoporosis, lung cancer, hypercholesterolaemia and pneumococcal infections in children.

How are the projects for each disease area selected?

Those projects come up from experts or clinicians across the emirate of Abu Dhabi - all clinicians are warmly invited to come up with initiatives. We, the regulator, (then analyse) what it would really take to implement initiatives; what the impact would be on various stakeholder groups, including our hospitals and other parts of the government and so on. And what are the health economics - the cost per quality adjusted life year (QALY)? Then we seek and get approval at the health authority, and begin planning implementation. Once that is done, we have a clear, evidence-based project with a set of targets and we meet regularly to monitor performance against those targets and to redesign the intervention if necessary.

Who oversees the initiatives?

At the moment we have set up a public health executive, made up of senior managers, each in charge of core functions for one of our three regional preventative medicine departments. We're setting up a non-executive board that will have an advisory and supervisory role over the course of the next month or two.

What initiatives top the list?

Cardiovascular disease is our top priority - partly because it's the single biggest killer today and partly because the young population in Abu Dhabi today (an average age of 28 years) is laying down a pattern of illness for the future. We have a duty to act now to prevent a future clinical time bomb. But to take CVD as an entity across the board is too vague and too woolly; it is a multi-causal illness and to really change outcomes we need to prioritise the individual risk factors for our population. Our priority is diabetes mellitus and we are working in partnership with a number of agencies, including the Imperial College London Diabetes Center, on health promotion, on collecting baseline data and designing a mass screening programme for up to 60,000 people.

Road death is our second big priority. With an annual incidence of road death of 29.3 per 100,000, we have the highest known rate in the world. That is clearly a big concern; the question is what to do about it. Dr Jens Thomsen, our consultant in environmental health, is identifying, based again on data that we have managed to get from the police and from the Ministry of Transport, what the main causes of road death are and, in terms of root cause analysis, what can we do about those causes to reduce the level of death. Typically you look at factors pre-, during and after the crash; factors that the driver can control and the regulatory authority or clinicians can control. Within those, we have two or three priority areas that we believe, based on the data we have, will really shift the dial.

Have you seen any progress in any of the disease areas yet?

Since I arrived in September last year, the first initiative in the bag was the launch of a pneumococcal conjugate vaccine. It is all but on (the vaccination schedule); we are just going through the final round of negotiating on price.

Are you concerned about a backlash over the vaccine?

Clearly HPV is a sexually transmitted disease, and it is important that we deal with a vaccine against cervical cancer that is caused by an STD in a culturally sensitive way.

What we want to do is drive uptake as quickly as possible, and the terminology we use is going to be based on that used in other countries where people are sensitive about these topics. We will be continuing to drive the uptake of pap smears.

Abu Dhabi has now enforced compulsory healthcare insurance. How do you see your plans for

preventive care fitting in with a private system?

There are two ways that it will be dealt with. First by direct government subsidy and funding, and the second is actually through the health insurance. The health authority for Abu Dhabi, as the regulator, sets forth for the health company what is included in their premiums. So if we say vaccinations are all included, they are all included. We have absolute authority and discretion to be able to do that.

But Daman (the Government's insurance provider) does not cover preventive care in its low-income plan, which the majority of residents will be covered by.

Correct. There are no current plans to change this, but it is under review. So over the course of the next few months, a decision will be made on what will be sitting in the basic package and the enhanced package. The principle that we're working to is that nobody is disadvantaged because of their health care in terms of preventive medicine, so any gaps that there are in principle from health insurance will be met through other sources of funding. However, in reality, different stratums of the population do experience different public health issues, and what we want to do is identify what those are and deal with them one by one. So if it turns out that, for example, low-paid migrant workers are experiencing a particularly high level of lung cancer, then that would show up in our data and we would generate some programmes which are designed to deal with those in turn. Money will be found from one of a variety of sources to make sure that this happens.

Will you be extending these plans into schools?

Of course, we plan to work in schools. The provision of school health is changing, or is set to change. The timelines are not established, but the school health programme will change in terms of its structure, so that the health authority will have a more regulatory role. What we want to do in that context is to set guidelines; a curriculum as it were, for kids in their schools, against which various agencies such as GPs, practice nurses, school health nurses and teachers themselves will be expected to create impact or teach different bits of the curriculum. I don't want to talk in loose, vague terms until there is a concrete plan in place to do particular stuff. But it is on the horizon.

What practical changes can physicians expect to see?

I hope, a number of things. Firstly, if they have good ideas of specific interventions, I hope they notice an authority that is all ears and (wants) to help our clinicians to help our patients. If our clinicians have some energy and enthusiasm for working on particular topics, we want to hear from them.

Number two, they will increasingly hear more, particularly in terms of the disease priority areas, from the authority and also potentially from their patients. We hope to achieve an increase in awareness of various illnesses that can be prevented and treated. For example, patients should be more aware that they need to lose weight, so primary care clinicians may notice their patients asking for help to lose weight.

Our approach is pragmatic; so whatever it takes to really reduce the level of death we are willing to help drive it. If a clinician, or anyone, can demonstrate a good evidence base, and cost-effectiveness, we will help turn their idea into a concrete proposal.

Where do you see public health in Abu Dhabi in five years time?

I would like to see Abu Dhabi public health being the best in the world in a number of dimensions. The first is building a national, continuous audit to identify the biggest killers and causes of disease, and create projects that are designed to influence those. Within five years I would expect that to lead concretely to an increase in life expectancy and a decrease in age and cause-specific death incidence in all of our population segments.

Secondly, I would like for the processes in public health to create learning for all people in this region. For example, if there is a uniquely Arab way to look after diabetes, if sulfonylureas is better than metformin for controlling type 2 diabetes in the Arab genotype, it would be great to have developed an evidence-base around that kind of topic. Thirdly, I would like to create an evidence-based consciousness in every clinician, in each non-clinician in the population, about what it is to work in partnership to reduce the level of illness and level of cause-specific death. What I mean by that is for every doctor, or nurse when they interact with patients, for every mother when looking after their child, for every person when they are making a decision about lifestyle, to be beginning to think about the impact that might have on their health and the health of others. Public health issues, for example vaccinations and communicable diseases, know no borders.

That's ambitious.

There's no reason not be ambitious in this emirate.

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