Can nations like the U.S. solve the puzzle of why the health of its people worsens even as it spends more per capita than most countries on health care? A recently released report by PwC's Health Research Institute says the two trends can be reversed. But there's a catch: It will not happen without a strategic plan that envisions bringing together partners from sectors that have not worked in a coordinated fashion in the past.

The report–Social Determinants of Health–lays out the challenge ahead for those who would truly reform and restructure the composition and delivery of the health care system. The report is based on an ominous premise: that clinical care is responsible for 20 percent of personal health, while 80 percent of the responsibility lies in patient behaviors, one's physical environment and socioeconomic conditions.

The institute's findings are based on surveys earlier this year with 8,000 consumers worldwide, as well as interviews with leaders in various health sectors. One question for consumers elicited particularly insightful responses. When asked what was standing in their way of a healthier lifestyle, 35 percent identified "lack of sleep" as the number one cause. The second major factor: too much technology. The third: lack of motivation to improve my health. Those types of roadblocks to better health cannot be addressed through traditional medical means.

Thus our highly advanced medical system can only do so much. "The social determinants of health — often-ignored social factors such as employment; housing; income inequality; and level of access to clean water, education and transportation — undermine progress and can swamp the health systems that ignore them," the report states. "Because even the most advanced medical interventions are rendered ineffective when people struggle with social isolation, income inequality, poor nutrition and pollution. As social factors counteract medical best practices, health systems often remain focussed on creating solutions at the wrong interaction point: after people are already sick and in crisis."

The report recommends an ambitious five-step strategic response to the social determinants that offset the billions spent on health care "solutions."

Step 1. Build the collective will

The institute understands that addressing personal and social factors in health cannot be achieved without bringing together participants that generally do not have a unified focus. But, the report says, the accelerating cost of social determinants paid by all parties should compel them to coordinate their efforts. "Ownership and responsibility are clear when true costs are understood. It will take a coalition of partners who may need to stretch their roles, but leaders must find ways to show prospective partners how their goals meaningfully align. Constructing the right coalition also will require looking beyond the sector and traditional partners to consider the community groups, government agencies, universities, retailers, technology companies and new entrants that might contribute."

Step 2. Develop standard but adaptable frameworks

This is all about setting mutually agreed-upon objectives and creating systems to seamlessly connect those involved in the process. "Coalition partners should adopt a common framework to clear obstacles and fast-track efforts to work together," the report says. "Once they have done the hard work of building coalitions, partners must overcome the everyday challenges of merging disparate workplaces with different missions, incentives and perspectives. Coalition leaders must be sure all partners are invested in, and agree on, the common purpose. … The leaders should be clear about how members will achieve change, and the goals should demonstrate how the alignment of the partners' work benefits each player."

Step 3. Generate data insights to inform decision making

Big Data will play a significant role in establishing the cooperative framework, defining goals, and measuring progress. "Data analytics can guide your plan," the report says. "Selecting the programme investments most likely to spark health improvement can seem a mysterious endeavour. But leaders are finding that predictive analytics can illuminate areas to target that will mean less time and money wasted chasing ineffective interventions." Partners should collaborate to not only share data, but to seek new data resources to further inform the strategy. "Organisations should simultaneously be improving data collection involving social determinants of health, using opportunities such as the adoption of new electronic medical record systems or upgrades to data systems to expand the categories of data collected. … These strategies allow organisations to look at forecasts for how populations will respond in the first year, ten years down the line and over their lifetime, and to further quantify the impact of these investments, even prior to making financial commitments."

Step 4. Engage and reflect the community

This step is all about grounding the collaboration in the real world. "Social determinants of health programmes must be grounded in the reality of how people live and work. … The success of any social determinant of health strategy ultimately depends on the targeted community's response. Those carrying out the intervention must have the credibility and knowledge to work in the area so they can build trust in the population. … Partners should consider the conversations that these frontline workers will have and how they will be viewed in the community, whether it is with suspicion or respect. Systems and policymakers need to be mindful not only of cultural differences, but also of geographic disparities in resources seen between states and regions."

Step 5. Measure and redeploy

The institute advises that the path forward will be unpredictable, and the strategy will require constant fine-tunings and even sharp turns, based on the metrics selected to guide it. "Partners must use evidence to fine-tune and grow social determinants of health efforts and to keep partners accountable. … Successful social determinants of health intervention campaigns are exercises in continual improvement, in which experience, data and insights are gathered and fed back into the system. Feedback enables the development of improved strategies and shows where partners need to build better social determinants of health capabilities or strengthen processes. … As organizations use metrics to reveal gaps in business capabilities, they also need to build in accountability, such as incorporating expectations for internal leadership, making sure to address needs of coalition members and building social determinants considerations into contracts."

The report emphasizes that the strategy it has proposed will take years to deliver on the promise of better health for more individuals at a lower cost. The partners must be willing to commit to a long-term strategy; otherwise it will ultimately fail. But the effort must be made. "Pursuing this path is no longer optional; all players must act, or risk being swept under by the rising rates of illness."

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5 steps to integrate social determinants of health into our health care system

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