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Re-orientation of Health Promoting Hospitals and Health ServicesLessons from Pandemic: Taiwan experience

Consultant, Hualien Tzuchi HospitalProfessor, Tzuchi UniversityFormer Director General, Health Promotion AdministrationFormer Secretary General, Taiwan Network of Health Promoting Hospital and Health Services

Dr. Yingwei Wang

SDG

Aging

Urbanization

Climate change

Migration

Multimorbidity

Globalization

TechnologyCost NCD 2

The Pandemic 4th Wave

• 1st Wave: Immediate mortality and morbidity of COVID-19.

• 1st Wave Tail: Post-ICU and admission recovery for many patients.

• 2nd Wave: Impact of resource restrictions on non-COVID conditions – all the usual urgent things that people need immediate treatment for – acute.

• 3rd Wave: The impact of interrupted care of chronic conditions (people stayed home).

• 4th Wave: Psychic trauma, mental illness, PTSD, economic injury, burnout, and more.

Joe Babaian in healthcare leadership. https://hcldr.wordpress.com/2020/04/07/the-pandemics-4th-wave/3

Climate (Pandemic) resilience in health care facilities

WHO guidance for climate-resilient and environmentally sustainable health care facilities. Geneva: World Health Organization; 2020. 4

Strategies to strengthen resilience by health system function and stage in the shock cycle

Strengthening health systems resilience: key concepts and strategies (2020) www.euro.who.int

Stages of a shock cycle

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Covid-19 cases no. in Taiwan 2020-2021Lo

cal c

ases

Impo

rted

cas

es

Com

mun

ity o

utbr

eak

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Covid-19 outbreak in May 2021- but case number dropped to near zero in late September 2021 -

No. of screening for Covid-192020 01 – 2021 10

Number of local Covid-19April – sporadicMay – 400/daySeptember <10/day

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Health system respond to Covid-19 pandemic

National

Local

OrganizationHealth Promoting

Health service

Individual Patient / family

Macro-level

Meso-level

Micro-level

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• Individual: knowledge, attitudes, self-efficacy, health literacy skills, values, personal psycho/social/demographic attributes;

• Interpersonal: people with close relationships to the individual: immediate family, relatives, close friends and co-workers, peer network;

• Organizations: agencies, social institutions, public/private partnerships;

• Community: schools, workplaces, neighborhoods, places of worship, community primary care;

• Policies: national healthcare organizations, governmental ministries, mandates, laws.

IUHPE – Global Health Promotion Vol. 28, No. 2 202110

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How has SARS affected the response to COVID-19

-Taiwan experience -

• “The biggest issue at that time was ignorance” about the virus, Chen says. “We didn’t know how to diagnose it, we didn’t know how many it would kill, we didn’t know how to treat it. We didn’t know anything! This made us very nervous.”

• Another factor contributing to the severity of the crisis in Taiwan was the lack of strong infection-control standards in Taiwan’s hospitals at that time, he notes. The most egregious example was the Taipei Municipal Heping Hospital outbreak in April 2003, when an ineffective shutdown and quarantine procedure resulted in over a hundred infections and dozens of deaths, many among hospital staff.

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The Vice President mentions that the Communicable Diseases Control Act, the statute that sets the standards for quarantine and containment of infectious diseases in Taiwan, had not been updated in decades at the time of the SARS outbreak.

Taiwan’s Centers for Disease Control was an underdeveloped agency when SARS hit. “Our CDC was not well-staffed, didn’t have great equipment, and was not well-prepared.

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Individual level – citizen behavior / professional behavior

• Facial mask not available : • Under report or not report for disease history • Not follow about home isolation • News reporter hided in the hospital to get the first hand information • The Mayor refused the transferred infectious patient • People against the medical wasted • Senior medical officer remoted control/command for the disease control

• Physician / nurse asked for temporary leave

What happen during SAS in 2003

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Meso level – Hospital administration• Many Hospitals refused infectious patient. Hospital was working alone at that time

• No restriction for the discharged patient

• Hospital under reported of infectious cases: in considering of the operation and income of the hospital

• Freely movable of the nursing aid

• Hospital infections control was not the major issue in Hospital Accreditation

• The consideration in private hospital

Macro –level - National level / infectious control policy

• Remote area / island : inadequate health facilities • Referral system broken• Absent of effective infectious control policy

What happen during SAS in 2003

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• “I thought, oh wow, SARS has returned!” he told Taiwan Business TOPICS in an interview. But he said he felt confident that if it did turn out to be another appearance of the SARS coronavirus (of which no cases have been reported since 2004) and were to make its way across the Strait, Taiwan would have no problem defending against it. Taiwan had the experience and would be prepared to keep the contagion under control.

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• “Doctors now ask their patients about their TOCC,” Chen says, using an acronym that stands for travel history, occupation, contact history, and cluster – whether or not they had engaged in any group activities in the time period leading up to their illness.

• “We now have a very good computerized system for customs and immigration that can show us very easily which destinations people have previously visited,” says Chen. “Through data collected from our National Health Insurance system…

Minister of Health and Welfare Chen Shih-chung, left, and Vice President Chen Chien-jen

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Daily press conference

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20 million

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Tracing social contact App

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Comparing 7 different ‘washing hand’ posters by PREDICTIV project

The practice of health literacy

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Local government - New Taipei City

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Health system respond to Covid-19 pandemic

National

Local

OrganizationHealth Promoting

Health service

Individual Patient / family

Macro-level

Meso-level

Micro-level

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What is health promotion?

Health promotion enables people to increase control over their own health. It covers a wide range of social and environmental interventions that are designed to benefit and protect individual people’s health and quality of life by addressing and preventing the root causes of ill health, not just focusing on treatment and cure.

1986 World Health Organization (WHO) Ottawa Charter for Health Promotion

Empowerment

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Key concept of Health Promotion

3 strategies • Enable • Mediate• Advocate

5 Domains • Building healthy public policy• Create supportive environment• Strength community action • Development personal skills• Reorient health services

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• Combined use of the Ottawa Charter strategies are far more effective than single strategy• Combination can be adapted for use in different settings• The population should be involved in the action and decision making process• Learning and communication, granting autonomy to the communities and population.

Development of Health Promotion

Health promoting hospitals Health promoting schools

Safe Community Healthy City Healthy Community

Healthy workplace

Jakarta Declaration on Leading Health Promotion into the 21st Century (1997)

The Bangkok Charter for Health Promotion in a Globalized World (2005)

Ottawa Charter for Health Promotion (1986)

Building Healthy

Public Policy

Creating Supportive

Environment

Strengthening Community

Action

Developing Personal

Skills

Reorient Health

Services

Helsinki Statement (2013), health in all policies, universal health coverage

Shanghai Charter Health Promotion (2016) Healthy cities and Health Literacy

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9th Global Conference on Health Promotion, Shanghai 2016

Health Literacy is an important factor in improving health outcomes

Increase knowledge to help people to make healthiest choice and decision for themselves or theirs family to achieve the goal: Empowering citizens Reducing health

inequities

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Empowerment Framework - 4 dimensions

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Empowerment

Participation

Supportive network

Supportive network

Resources

Training/Information

Training/Information

The first international HPH conference 2007 The first membership certificate 2005

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HPH Regional and National Networks 2006

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The development of HPH in Taiwan

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0

50

100

150

200

250

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

529 41

61 67 79 93

131151 160 163 163

142 140

91

184202Health Promotion Hospital

Healthy Hospital

NO.

2006Joint WHO

HPH international

network

2008HPH accredication

2012Empower local

government to joint the program

2017Integrating health

hospital

The milestone of HPH development

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1. 管理政策2.病人評估3.病人的資訊與介入4.推動健康職場及確保臨床健康促進的能力5.執行與監測6.高齡友善7.以人為中心之照護8.氣候行動

管理政策 病人評估 病人的資訊與介入 推動健康職場 執行與監測

1. 管理政策2.病人評估3.病人的資訊與介入4.推動健康職場及確保臨床健康促進的能力5.執行與監測6.高齡友善7.節能減碳

2006-2016

2017-2020

2021-

HPH certification

Healthy Hospital(HH) certification 1.0

Healthy Hospital(HH) certification 2.0

Level of Health Hopital (HH) hospital

Healthy Hospital-Advance level

WHO-HPH-46 items Age-friendly Healthcare-18 items Tobacco Free Hospital-48 items Environment-friendly Hospital-10 issues

38 items

Healthy Hospital-Basic level

Using PFM(patient-

focused method)

UsingPaper review

Or PFM

Pay for performance

Service indicator1. Responsibility2. Quality of care 3. health literacy

Demonstration Center

Cancer diagnosis and treatment quality certification hospital

Baby-Friendly Hospital Tobacco Free Hospital

2020 Healthy Hospital Certification 2.0 Simplify & integrates (27 items) Aging-friendly Person-centered care Climate Action Certified by Gold/Silver

Regular reporting and health information

Healthy hospital 2017 Integration of different certification

Health Hospital Accreditation 健康醫院認證 (2017)

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01

StandardLow carbon hospital

06

01

Policy and Leadership

02

Patient Assessment

03

Patient Information and Intervention

Promoting a Healthy Workplace and Ensuring Capacity for CHP

04

Implementation and Monitoring

Age-friendly Healthcare

05

07

Health literacy social ecological model (HLSEM)健康識能的社會生態模式

43McCormack, et al., Improving low health literacy and patient engagement: A social ecological approach, Patient Educ Couns 2017 Jan;100(1):8-13

病人參與 健康識能

Health Literate OrganizationGuidebook and Toolkit

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Healthy Hospital Accreditation 2.0 (2021)

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0607

08

0101

Policy and Leadership

02

Patient Assessment

03

Standard

Patient Information and Intervention

Promoting a Healthy Workplace and Ensuring Capacity for CHP

04Implementation and Monitoring

Age-friendly Healthcare

05 People-centered health care

Climate action

Healthy Setting

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Hospital

Medical CenterRegional HospitalDistrict Hospital

Primary care

ClinicPublic Health Center

Long term care

Long-term Care FacilitiesNursing Homes

Health Promotion and Health Services Health Literacy Age-friendly Health Promotion Environment-Friendly Tobacco-free Person-centered

HH 2.0

Certification of Age-friendly

Certification of Age-friendly

Certification of Age-friendly

New HPH standards from International Network (2020)

• Standard 1: Demonstrating organizational commitment for HPH – Substandard 1: Leadership – Substandard 2: Policy– Subdimension 3: Monitoring, implementation,

and evaluation

• Standard 2: Ensuring access to the service– Substandard 1: Entitlement and availability – Substandard 2: Information and access– Substandard 3: Socio-cultural acceptability

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• Standard 3: Enhancing people-centered health care and user involvement– Substandard 1: Responsiveness to care needs – Substandard 2: Responsive care practice– Substandard 3: Patient and provider

communication – Substandard 4: Supporting patient behavioral

change and patient empowerment– Substandard 5: Involving patients, families,

caregivers, and the community– Substandard 6: Collaborating with care

providers

• Standard 4: Creating a healthy workplace and healthy setting– Substandard 1: Staff health needs,

involvement, and health promotion– Substandard 2: Healthy setting

• Standard 5: Promoting health in the wider society– Substandard 1: Health needs of the

population – Substandard 2: Addressing community health – Substandard 3: Environmental health– Substandard 4: Sharing information, research,

and capacity

New HPH standards from International Network (2020)

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What happens after Covid-19 on HPH-at early stage of Pandemic -

Outpatient clinic visit decreased 5 million /Jan-March 2020

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The impact of Covid-19 on NCD, Age, Gender

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• The risk factors for COVID 19 mortality

– Male： 1.76 X

– > 65 Y/O： 6.06 X

– Smoking： 2.51 X

– DM： 3.68 X

– Hypertension： 2.72 X

– CV disease： 5.19 X

– Respiratory ：5.15 X

Z. Zheng, et al., Risk factors of critical & mortal COVID-19 cases: A systematic literature review and meta-analysis, Journal of Infection,https://doi.org/10.1016/j.jinf.2020.04.02

Today:

• Italy: Among those dying of COVID-19 in hospitals, 68% had hypertension and 31% had type 2 diabetes.

• India: 30% fewer acute cardiac emergencies reached health facilities in rural areas in March 2020 compared to the previous year.

• Netherlands: The number of people newly diagnosed with cancer dropped by 25% as a result of the lockdown.

• Spain: Among patients with severe COVID-19 disease, 43% had existing cardiovascular diseases.

Since the COVID-19 outbreak, people living with NCDs are more vulnerable to becoming severely ill or dying from COVID-19

Source: https://www.who.int/teams/ncds/covid-19

SDG 3.4

The world is at a critical juncture. The execution of a forward-looking strategy inclusive of NCDs is required to build back better.

Build back better tomorrow:

• Build bridges between national humanitarian emergency plans and NCDs responses

• Address the historic underinvestment in NCDs, call for new international funding patterns, a reset of global initiatives, and build new partnerships for NCDs.

• Develop systematic approaches to digital health care solutions for NCDs

2019 2030

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https://www.bertelsmann-stiftung.de/en/topics/aktuelle-meldungen/2018/januar/patients-value-dr-googles-versatility/

NCD – Video consultation

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Diabetes self-management APP-

Recording personal healthy number

- human coaching- education information

Develop healthy life style Manage and reduce the risk of type

2 diabetes

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My Health Bank

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Heightening the awareness

of self-care

Reaching self-data anytime

anywhere

Telemedicine, eHealth, telehealth, telecare and mHealth

Int. J. Environ. Res. Public Health 2014, 11, 1279-1298

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Prospect of 3P

Person-Centered Care

Practice-oriented

Person Digital Health

Get a modern PowerPoint Presentation that is beautifully designed.

Health Literacy SDM

Integrate Multimorbidity ICOPE

Mobile Health for Ageing (mAgeing)

PHR (Personal health record))

Health system respond to Covid-19 pandemic

National

Local

OrganizationHealth Promoting

Health service

Individual Patient / family

Macro-level

Meso-level

Micro-level

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Life after Covid-19 pandemic

People will have to change their behaviorto prevent second waves of the virus.

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Source: https://www.economist.com/international/2020/07/04/covid-19-is-here-to-stay-the-world-is-working-out-how-to-live-with-it; https://www.atlassian.com/blog/teamwork/lessons-of-pandemic-change-company-culture

How the new normal will change company culture for good. Remote work will be normalized (finally) Business strategy will focus on adaptability

How Culture Affects Your Decision to Wear a Mask?

EAST

WEST

(Source: https://kknews.cc/zh-cn/entertainment/5g64o58.html; https://m.juksy.com/archives/91228; https://www.scmp.com/news/china/society/article/3075211/face-masks-and-coronavirus-how-culture-affects-your-decision)

https://www.thelancet.com/journals/lanwpc/homehttps://doi.org/10.1016/j.lanwpc.2020.100044

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Source: English Island

Social isolation Social distancing Physical distance

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社交疏離 社交距離 地理疏離

Regarding older people and also those with underlying health conditions, having been identified as more vulnerable to COVID-19, and to be told that you are very vulnerable, can be extremely frightening and very fear-inducing.

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Eating together through internet –Social connection

Reflection- Confronting the “Multiple Existential Threat” -

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COVID-19 and SDGs

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“devastating” effect on human health

Source：impact hub taipei

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The relevance of healthy goal and other goals

HealthGoal 1: End povertyTarget 1.3: Implement social protection system for all

Goal 1: End povertyTarget 1.3: Implement social protection system for all

Goal 4: Ensure inclusive and equitable education…Target 4.2: ensure to access to early childhood development, care and pre-primary education…

Goal 4: Ensure inclusive and equitable education…Target 4.2: ensure to access to early childhood development, care and pre-primary education…

Goal 5: Achieve gender equality and empower all women and girlsTarget 5.2: end all forms of violence against all women and girl…

Goal 5: Achieve gender equality and empower all women and girlsTarget 5.2: end all forms of violence against all women and girl…

Goal 6: Ensure availability and sustainable management of water and sanitation for allTarget 6.1: achieve universal and equitable access to safe and affordable drinking water

Goal 6: Ensure availability and sustainable management of water and sanitation for allTarget 6.1: achieve universal and equitable access to safe and affordable drinking water

Goal 2: End hunger, achieve food security and improve nutritionTarget 2.2: end malnutrition, achieve target for reductions child stunting and wasting

Goal 2: End hunger, achieve food security and improve nutritionTarget 2.2: end malnutrition, achieve target for reductions child stunting and wasting

Goal 16: Promote peaceful and inclusive societies for sustainable development…Target 16.1: reduce all forms of violence and related death rates everywhere

Goal 16: Promote peaceful and inclusive societies for sustainable development…Target 16.1: reduce all forms of violence and related death rates everywhere

Reference：The Sustainable Development Goals: The implications for health post-2015

Other goals and targets e.g. 10(inequality), 11(cities), 13(climate change)Other goals and targets e.g. 10(inequality), 11(cities), 13(climate change)

People, planet and participation: The

Kuching Statement

• People: People’s physical, mental and social wellbeing is the core business of cities. . . . successful cities put the focus on quality of life.

• Planet: People cannot thrive without the Earth’s support systems or the biodiversity of natural ecosystems.

• Participation: In order to put people and the planet at the heart of governance, healthy, just and sustainable cities engage fully with their citizens and community organizations.

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IUHPE – Global Health Promotion Vol. 28, No. 2 2021 69

“We cannot re-write the chapters of history already past, but we can learn from them, evolve and adapt. The new normal may even be a better normal, certainly a different normal”

A quote from Ian Davis, Managing Partner at McKinsey, in his article ‘The New Normal’

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Healthy At Home

• Eating healthily• Staying physically active

Digital Health Reforms

• Digital interactive technology platform

• Personal App for self-management

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• Can “HPH 2.0” develop a more resilience health service in the

changing world?

• Do we need “HPH 3.0”?

Einstein is quoted as having said that if he had one hour to

save the world he would spend fifty-five minutes defining

the problem and only five minutes finding the solution.

Take home message

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促進健康 Promotion,預防疾病 Prevention,安全防護 Protection,共同參與 Participation,夥伴合作 Partnership!

⺠眾參與Person engagement ⺠眾增能Person empowerment

⺠眾為中⼼的照顧Person-Centered Care

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