When companies, governments, universities and healthcare institutions work in tandem to push the frontiers of knowledge, they become a powerful engine to find innovative solutions to major social problems including health.The article talks about the healthcare scenario in Sweden and how the country is reforming its healthcare system to benefit its people.

Across Europe the rising cost of healthcare,caused among other things by the ageing of the population and the parallel rise in chronic illness; has made policymakers support the development of more effective preventive measures and early diagnosis products. At the same time, patients have started to take more responsibility for their own health, treatment and care, thus becoming a major cost driver of the healthcare system.

Innovation within material sciences, genetics, biotechnology and computational information has escalated in recent years, bringing significantly improved chances of

surviving disease. In Europe and especially in Sweden, patient-centered care, evidence-based care, and early detection are dictating the path to follow for designing the healthcare of the future.

Sweden spends about 11% of its GDP on health care and nearly 80% of it is publicly financed. Healthcare expenditure as percentage of GDP is higher in Sweden compared to many countries of similar or larger size.

The following are some of the major innovations and reforms introduced during the last years for containing costs.

• A shift from hospital inpatient care towards outpatient care at hospitals and primary care facilities

• More choice of provider, competition and privatization to support the development of primary care

• Regionalization of health care services including mergers between county councils

• Privatization of the pharmacy sector

• Continued specialization and concentration of services within the hospital sector

• National reforms for shortening waiting times for services

• Cost-effectiveness and social perspective are becoming key indicators for reimbursement.

Health economics is a priority for the 21 county councils and 290 municipalities in charge of health provision in Sweden. Some of the latest initiatives include:

• New mechanisms to support evidence-based and cost–effective vertical priorities

• Health outcomes and benefits from the patient perspective

• Process orientation

• New valid performance indicators

• Increase abilities to monitor performance on a regular basis by investments in health quality registers and new information technology

Cost-effective methods for early diagnosis and treatment can anticipate future societal costs

The Swedish Cardiopulmonary Bioimage Study (Scapis)

The Swedish CardioPulmonary BioImage Study, one of the largest studies of its kind in Sweden, is a major joint national effort to reduce mortality and morbidityfrom cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD) and relatedmetabolic disorders, all of which are important issues for public health. A Swedish cohort of 30,000 men and women aged 50-64 years are characterized with help of advance imaging techniques (Ultrasounds, MRI, Computer tomography, 3D ECG, etc.) together with information obtained by proteomics, metabolomics and genomics.

A comprehensive pilot study with over 1000 patients were completed at the

Sahlgrenska University Hospital in West Swedenin 2012 and recruitment to the nationwide multicenter study is ongoing.

Centre for imaging and intervention at Sahlgrenska University Hospital

In 2015, a new centre for imaging and intervention opened at the Sahlgrenska University Hospital, one of the largest hospitals in Northern Europe.

The center is unique among the Nordic imaging centres in that it was initiated by a hospital, rather than by academia. The regional health authorities have recognized that advanced imaging and intervention are critical not only to the provision of the best healthcare possible but also to making the care cost-effective. The newly built 21 000sqm-center houses Hi-tech operating rooms with advanced imaging equipment such as gamma and PET cameras, X-rays, computed tomography, ultrasound and magnetic resonance.

Academy, healthcare, county council and Industry are already collaborating in a model in which technology development and transfer can evolve from the traditional ‘pull’ and ‘push’ model to an integrated process in which problems and solutions are addressed on a day-to-day basis.

The use of microwave techniques for the treatment of hyperthermia of deep seated cancer tumours; breast cancer detection with microwave tomographyorstroke diagnostics are some of the cross-disciplinary collaborations that have resulted of this long-term strategic triple helix collaboration.

Smart textiles with medical applications

Companies, universities and research centers in western Sweden have been collaborating for almost a decade now around the design, development and production of the next generation of textile products.With Smart textiles, a large part of the health monitoring can be done from home in the future. One example is a regular shirt with integrated sensors that can be used to measure breathing and heart activity and thereby reducing the number of visits to the hospital. Textile based sensors made of conductive fibres incorporated in clothing to record electrical activity from the heart (ECG), brain (EEG), or muscles (EMG), might become part of the future health care of patients suffering from sleep apnea, breathing difficulties or stress-related conditions.

When companies, governments, universities and healthcare institutions work in tandem to push the frontiers of knowledge, they become a powerful engine to find innovative solutions to major social problems including health.However, product innovation, value networks and ecosystems alone will not be enough. How we innovate and connect with customers and patients is crucial. We need to involve patients and patient organizations in the innovation process and decision-making. We need to take the time to see the patient in all aspects of his life. It might be the best alternative for both providing more quality care and at the same reducing the spiralling healthcare costs.

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In most other countries, the constitution requires the government to provide some form of healthcare. The implementation, however, suffers from deficit of policy, government or resources even in the countries that consider healthcare as a part of social justice. The Author talks about how India can lead with innovations in legislation, policy, governance and finance to provide health for all.

Adequate healthcare is both, a prerequisite and a consequence, of the growth of a country. A health system can deliver public health and medical services, if its solid foundation includes skilled workforce, information systems, medical products, technology, adequate financing and governance. While technology can provide innovative tools to improve health, it is the regulatory framework whichcan provide the enabling ecosystem. It is important that Innovations not be limited to drugs and devices but also include regulations.Ultimately,it is laws that determine financing and structure of healthcare.

The nations of the world have included healthcare in their legal framework in some form.Almost all countries are signatories to one or more international human rights or health rights declarations.

One third of the countries include healthcare as a constitutional right for individual citizens. Russiaand former countries of the Soviet bloc Italy, Spain, Brazil, Philippines and South Africa have maintained health as human right in their constitution. On the other end of the spectrum are countries like the USA, which have no individual constitutional right to healthcare.

In most other countries, the constitution requires the government to provide some form of healthcare. The implementation,however, suffers from deficit of policy, governance or resources even in the countries that consider healthcare as a part of social justice.

India extrapolates health rights from other parts of the constitution.The right to health in India is outlined the Directive Principles of State Policy- Articles 42 and 47 and the fundamental right to life as stated in article 21.

Article 42 states that the State shall make provision for securing just and humane conditions of work and for maternity relief.

Article 47 states that the State shall regard the raising of level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties and, in particular, the State shall endeavor to bring about prohibition of the consumption, except for medicinal purposes, of intoxicating drinks and of drugs which are injurious to health.

Article 21,“The Fundamental Right to Life” guaranties individual life.

The Indian judiciary has interpreted the “Right to Life’ in many ways. It has held that humane working conditions, health services and medical care are an essential part of Article 21. Public interest litigation, as well as litigation arising out of claims made by individuals,has generated substantial case law showingright to health is an integral part of the Right to Life.

For technological innovations to flourish in its current stage of development, India needs more proactive regulations to progress towards universal healthcare.

Currently the Indian government spends about 1 percent of GDP on healthcare. Compare that to 3 percent in China and 8.3 percent in the USA. Private expenditure on healthcare is in addition to public expenditure; approximately 70% of health expenditure in India is from private sources.

A study done by PGI Chandigarh, suggests that universal health care services for entire 1.2 billion population, the annual cost of providing preventive and curative services will be INR 2415 billion (USD 54 billion). This would amount to increasing the allocation to health sector from current nearly 1% to 3.8% of GDP.

Indian business association, FICCI and consultants EY, estimated in 2012 that universal health cover would require government health spending to increase to 3.7-4.5 percent of GDP.

The current government, under the National Health Assurance Mission, would provide all citizens free drugs and diagnostic treatment and insurance cover to treat serious ailments. It would cost an estimated $11.4 billion annually.

In 2010, a High Level Expert Group on Universal Health Coverage recommended increasing public financing from 1% of the gross domestic product to at least 2.5% to provide essential health care package through tax funding and employer-provided insurance.

The Lancet published an India focused issue on health in Jan 2011. The lead authors (K SrinathReddy, Vikram Patel, Prabhat Jha, Vinod K Paul, A K Shiva Kumar, Lalit Dandona),summarized the recommendations of various working groups as ‘call to action’ as follows. They propose the following targets to be achieved by 2020 through the creation of the Integrated National Health System with three overarching goals: ensure the reach and quality of health services to all in India; reduce the financial burden of health care on individuals; and empower people to take care of their health and hold the health-care system accountable.

Service delivery

• The entire population should be covered by an entitlement package of health care with

financing from a combination of public, employer, and private sources. Full range of relevant diseases need to be included in the entitlement package of health services with cost-effective interventions that include health promotion and disease prevention.

• All health practitioners and facilities in the public and private sectors have to be registered with the Integrated National Health System.

Health Financing

• Public spending on health should be increased from 1% to 6% of the gross domestic product, and 15% of tax revenues—including new taxes on tobacco products, alcohol, and food with little nutritional value—should be earmarked for this purpose.

• Reduce the proportion of out-of-pocket spending from 80% to 20% of the total health expenditure.

• Increase spending on health research to 8% of the health budget.

Human resources for health

• Establish the Indian Health Service with guidelines developed through an autonomous National Council for Human Resources in Health.

• An updated training curriculum should be fully in place for medical and allied professions that is relevant to the situation in India.

• Establish suitable incentive structures to retain health providers in underserved areas.

Health information system

• Have in place comprehensive health information and surveillance system that covers all major diseases, health-system issues, and key social determinants, which also facilitates assessment of public health interventions.

• Establish adequate research capacity in India to investigate and report key issues that affect the health system and policy for further improvements.

• Have in place a fully functional autonomous council that compiles and synthesizes relevant information to develop guidelines for evidence-based health care and its assessment.

Drugs and technology

• Implement a national network of pharmacies for generic low-cost drugs for the entire population.

• Establish mechanisms for bulk purchase of patented drugs at low cost.

• Have in place mechanisms to check and control the use of perverse incentives by pharmaceutical and biotechnology companies for health-care providers.

Governance

• Have in place mechanisms to make functional the components of the National Health Bill.

• Have a system in place that requires all middle and senior functionaries in public health to have relevant training in public health.

• Ensure devolution of responsibility for health care to district management systems along with accountability mechanisms and explicit community participation (The Lancet, Jan 2011).

India, at current stage of development needs more healthcare in every form and not less. Multiple studies have confirmed the fiscal feasibility and for technological innovations to flourish we needs a progressive enabling ecosystem.

Opposition to right to health emphasizes that it could increase the fiscal deficit;it could create shortage and increase the wait time for medical services, which would lead to rationing and lower the quality. It could also cause people to overuse health care resources. While appreciating valid opposing view, human development is not possible without guaranteed healthcare. Financial burden of a single episode of disease pushes millions of Indians into poverty, which stifles the market for technological progress.

Health and longevity have improved as never before in human history. And with explosive growth in the knowledge of human biology and genetics, it is likely that the life span will increase exponentially. It may even change the very definition of health to include happiness, intelligence and aesthetics as components of a new paradigm. It is imperative that innovations in legislation, policy, governance and finance will have to stay ahead of the burgeoning technologic innovations and not fall behind to irrelevance. It is important to have innovative strategic thinkers in the leadership positions that understand biology, healthcare, governance and finance.

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ScanBalt BioRegion is a macro-region within health and life sciences encompassing Denmark, Estonia, Finland, Iceland, Latvia, Lithuania, Norway, Poland, Sweden, Northern Germany, Northern Netherlands and North-western Russia (The Baltic Sea Region). The region has more than 50 health care clusters and networks, which are mainly triple helix-based regional networks with coordinated involvement of public institutions, authorities, administration and private companies.

ScanBalt BioRegion is home to more than 50 university hospitals and 60 universities with a health and life science focus  including 25 with a focus on medical technology and 75 health care sector science parks. The region is  host to at least 3000 companies within health and life sciences.

ScanBalt BioRegion is a flagship in the European Union (EU) strategy for the Baltic Sea Region and has, since 2002, acted as a smart specialization platform, promoting coordinated funding between various EU funds, national and regional public-private financing.

Strong market drive in the healthcare sector[1]

Demographic shift is a major engine of the healthcare sector throughout ScanBalt BioRegion. Every segment of the health sector across the entire region is currently growing. While the population of the Nordic countries is constantly rising, Germany, Poland and the Baltic States are confronted by declining population. This shift may of course be affected by current and future migration tendencies.

Consequently, the demand for medical supplies and services is growing at an above-average rate, especially in the areas of nursing, geriatric and psychosocial care, palliative medicine, preventative medicine, rehabilitation, sport, wellness, health and Ambient Assisted Living (AAL).

In particular, ScanBalt BioRegion is a dynamic growth market for medical technology.

Poland and the Baltic States have a great need to catch up in the area of technical medical equipment (and the more stringent technical and hygiene standards of the EU). The demand for efficient and high-grade technical medical equipment (such as surgical installations, diagnostic apparatus, monitoring systems and tele-medicine) in the northern and western parts of the Baltic Sea Region is also on a continuous upward trend.

There are large-scale modernization and expansion plans in the pipeline in the hospital sector across the region. A decisive role is played by the EU development funding in Poland and the Baltic States. There are still differences across the Baltic Sea Region in terms of the frequency and quality of the available medical treatment and an increase in cross-border patient streams is anticipated. Thus specialization, cooperation and common quality standards are needed throughout the region.

In the medium and long term, ScanBalt BioRegion is among the most dynamic healthcare markets in Europe. Healthcare spending in Poland and the Baltic States is growing at a disproportionately high rate and is fast approaching the average for Europe. For several years, the growth of employment in the health sector has been remarkably more dynamic in the entire ScanBalt BioRegion than that of employment overall (except in Sweden).

Promoting innovation

Health care is split into sectors which function separately: health care providers, enterprises & research institutions, regulatory and financing institutions. Support for innovation to develop new products and services thus has to be addressed in a holistic way. Focus on value creation and societal usefulness is essential for the long-term stability of health care systems. Unmet health needs and user-driven innovation are the key success factors for a thriving innovation system.

As models of care evolve and needs change, there is a need to bridge the existing cross- sectored gaps by involving key regional actors in the value chain of healthcare innovation[2]. The main objective is to support the creation of sustainable, cost-effective, citizen-centric healthcare systems, promoting new jobs and businesses.

A key element is to strengthen trans-national and cross-sectored approaches for launching projects and initiatives aiming at removing disparities, gaps and barriers and fostering cooperation for innovation within the health economy, in order to overcome the major societal challenges and bring innovative products into the market. A ScanBalt BioRegion health care innovation ecosystem provides a promising model implementing innovation support activities in a macro-regional context, with a complex network of entities and relationships. Such an ecosystem in ideal form ensures that all individuals are given optimal conditions to apply their skills and competencies, while contributing to the interconnectedness and interdependency of all stakeholders[3].

Smart specialization and coordination between funding

Smart specialization should prioritize domains, areas and economic activities where regions or countries have a competitive advantage or have the potential to generate knowledge-driven growth and to bring about the economic transformation needed to tackle the major challenges of the society, nature and environment. [4] To have a smart specialization strategy calls for making choices in investment-related matters. Thus, smart specialization and coordination in funding are closely connected.

Collaboration in ScanBalt BioRegion not only assists to promote smart specialization in the region and distribute best practices, but also takes a much more active role by building and implementing a macro-regional strategy based on the principles of smart specialization, which can be reflected into national or regional policies.

It is a process of consensus setting within the regions, identifying top priorities and appointing leaders and ambassadors of various concrete initiatives, having the capacity to drive them forward. This process has been going on in ScanBalt BioRegion since 2001. However a macro-region has a potential much wider, ensuring alignment between the structural funds and the EU policies. In particular, macro-regional collaboration can mobilize regional and national investments, which otherwise would not have been available for trans-national collaboration following a common vision and strategy for the macro-region.

In ScanBalt BioRegion this is most clearly seen by the role of regional liaison offices who invest into trans-national collaboration within topics of their particular interest and where they have a specific competence, although still referring to the overall strategy for ScanBalt BioRegion.

Collaboration outside ScanBalt BioRegion

While it is a top priority to build up the internal innovation ecosystem in ScanBalt BioRegion, collaboration with other regions and countries is of huge interest as well. ScanBalt BioRegion is actively trying to promote partnering with other EU macro-regions such as the Danube Area or the Mediterranean.

This is mainly handled via various EU projects. Outside the EU, focus has so far been mostly on Vietnam where there are ongoing projects of training of medical doctors. Collaboration with India is an exciting new topic, which can combine the forces of two fast growing health economies and result in new business opportunities. The focus of the Indian government on biotechnology is a very good background for such efforts. In any case ScanBalt BioRegion together with the partners always tries to contain the efforts in projects, which ensure concrete deliveries.

Of course the individual regions, clusters, networks, universities and industries in ScanBalt BioRegion, all have their own priorities and activities for collaboration but ScanBalt BioRegion is an add-on to their individual efforts and may serve as a one-stop-entry and facilitate the processes.

ScanBalt® fmba: the organization promoting health economy on Top of Europe

ScanBalt® fmba is a not-for-profit association representing Scanbalt BioRegion. The ambitions of the regions and the regional networks constitute the basis of the organization. The mission is to make ScanBalt BioRegion a globally competitive Health and Bio economy.

The vision is to be a catalyst, facilitator and developer of concrete projects and strategies; to provide a platform for collaboration and visibility and to Influence and modify relevant policy agendas. ScanBalt aims to provide added value for the members in their pursuit of regional ambitions and promote mutual beneficial relationships between them. It acts as a cost-efficient value-added service provider and the members have a direct return of investment on their membership of approximately 15:1 on average.

The key activities are:

Think Tank: Continuous dialogue between regions, clinics, clusters, SMEs and funding sources

Accelerator: Workshops for concrete projects ideas in the pursue of funding

Match-making: Between health care and tech providers, investors and decision makers

Communication: ScanBalt News (approx 20,000 subscribers), web, social media, events

It is possible for regions, companies and institutions located outside the ScanBalt BioRegion to become associated members, which in essence have rights, services and benefits equal to other members. This may be a tool to promote interaction with potential partners in the region.

References:

[1] Based on: The Health Economy in the Baltic Sea Region: Challenges and Opportunities, ScanBalt Nov 2013 – A publication from the BSHR HealthPort project co-financed by the Baltic Sea Region Programme 2007 – 2013.

[2] Driving cross-sectoral innovation in health and life sciences – An Innovation Agenda for the Baltic Sea Region Health Economy; BSHR HealthPort, Oct 2013, http://scanbalt.org/projects/finalised+projects/bshr+healthport/reports

[3] Blank, W., Frank, P., & Karopka, T. (2013). Health and Life Sciences as Drivers for Regional Development and Prosperity in the Baltic Sea Region. Journal of East-West Business, 19(1-2), 122–137.

[4] http://s3platform.jrc.ec.europa.eu/ris3faq#1

About the author

Peter Frank, General Secretary of ScanBalt® fmba since 2004. He has more than 18 years’ experience with cluster development and management, public-private innovation collaborations and public affairs. In addition he has worked as a researcher and as an auditor.

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