Rush University Medical Center in Chicago decided to transform its culture into one where the fires simply don’t get started in the first place.

After implementing the first stages of its new programme, the Continuous Pursuit of Excellence (CPE), “we are getting really tremendous results,” says Richa Gupta, MBBS, MHSA, Rush’s vice president for performance improvement and operational effectiveness, who has led the planning effort. 

Employee engagement has improved across the board in those areas that were part of the first-year demonstration of how the system would work. In one inpatient surgical unit, patient satisfaction scores rose to 87 per cent in 2017, exceeding the target of 81.5 per cent. Employee engagement scores in the same unit zoomed from 42 per cent in 2016 to 61 per cent in 2017. Fewer patients experienced preventable harm at Rush in 2017 than in 2016, and more than one major equipment expense was averted.

After this first, yearlong test of its new way of approaching management of patient care, Rush leadership is convinced they can create an environment throughout the hospital in which satisfied patients and staff are the norm, mistakes are few, wait times are brief, and equipment is used so efficiently that less of will be needed over time.

An “Institutional Mindset Change”
CPE is not a project, it’s an institutional mindset change. “To do healthcare well, you have to use these improvement tools everyday in the continued support of excellence. This is how we are going to run our organisation,” Gupta says.
How has Rush developed this vigorous new approach? The hospital, which both Vizient and U.S. News & World Report consistently rank among the best in the U.S., is part of a relatively small cohort of hospitals so far to adopt a “lean” culture, while at the same time putting the well-being of the patient front and centre.

A Model of Efficiency
That term, “lean,” has many meanings. But this use originates in a distinctive culture rooted in respect for people and continuous improvement fostered by Japanese car manufacturer Toyota in its factories and even its suppliers. A lean enterprise works assiduously to reduce waste in every department and activity while maintaining peak production. The approach requires the engagement of employees from the top of the organisation to the bottom, and typically a re-imagining of the role of leadership as well. Lean values have made inroads in recent years into American business, education, and other industries; now they are coming to healthcare. 

Rush executives have been thinking about making this change for a while. The hospital engaged JWA Consultants of Mercer Island, Washington., to assist in their “lean journey.” Senior managers travelled to a non-healthcare setting and a few different hospitals to see how the approach works, to understand the commitment and the “change in mindset” required, and to get a sense of the infrastructure and management system they would need to set up.

Then, Rush began its CPE journey. A primary goal of a lean culture is to “flip the pyramid” on its head, to empower the people who work closest to the point of care, with managers coming in as needed to support them.
“How do we get 10,000 problem solvers?” Gupta says, referring to Rush’s workforce. “Our frontline people know best what the problems are, and how to solve them. Managers don’t need to sit in offices telling people what to do; their role changes to supporting and coaching their teams.”

The lean system is a profound change from the traditional management style. “To tell leaders we want to lead differently is a bold ask,” Gupta says. “In most healthcare organisations directions flow from the top, but a lean culture really changes our role.”

Gupta’s staff implemented a new daily management system in the demonstration units, which gives structure and transparency to communications. A key innovation was the huddle, a daily event when the staff of a particular area gathers to assess what’s likely to come their way during the day. While CPE uses sophisticated methods to maintain its metrics, the heart of the programme is surprisingly low-tech, employing tools like colour-coded whiteboards to track how the day’s activities are progressing.

“In five seconds, from five feet away, you should be able to tell what’s going on in this unit just by looking at the board. Green dots signify smooth sailing; a blur of red is a day that needs management support to address issues,” Gupta explains. “The hands-on nature of the whiteboards helps staff engage. We want people to own what’s happening in their unit, to think about what they’re putting on the board. It’s meant to be very dynamic in nature.”

Rush staff are telling their managers that even though some have been working in healthcare for decades, they’ve never before been asked for their ideas about ways to systematically improve both the enterprise and their own daily work. 

“They love it,” Gupta says of Rush’s front-line personnel. “We’re seeing an increase in staff engagement in CPE areas that’s far higher than the rest of the organisation. This system gets people to understand and own their work. It offers a totally different level of empowerment.”

CPE in Action
Although patient care is a hospital’s business, patients aren’t widgets; they’re full of surprises. While it’s easy to get caught up in the technical changes, Gupta says, “We’ve also had 19 per cent reduction in patient harm, and an increase in patient satisfaction.” 

Bernard Peculis, Rush’s director of imaging services, notes that “in business, you can work to eliminate variants. In healthcare, every patient is different and has their own set of concerns. You have to see things coming, and be prepared to respond.” 

Peculis has been in the thick of the early stages of the transformation at Rush. He heads up the diagnostic imaging department, which has 10 different sections. Of those, the MRI and nuclear medicine areas were among the test units for the CPE, and have been picking apart their processes and putting them back together for about a year now. “Those two units have seen some real gains in term of operations efficiency,” Peculis says. Four additional imaging sections joined the programme last fall. 

Imaging is a major contact point for patients. “We want to ensure a positive experience,” Peculis says. “Then, we want to reduce the time it takes until the final report is available. We do this by minimising idle room or table time. As soon as one [imaging session] is done, the next patient is ready to go.”

In the past, the imaging department didn’t have a holding area. “The techs had to deal with issues with little or no warning. A new holding area has become critical to ensuring a smooth flow into the imaging area. It allows techs to get a sense of the patients as they present, and how they need to be prepared for their exams,” Peculis explains.

The results in the test areas have been impressive. Peculis anticipated having to acquire a fourth MRI machine, but he’s been able to defer that purchase. Instead, the department has substantially increased the number of patient tests per eight-hour shift on the existing scanners. “Historically, you’d have four to five cases per scanner on the first shift. Now, we’re doing seven to eight,” Peculis says. As a result, the wait time between a provider ordering a diagnostic test and the test starting has been cut from 16 to eight hours. Similarly, nuclear medicine personnel have rejiggered how they stack their work up through the day, and cut the number of cameras used from seven to three.

Empowering Employees
“It’s not just about the equipment, it’s also the staff,” Peculis says. “They’re focused on working efficiently. We’ve been so successful because our people are all engaged in taking accountability for the process.”

Like other Rush leaders, Peculis has seen his job change significantly with the implementation of the CPE, even though the initiative is relatively new. “I’ve had to get out of my head the concept that being in leadership means you need to have all the answers,” he says. “This is more about setting up an environment where people feel their feedback is valuable, and can drive change. It means being less directive and more supportive.”

Early on, it became clear that CPE doesn’t have an endpoint. “You just keep chipping away at obstacles as they crop up,” Peculis says. He especially appreciates the daily huddle, where everyone has a chance to “get their arms around what they have in front of them for the day. As a result, you’re less apt to have things blow up in your face.”.

Peculis is confident that CPE is worth the big changes it’s bringing to his department—and to Rush. “The end result is better service to the patient,” he says. “CPE is built around meeting and exceeding patients’ expectations about the care they receive.”

Specialists from London’s Harley Street Medical Area talk to Arab Health Magazine about how rounded, personalised treatment can help people fight this highly destructive illness. There are three world class clinics located in the area that specialise in the treatment of addition — Priory Wellbeing Centre Harley Street, Nightingale Hospital and London & Surrey Care.

“You can lead a horse to water, but you can’t make it drink.” That’s what we say, often with a sigh, when contemplating those people who are seemingly incapable of helping themselves. 

Lead addiction counsellor at the Nightingale Hospital in Marylebone, Raymond Dixon has a slightly different spin on this hoary old proverb. “You can lead a horse to water. You can’t make it for a normal life.” 

Dixon helps addicts of all stripes find their way into and through a series of treatment programmes — and, as a recovering addict himself, he knows all too well the barriers that can stand in the way of success.

The complex nature of addiction means that these barriers — physical, mental, emotional or practical — can vary from person to person. “We are never just dealing with addiction,” says Dr Najem Al-Falahe, medical director and lead consultant of London and Surrey Care. 

“We are always dealing with addiction plus something else. Always.” 

It’s for this reason that the addiction programmes available in the Harley Street Medical Area (HSMA) tend to adopt a holistic approach to the disease — treating the addiction’s root causes as well as its symptoms — that is highly tailored to the individual. Each programme begins with a comprehensive assessment of the medical history and personal and professional life of the patient.

 “Sometimes we can end up seeing the family, without the patient, for six months,” Dr Al-Falahe explains. 
“That’s because patients who suffer from addiction are in denial and we need to work with the family to create the right setting for the patient to accept starting the treatment. Patients need to feel like we are here for them non-judgmentally, and they need to understand the journey they are on.”

This emphasis on understanding is all a far cry from a few decades ago, when Dixon himself was undergoing treatment and attitudes were “quite punitive”. The once-dominant idea that if you are an addict “you are a bad person and you need to just stop what you are doing” is fading — slowly. Today, the prevailing understanding is that addiction has nothing to do with moral fibre, and everything to do with having a bona fide disease: a health problem that requires treatment, not admonishment.

Addictive behaviours are driven by changes to neurochemical and molecular activity in the brain. Dr Al-Falahe indicates there is a stark difference between the brain chemistry of an addict and a non-addict. 

“Two areas of the brain are affected: the limbic system, which rewards the addictive behaviour, and the pre-frontal cortex, which is involved in decision-making. It becomes a bit of a vicious circle — they don’t have control, so they go back to the substance, which rewards that behaviour, and so on. Addiction fulfils all the criteria of an illness,” he continues. “It is an illness that affects eight per cent of this country.”

This is the scale of the problem: four to five million people dragged down by drug or alcohol addiction and a dizzying array of related issues. Factor in the impact this has on friends and family, and the chances are that pretty much everyone in the country has been touched by this insidious, often ife-threatening disease. 

“One of the biggest failures in public health has been not taking on alcohol addiction with the same rigour as we took on smoking — one of the most successful health campaigns ever seen in this country,” says Dr Paul McLaren, adult psychiatrist at the Priory Wellbeing Centre Harley Street. 

“Alcohol is the biggest substance abuse problem. Yet public investment in tackling alcohol addiction remains disappointingly thin.

“When you talk about addiction, you are in essence talking about loss of control over a substance or behaviour that is causing you harm,” explains Dixon. 

“For it to be technically classed as addiction, your misuse needs to be marked by withdrawal symptoms and increased tolerance. So, where once you’d have been high on a line of coke, it now can take several lines.” 

So-called ‘addictions’ to gambling, sex, food and shopping are not technically addictions, though they resemble them in their impact on the brain’s reward systems. 

“They are classified as impulse control disorders,” he continues. “That said, the consequences and drive of these behaviours are exactly the same.”

Impulse control disorders evolve with the times. 
“One that’s been rearing its head a lot recently comes under the umbrella of technology ‘addiction’: mobiles, social media, gaming and so on. The key in this case is really, if they’re young, to spark their personal motivation: being realistic about the fact that while that might seem okay at 16, you’ll cut a pretty sad figure when you’re 27, jobless and alone.” 

It is early days. The compulsive potential of technology is not yet fully understood, and while Dixon’s persuasive approach, in tandem with other tactics like cognitive behavioural therapy, has proved fairly successful, he is all too conscious of a major challenge: that abstinence is not an option when it comes to something we depend upon every day.

“When you talk about technology or eating, these are things we cannot avoid on a daily basis — so dealing with the problem is all about controlling your relationship with the Internet or food, for example, rather than abstaining altogether.” 

This contrasts starkly with the abstinence model favoured by all three of the HSMA clinics when it comes to alcohol or drug addiction. One of the biggest concerns of Dr McLaren, as well as Dixon and Dr Al-Falahe, is the strand of thought that says an alcoholic can be restored to being a social drinker. 

“It’s what they call ‘harm reduction’. While it has its place for those using at harmful levels, I personally don’t think it helps with tackling addiction,” Dr McLaren insists. As Dixon points out, the whole basis of addiction is a fundamental loss of control. “It’s a contradiction in terms to try to teach control as treatment. You don’t say to the diabetic, ‘Just have one jam doughnut and you’ll be fine.’”

For Dixon, the three pillars that have underpinned Alcoholic Anonymous in the UK since 1947 remain at the heart of effective treatment. The first is that addiction is a disease; the second, that abstinence (as far as alcohol and drugs are concerned) is the only option; and the third, that the power of one addict talking to another is among the most effective cures. To these principles, those clinics at the forefront of addiction treatment have added the hallmarks of a more rounded approach: psychiatry, pharmaceuticals and practical support, such as debt management or relationship counselling. 

“If you have a gambling problem, and a debt of thousands, you aren’t going to be able to concentrate on treatment until that’s been cleared,” Dixon points out. Likewise, a marriage failing, legal problems, or issues in the workplace. Stress feeds addiction. “If we don’t address it, there is a high likelihood the patient will relapse.”

Programmes can take a long time —up to 14 months — and will likely involve multiple professionals, from GPs and psychiatrists to occupational therapists and marriage counsellors. HSMA clinics are also anxious wherever possible to involve and support the patient’s family. Some patients are treated effectively outside of the hospital environment, attending therapy sessions while maintaining their home and even their working life. Some are too dependent, or too physically ill, to be treated purely on an out-patient basis and require a period of hospitalisation.

Dixon, like many of the specialists in the Harley Street Medical Area, places great store by the power of abstinence and talking therapies to help restore equilibrium to the brains of addicts. Yet that doesn’t preclude looking to the developing areas of neuroscientific and genetic research. “On the contrary, all the clinics I speak to have a watchful eye trained on new findings emerging from centres in the UK and the U.S., and there is an expectation that new pharmaceuticals and diagnostic aids will soon emerge,” he says.

“Currently, pharmaceuticals are not magic bullets, but they can certainly help,” says Dixon. Medicines in use today generally fall into two categories: those that reduce an addict’s cravings and those that block the pleasure receptors in the brain. “Their effectiveness is only temporary — you need to find other permanent coping mechanisms while taking them,” Dixon continues. “The use of pharmaceuticals for us is really to help a patient during that treatment period, to readjust and change.”

“One of the most exciting areas of research is vaccination,” says Dr Al-Falahe. “These would render immunity to the substance in question — morphine, for example.” Another source of hope is an enhanced understanding of the conditions that may predispose someone towards addiction. “Why do some people try smoking once and are able to leave it, and others go on to be addicted?” he continues. 

As Dr McLaren points out, while there are always environmental factors at play, the existence of a genetic component to addiction has become increasingly plausible. One theory centres around there being an ‘addictive gene’, which can be activated by certain substances or circumstances, and can lie dormant until later in life: “There are a lot of people whose addictive use of alcohol doesn’t begin until their forties, fifties or sixties,” says Dixon. “There was a foot-break on this gene — their career, perhaps, or their children — but then they retire or their kids go off to university.” Gradually, what was one glass of wine a night becomes a bottle, then two, then three during the course of the day.

There are three basic stages along the path to addiction. “There is the social use of alcohol and drugs, where we have control. Most of us stay in this zone all our lives,” explains Dixon. 

“There is the abuse stage, which might be triggered through a crisis or through prolonged use, but it escalates and there is a partial loss of control. The third stage, into which a percentage of abusers will move, is dependency. That’s where control is lost. It is no longer a social activity, it is a coping mechanism — and there’s no going back to the abuse or social use stage after that.” 

What determines whether you end up there appears to be a cocktail of environment, experience and genetics. What determines whether you seek help or not is whether the reasons to quit become so overwhelming, you’d rather seek treatment than continue to drink or take drugs.

“By the time people reach us they’ve often lost their jobs, their marriage, their homes,” says Dr McLaren. “Their motivation is enormous —  but that motivation fades as they get better.” That’s why post-treatment support groups are so important, be that Alcoholics or Narcotics Anonymous, or one of the many alternative support programmes. 

“Some people last a week and then relapse. Some people last a year and then relapse. Some people last 20 years and then relapse.” The key is the follow-up and the involvement of friends and family. “If you only open the door, the probability of relapse is much higher. We have a group here, which is free for patients who have had treatment with us, and it tremendously increases their chances of success continuing.”

However effective the treatment, relapse is often part of the process. But a horse that has been thirsty before can, particularly within the comfort of a whole herd of horses, quickly become thirsty again.

The need for transformative change in healthcare has never been greater. We face pressures from regulators, payers, and patients to provide safe, high-quality, affordable and accessible care. Every healthcare organisation is trying to respond to this change, though the results vary. We seek to change processes, meet goals, and enhance culture. But, we face a paradox: the outcomes we strive for rely on excellent teamwork and collaboration, but our structures are steeped in silos and fragmentation. Transforming healthcare requires altering how we work. Let me share our journey. We realised that an organisational model was needed to support the highest quality care across our integrated care model. At Cleveland Clinic, we established a specific function, called Clinical Transformation, to coordinate efforts around safety, quality, patient experience, and continuous improvement.

Our charge was to support the integration of our health system, ensure collaboration, and provide consistent tools to make it easy for caregivers and leaders to interact with subject matter experts. These centralised resources support our regional hospitals and clinical institutes to drive quality outcomes and serve our patients. 

Nursing partners and administrative support are catalyst to build local capacity for improvement. Patients are also an important partner in this work — inviting, listening and acting on their input helps us achieve better, quality outcomes.

While building this structure, we know that the resources are finite. Prioritisation is critical. To determine our priorities and measure progress, our work is carefully aligned to a Strategic Agenda Management process. This process engages stakeholders from across our health system in reviewing our mission — care of the sick, investigation into their problems, and education of those who serve — and establishing specific goals and priorities that define our work as an organisation. Safety and Quality goals are instrumental in this structure, and help prioritise where and how Clinical Transformation resources work. 

These goals and targets are created with our stakeholders from across the system, including our academic main campus and regional hospitals. We engage clinicians, administrators, quality professionals, and patients to help us define and set our priorities and our agenda. While we review comparative benchmarks and publicly reported measures, our goals must ultimately remain true to our mission.

Monitoring our progress and identifying performance gaps are essential. As such, area specific scorecards and dashboards were developed to measure progress and hold local leadership accountable to their metrics. Through monthly operating reviews with executive leadership, we can gauge progress, celebrate successes, and identify and remove barriers to success. Transparency of the dashboards across institutes, hospitals, providers and departments, allows us to readily identify high performing areas and share best practices. And a healthy competition certainly provides motivation to continuously improve.

High reliability principles are also critical toward achieving our goals. We have partnered with the Joint Commission to master the three components of high reliability: leadership commitment, safety culture, and robust process improvement.  As leaders, we must commit to zero harm, which is reinforced through our strategic agenda, leadership meetings, and local venues. Our goals are aligned with these concepts and tied to aspirational targets for safety and harm events. Our safety culture is built on the premise that any caregiver can speak up and report safety concerns and our engagement survey results indicates this is working. Equally important to strengthening our safety culture is supporting our leaders through training and skill building. Finally, we use data-driven problem solving to drive quality and performance improvement. Developing an internal improvement model and deploying various tools, such as Lean and Six Sigma, to our frontline clinical and administrative teams are a few examples. Above all, we recognise that improvement efforts must be driven by our frontline – those that are closest to the work, know best how to improve the processes. As our high reliability practices broaden and evolve, we continue see encouraging results in our outcomes, and there’s a noticeable correlation between safety culture, caregiver engagement, and clinical outcomes.

Driving this culture requires involvement throughout the organisation, including our most senior leaders. Fortunately, our CEO and board members are committed to quality and safety. This commitment extends to our Board of Directors who uphold a responsibility for quality at Cleveland Clinic by actively participating in leadership rounding, team simulation training, and are serving on our quality committees.

Sustaining a high reliability culture requires constant attention and recognition. Be mindful of the importance to celebrate success with quality and safety events, e-mails, letters, and awards. A brief, handwritten thank you note sends a powerful message. Engaging and igniting your caregivers will bring endless benefits to your patients, their families and each other.   

To Summarise  
Set specific goals and targets and empower your frontline caregivers to drive improvement to reduce unnecessary variation. Ensure leadership is accountable to results and to culture. Leadership, the CEO, board members, physicians and all caregivers need to be engaged and focused on what adds value to your organisation; and remember the value in rewarding and recognising success.

The Digitisation of Healthcare 
Understanding the direct link between technology and patient care is critical but can be overwhelming. Physicians rely on up-to-date patient information to make educated decisions on the best care. Access to patient data is critical to their care and can sometimes mean the difference between life and death. Electronic Health Records (EHRs) flow from system to system, hospital to hospital, from the point of the patient registration to data gathered in different departments such as labs, radiology, cardiology and more, to discharge. Couple that with financial and insurance data collected, and we begin to see the sheer magnitude of the availability impact on the healthcare industry. 

Business Continuity—Keeping the Digital Life Alive
Downtime can have a catastrophic impact on digital life for caregivers, administrators, stakeholders and patients. 
In a study published by the Journal of Biometrics, researchers stated that of the patient safety incidents reported to the U.S. Food and Drug Administration, 96 per cent were related to technical issues. Some incidents resulted in futile searches for test results, inability to read test results and duplicate orders for procedures. 

On a broad scale, the WannaCry ransomware attack in May 2017 affected 230,000 computers and took down entire pillars of Britain’s National Health Service (NHS). WannaCry is a virus that exploits a known weakness in Microsoft Windows, a platform that is widely used in hospitals across the world. The virus blocks all data on computer systems until a ransom is paid, so every aspect of digital life for caregivers, administrators and patients is affected. 

In this case, the virus infected medical devices, caused ambulances to be diverted, and shut down 16 hospitals in the UK. For other hospitals, with computer systems shut down, operations had to be cancelled and emergency services halted. In addition, patient records became inaccessible.

The Evolving Threat Landscape
Cyberthreats to healthcare include hackers, botnet attacks, exfiltration (stealing medical information) and malware such as ransomware. By all accounts, a cyberattack on a healthcare practice is a matter of when, not if. Cyberattacks can shut down healthcare practices and dramatically impact patient care. They can also severely damage the brand and incur steep regulatory penalties.

Securing Availability and Business Continuity in Healthcare
There are critical units in hospitals and care centres that have no allowable downtime. Some surgical procedures depend on real-time data from digital diagnostic equipment. Sadly, there have been cases of patient deaths due to downtime events. According to a recent report, downtime delayed post-surgery treatment that led to a permanent disability for one patient, and death for another patient when images could not be transmitted for diagnosis. 

In addition to the tragic loss of life, if a healthcare practice is not able to immediately restore access to data it faces regulatory fines, lost consumer trust and damaged employee morale. The key to surviving and thriving in the new healthcare landscape is a reliable, comprehensive business continuity plan. A keystone of a business continuity plan in this context of digital transformation is availability.

Three Critical Steps 
With so much at stake, healthcare organisations must address business continuity, and they must do so quickly and thoughtfully. The three most critical steps to healthcare business continuity are: 

1. Ensure continuity and availability 
– Optimised backup and recovery strategy: Organisations need fast, reliable, scalable backup and recovery tools designed especially for enterprises. They must be able to quickly restore backups to meet Health Insurance Portability and Accountability Act (HIPAA) and other regulatory requirements. A good guideline for backups is the 3-2-1 rule: Have at least three copies of your data, store the copies on two different media and keep one backup copy offsite.

– Ensure you can quickly recover entire machines to the application level: Verifiable recovery of every file, application and virtual server every time is a must-have. 

– Ensure data loss avoidance: Your availability solution should enable you to achieve major improvements in recovery point and recovery time objectives (RTPO) of less than 15 minutes for all applications and data. 

2. Achieve digital transformation agility 
– Cloud-based workload mobility: To ensure you can quickly recover entire machines, deploy cloud workload mobility to better cope with change and manage data more easily. You also must have the ability to test all applications and upgrades before they go into production. For cloud-based workload mobility leverage Azure or other public clouds for test/dev environments. This provides an easy way to spin up servers and workloads quickly. 

– Workload mobility: The complex infrastructure of an enterprise involves physical and virtual machines, as well as private, public or hybrid cloud. To achieve an optimal setup, you need the right data management and availability solution that provides a certain degree of flexibility, to manage and migrate data easily. 

3. Enable analytics and visibility 
– Visibility and compliance to prevent system failure and downtime incidents: The visibility tool you choose should have real-time monitoring and reporting for any virtual environments in your infrastructure. 

– End-to-end visibility for both physical and virtual machines: To be effective, it must also have end-to-end visibility for both physical and virtual machines, in order to prevent possible failures of any type of application or system. 

– Creation of incidents based on events that happen in your environment: Finally, it must generate incident reports based on the events that happen in your environment, so you can correct and modify as needed. 

In conclusion, meeting the high digital expectations of next-generation patient care can feel like a moving target for healthcare IT. Downtime, data loss and data security breaches put everything that is important to a healthcare practice at risk. Downtime events can even put patient lives in danger. The fact is, no healthcare organisation can afford to be unprepared in the modern healthcare market. To be successful in the new landscape, healthcare practices must be confident in their business continuity strategy. A holistic availability strategy may include deploying cloud workload mobility, increasing visibility and compliance, and optimising backup and recovery strategy. 

References available on request.

Shisha smoking – also called hookah, narghile, waterpipe, or hubble bubble smoking – is a way of smoking tobacco, sometimes mixed with fruit or molasses sugar, through a bowl and hose or tube. The tube ends in a mouthpiece from which the smoker inhales the smoke from the substances being burnt, into their lungs.

Despite the many perils of shisha smoking, shisha is gaining popularity among the youth, which is a cause of great concern.

Epidemiology
The Global Youth Tobacco Survey concluded that, whilst cigarette smoking prevalence was decreasing among 13-15-year-olds, 33 out of 97 global regions showed an increase in other tobacco use which was mostly attributed to shisha. Nine per cent to 15 per cent of 13 to 15-year-old school children in several countries in the Arabian Peninsula (Bahrain, Oman, United Arab Emirates, Kuwait and Yemen) indulge in waterpipe smoking, mostly surpassing the prevalence of cigarette smoking. According to a recent survey 8.4 per cent of students in the U.S. smoked shisha, which is second only to cigarettes. A study in Karachi, Pakistan, revealed 22.7 per cent of medical and dental students are shisha smokers. In another study carried out at Aga Khan University Karachi, shisha prevalence was found out to be 53.6 per cent.

Attitudes Regarding Shisha Use
Social norms
Social norms affect waterpipe tobacco smoking in a similar fashion to cigarettes, working via peer influence through modelling or imitation of friends’ behaviour, or through selective reinforcement by peers or parents of certain behaviours. For example, parental and peer waterpipe tobacco use is consistently and strongly associated with individual waterpipe tobacco use in a number of settings, including several Middle Eastern countries, Sweden, and the U.S. In a qualitative study across four countries in the Middle East, one participant was quoted as saying, “Now my father is enjoying smoking waterpipe with me. Every night, he prepares his waterpipe and asks me: don’t you want to prepare your own?” (Woman, smoker, 18–25 years – Lebanon). This study concluded by suggesting that socio-cultural norms towards waterpipe tobacco far outweighed its health considerations. Social media may have a role to play, given that from a random sample of 5,000 waterpipe-related tweets in 2014, 87 per cent normalised waterpipe use by making it seem common, normal to use, and portraying it positively.

Descriptive norms
Descriptive norms, also known as perceived prevalence, are the belief about how most of the people act in a social group. The higher the perceived prevalence, the more likely that the individual will believe that behaviour is normative. In one study of more than 1,000 adolescents in Lebanon, more than 65 per cent perceived the prevalence of waterpipe tobacco use to be higher than it was (ie, had high pluralistic ignorance). In a similar study among more than 400 college freshmen at a U.S. university, just under half had high pluralistic ignorance, and pluralistic ignorance was associated with waterpipe tobacco use but not with cigarette or cigar use. 

Injunctive norms
Approval or disapproval of waterpipe tobacco smoking is known as injunctive norms, and this area has mixed findings. Given waterpipe tobacco smoking is commonly performed as a social activity with friends or family, and a key feature of its use is sharing between users, it is seen as socially acceptable. In examples from Lebanon and Jordan, authors found that the encouragement from friends and family influenced waterpipe tobacco, whereas having friends who disapproved of waterpipe tobacco was associated with less use. This pattern has also been reported among youth in India, and in cross-sectional studies of Arab Americans in the U.S. and adolescents in Lebanon, friend and family influence was associated with waterpipe tobacco initiation for both male and female users. Among adolescents in Lebanon, nearly 30 per cent of waterpipe users had it paid for by their parents. 
Despite this, disapproval of waterpipe tobacco use has been documented in literature. In a cross-sectional study among 547 university students in Jordan, about 30 per cent of users claimed that their parents would discipline them if they found out about their waterpipe use; interestingly, this figure was higher for men (35 per cent), compared with women (20 per cent).

Perceived risk
Risk perception is an important determinant of smoking behaviour and behavioural intention. Qualitative research from the U.S., United Kingdom, and Syria broadly suggest a reduced harm perception compared with cigarettes. The perceived lack of nicotine and addictive potential of waterpipe tobacco suggest that users have a strong sense of perceived control over their waterpipe tobacco use. In one study among university students in North Carolina, those who believed waterpipe tobacco to be less harmful than cigarettes had more than 2.5 times the odds of being a past 30-day waterpipe user compared with those who believed waterpipe tobacco to be as harmful as cigarettes.

A common misconception fuelling this epidemic is the belief that shisha use is not addictive or injurious to health because the water used in the pipe absorbs nicotine. The reality however is in stark contrast to this. Shisha smokers are exposed to enough nicotine to develop an addiction because only some nicotine is absorbed by water.

A study reports that 30 per cent of university students consider shisha to be less deleterious than cigarette. Twenty one per cent out of 206 male shisha smokers in Egypt shared a similar belief. Similarly, 60 per cent of the Pakistani populace considers cigarettes to be more harmful. Studies in Egypt, Malaysia and Jordan delineated similar attitudes.

However, water pipe smoking carries three additional health risks over cigarette smoking. Firstly, the coal over which shisha is smoked adds to the already long list of toxins present in tobacco. Secondly, a single shisha session results in the smoker inhaling up to 200 times more smoke than cigarette smokers. Thirdly, the rates of second-hand smoking associated with shisha are high due to its high social acceptance.

Because of the way a hookah is used, smokers may absorb more of the toxic substances also found in cigarette smoke than cigarette smokers do. An hour-long hookah smoking session involves 200 puffs, while smoking an average cigarette involves 20 puffs. The amount of smoke inhaled during a typical hookah session is about 90,000 millilitres (ml), compared with 500–600 ml inhaled when smoking a cigarette.

In a study about second-hand smoke in indoor hospitality venues in Pakistan the mean PM (2.5) value was 101 μg/m(3) (95 per cent CI 69-135 μg/m(3)) for non-smoking venues, 689 μg/m(3) (95 per cent CI 241-1138) for cigarette smoking venues and 1745 μg/m(3) (95 per cent CI 925-2565) for shisha smoking venues. The significant levels of SHS recorded in this study, in particular from shisha smoking venues, could represent a major public health burden.

Health Effects
Shisha smoking predisposes its users to a plethora of cancers like lung, bladder, and oral cancers. Dar NA reports that there is significant association between esophageal carcinoma and shisha smoking (OR = 1.85, 95 per cent CI, 1.41-2.44). Its association has also been reported in studies conducted in China, India and Iran. Shisha also increases the risk of developing pancreatic and prostate cancer. There is significant association between shisha smoking and squamous cell carcinoma and keratoacanthoma of lip. In terms of gastric cancer, a large 10-year prospective cohort study supported the association with waterpipe tobacco smoking even after adjusting for cigarette smoking. In this study, waterpipe tobacco smoking was associated with 3.4 (95 per cent CI: 1.6–7.1) times the risk of developing gastric cancer compared with non-smokers.

Shisha smoking also has detrimental effects on the cardiovascular system and after 45 minutes of shisha use, heart rates are found to be significantly increased. Many studies report that a mean increase in systolic and diastolic blood pressure and heart rate of shisha smokers is observed after shisha smoking. Moreover, serum concentration of HDL, Apo A in shisha smokers were significantly lesser than non-smokers whereas LDL-cholesterol, Apo B and triglycerides were significantly greater in smokers. 

Hookah tobacco and smoke contain many toxins that can cause clogged arteries and heart disease. In a cross-sectional study from Iran of more than 50,000 participants, waterpipe tobacco users had nearly four times the odds of self-reported ischaemic heart disease or heart failure compared with non-users. In another cross-sectional study from Lebanon, 1,210 patients from four hospitals were evaluated for angiographically defined coronary artery disease. Patients with a long history of waterpipe tobacco smoking had three times the odds of severe stenosis compared with non-smokers.

Lung cancer, cancers of the food pipe, chronic obstructive lung disease, emphysema, precipitation of asthma attacks and pneumonia are some of the health hazards associated with shisha smoking. Regular shisha users have lung functions approximately 25 per cent lower than those who do not use this. Carbon monoxide and pulmonary function changes have also been reported in long-term waterpipe tobacco smokers. In one cross-sectional study in Pakistan, blood CO concentration was significantly higher in waterpipe tobacco smokers (10.5 per cent) compared with cigarette smokers (6.2 per cent) and nonsmokers (0.9 per cenr) (P < .01). Oxyhaemoglobin levels were significantly lower in waterpipe tobacco smokers compared with cigarette smokers and non-smokers. In another study of Saudi men and women, pulmonary function (forced expiratory volume at one second [FEV1], FVC, and FEV1/FVC) was impaired in long-term waterpipe tobacco smokers compared with non-smokers.

A study in Saudi Arabia showed that total antioxidant capacity and vitamin C levels were lower in smokers than in non-smokers.

Furthermore, mothers who smoked water pipes every day while pregnant had babies who weighed less (at least 3½ ounces less) than babies born to non-smokers. Babies born to hookah smokers are also at increased risk for respiratory diseases.

A research has found that cognitive functions including attention, alertness, and memory were significantly impaired in healthy adult shisha smokers compared to non-shisha smokers.

Shisha smokers are found to be significantly more likely to have hypertryglycedemia (OR 1.63, 95 per cent CI, 1.25-2.10), Hyperglycemia (OR 1.82, 95 per cent CI, 1.37-2.41), Hypertension (OR 1.95, 95 per cent CI, 1.51-2.51) and abdominal obesity (OR 1.93, 95 per cent CI, 1.52-2.45).

It was evaluated that the practice of sharing a waterpipe mouth piece poses a serious risk of transmission of communicable diseases including Tuberculosis and Hepatitis. The waterpipe and the water inside the shisha apparatus can become an abode for bacteria such as those causing TB which can lead to the spread and transmission of the disease. There is also some evidence that Shisha use may also decrease the sperm count in men.

Addiction and Cessation 
Whereas one session of shisha exposes users to an amount of nicotine equivalent to smoking one to five cigarettes, literature review has shown that for daily shisha smokers a single shisha session has nicotine exposure equivalent to 10 cigarettes due to cumulated increase in nicotine over time. 

Similar signs of nicotine addiction are seen in shisha smokers as are seen in cigarette smokers: failed quit attempts, cravings and withdrawal symptoms despite claims that quitting shisha is “not at all hard”.

The way forward
Changing perceptions:
The most important step in curbing the spread of shisha smoking is to reduce its social acceptance and make people aware about shisha being even more hazardous than cigarette smoking. Glamorisation of shisha and use in mainstream media should also be checked to prevent youngsters from indulging. Public health messages delineating the hazards of shisha smoking should be disseminated in electronic, print and social media. Awareness campaigns for school, college and university students should be organised and its perils should also be included in school curriculum.

Government actions and legislation
Measures like banning shisha cafes and banning shisha in restaurants should be implemented. Shisha cafes are a major cause of the spread of this habit and hence, they must be banned. Shisha smoking must be banned in all public spaces and educational institutions. Most countries in the region have laws banning smoking at public places. As shisha contains tobacco, laws should cover shisha in this ban as well.  

References available on request.

It is a chronic illness identified in children, adolescents, and adults worldwide and in the U.S. alone, 35 percent of adults (roughly 100 million people) and 17 per cent of children are obese.

It is therefore not surprising that today bariatric surgery has become an important player in tackling the heat burden of obesity. Bariatric surgeries are one of the most rapidly growing operative procedures performed worldwide, with an estimated >340,000 operations performed in 2011, and in Asia alone the absolute growth rate was 449 per cent between 2005 and 2009.

Over the past five years the number of weight-loss operations performed in the U.S. has been relatively stable with an estimated 179,000 bariatric surgeries performed in 2013. Of those, 34 per cent were gastric bypass, 42 per cent were sleeve gastrectomy, 14 per cent were gastric band, and 1 per cent was biliopancreatic diversion with duodenal switch. The remaining six per cent were revisional procedures.

Complications following surgical treatment of severe obesity vary based upon the procedure performed and can be as high as 40 per cent. Below the major complications of bariatric surgery are outlined based on the different procedures individually.

Roux-en-Y Gastric Bypass
Roux-en-Y Gastric Bypass (RYGB) is one of the most common bariatric procedures performed today. The procedure involves the creation of a small gastric pouch and an anastomosis to a limb of jejunum. This causes restriction in the amount of food as well as bypassing a part of the small bowel, limiting absorption. Although complex, the gastric bypass in expert hands is considered the gold standard of the bariatric procedures by many experts. 

Outlined below are some of the common complications arising after the procedure:

Anastomotic Stenosis
Anastomotic stenosis, at the gastrojejunostomy, is believed to occur in six to 20 per cent of patients post RYGB. The cause is uncertain, but proposed theories include: tissue ischemia, marginal ulcer, or increased tension on the gastro-jejunal anastomosis. Stenosis rate is higher in laparoscopic versus the open technique of RYGB and may be related to the use of circular staplers of small diameter. Anastomotic stenosis occurs when the anastomosis narrows to a diameter of <10 mm. Patients typically present in the initial post-operative period with nausea, vomiting, dysphagia, reflux, and possibly an inability to tolerate oral intake. The symptoms usually warrant endoscopy or an upper gastrointestinal series, both which can diagnose the condition. Endoscopic balloon dilation is usually the treatment and is most of the time successful, with 70-80 per cent responding to one dilatation. 

Marginal Ulcers
Marginal ulcers typically occur at gastrojejunostomy site and have been reported in 0.6 to 16 per cent of patients. Common causes of marginal ulcers include poor tissue perfusion at the anastomosis, presence of foreign material (staples or suture), non-steroidal anti-inflammatory drug use, Helicobacter pylori infection and smoking. Treatment of marginal ulcers comprise mostly of acid suppression with a prolonged course of proton pump inhibitors, usually followed by an endoscopy to ensure healing. Medical management is successful in 85 to 95 per cent of patients, but surgery may be indicated if perforation occurs or if symptoms persist despite medical therapy.

Internal Hernias
Internal hernias occur in mesenteric defects that are created during a RYGB.  These sites include the jejunojejunostomy mesenteric defect, Petersen’s defect (between the transverse mesocolon and Roux-limb mesentery) and in the transverse mesocolon in retrocolic bypasses. Internal hernias have been described in up to five per cent of patients after RYGB, and mesenteric defects are often closed with nonabsorbable sutures to reduce this incidence. Most bariatric surgeons will recommend closure of the mesenteric defects to decrease the risk of internal hernia. These usually are associated with successful weight loss possibly due to the re-opening of the hernial spaces due to reduction of the intra-abdominal fat and mesenteric fat. Conditions that increase the intra-abdominal pressure can precipitate internal hernia and our group has treated two cases of internal hernia presenting within a week from abdominoplasty for body contouring after gastric bypass. Internal hernias can be difficult to diagnose as their radiographic detection is complicated by their intermittency, with the pathognomonic “mesenteric swirl” sign on CT scan serving as the best indicator of diagnosis. In cases of diagnostic uncertainty diagnostic laparoscopy with inspection of the potential hernial spaces is recommended.

Dumping Syndrome 
Dumping syndrome can occur in post-RYGB patients and is due to ingestion of large amounts of simple carbohydrates. There are two types of dumping syndrome: early and late. Early dumping syndrome has a rapid onset (15 minutes) and is the result of rapid emptying of food into the small bowel. Late dumping syndrome can also occur, but its pathophysiology is not fully understood and likely includes changes in hormonal and glycemic patterns. Treatment usually involves behavioural modification, such as small, frequent meals, and separating solids from liquid intake by 30 minutes. In addition, patients are asked to avoid foods that are high in simple sugars and consume a diet consisting of high fibre, complex carbohydrate, and proteins instead. In the author’s experience, most patients exhibit symptoms of dumping but in the vast majority, patients are transient and respond well to dietary modification. In 0.5-1 per cent of cases, symptoms can be severe, persistent and difficult to manage.

Sleeve Gastrectomy
Laparoscopic sleeve gastrectomy (SG) is increasingly becoming a widely employed bariatric operation as it shows good weight loss and resolution co-morbidities. The procedure involves stapling the stomach over a bougie and removes a large portion (around 80 per cent) of the stomach. The most common complications of SG include leaks, and stenosis of the sleeved stomach and gastroesophageal reflux disease.

Gastric Leaks
Gastric leak after SG is one of the most serious complications and can occur in up to 5.3 per cent of patients. Although the etiology is unknown, leaks are thought to be due to local factors at the site of the staple line, including inadequate blood supply and gastric-wall heat ischemia. In addition, the sleeved stomach produces a high-pressure system, which can complicate the healing process and lengthen the amount of time for a leak to close. The mainstay of treatment for leaks includes early diagnosis, adequate drainage and gastric decompression. Clinically stable patients usually undergo percutaneous drainage of any collections, antibiotic therapy, and parenteral nutrition to augment the healing process. Endoscopic therapy with the use of stents has been proposed for management of leaks, but it comes with its own complication risks as well.

Sleeve Stenosis 
Narrowing or stenosis of the sleeved stomach is a possible complication after SG and the presentation can vary depending on the severity. Symptoms typically include dysphagia, vomiting, dehydration and the inability to tolerate diet. Two of the most common areas where stenosis occurs are the gastroesophageal junction and the incisura angularis, and this is usually diagnosed by a barium swallow test. Theories behind the development of narrowing or stenosis are over-sewing the staple line and using a bougie that is too small in size. Initial management of stenosis consists of endoscopic dilation. In cases where the area of stenosis is not amenable to endoscopic therapy, surgical intervention is necessary with conversion to a RYGB.

Reflux
Gastroesophageal reflux (GERD) with symptoms including burning pain, heartburn, and regurgitation can occur as an early or late complication after SG. Anti-reflux medical therapy is usually the mainstay of treatment, however GERD unresponsive to medical therapy are typically treated by conversion to RYGB. There are emerging reports of increasing rates of late GERD following sleeve gastrectomy and potential development of Barrett’s oesophagus with its potential association with cancer risk and the need for long term surveillance. In the author’s experience, there is also increasing evidence of documented with manometry of oesophageal dysmotility following sleeve gastrectomy. As the sleeve gastrectomy is a relatively new operation,  the exact effects of the oesophageal dysmotility post gastric sleeve in the long term remains to be seen.

Gastric Banding
Gastric banding (GB) is a restrictive procedure involving placement of an adjustable band at the gastric cardia near the gastroesophageal junction. The band can then be adjusted by injecting or removing saline from a subcutaneous port attached to it. GB is considered a safe as a bariatric procedure that does not alter the anatomy and has a very low mortality rate. Several complications are associated with it, most commonly band erosion, slippage and esophageal dilatation.

Band Erosion  
Band erosion through the stomach has been reported in up to 1 per cent of GB patients. It is thought to occur as a result of an excessively tight band leading to gastric wall ischemia. Band erosion is usually diagnosed by endoscopy and warrants its surgical removal as treatment.

Band Slippage
Band slippage involves migration of the band from its normal position leading in turn to symptoms of food intolerance, epigastric pain, and acid reflux. Anterior band fixation by gastro-gastric sutures is commonly performed to prevent band slippage. It occurs in 3 per cent of cases and can appear any time after surgery either as an acute slippage or in a more chronic form. Diagnosis can be confirmed radiologically demonstrating an alteration in the normal position of the band. Depending on the presentation of the patient, surgical removal or repositioning of the band is usually required on an elective or emergency basis.

Esophageal Dilatation
Esophageal dilatation proximal to the band is a recognised complication and it is usually associated with long-standing bands. Although the exact mechanism is unknown reports associate its development with a band that is inflated excessively. Treatment initially involves band deflation with surgical removal of the band or conversion to a stapling procedure if symptoms fail to respond.

Intra-gastric Balloon
Although not a surgical procedure per se, intragastric balloons have recently played a pivotal role in serving as both primary standalone weight loss procedure and planned first stage of a definite bariatric surgery. Initially considered very safe, recent evidence has emerged regarding the observed complications of balloon rupture and migration, small bowel obstruction, gastric perforation and even death. This has led the Food and Drug Administration in the United States to place a warning to consumers and healthcare providers regarding their safety. 

This terrible human cost is a major factor that impedes the continent’s efforts to escape poverty. Many deaths could be prevented with timely access to appropriate and affordable medicines. As a matter of fact, health is a very important prerequisite to achieving the Millennium Development Goals (MDGs). Since the year 2000 substantive amounts of money have become available through international organisations such as The Global Fund to increase access to life-saving drugs. Very few of these drugs are currently procured from African producers. In a globalising world this might seem appropriate, but the specific realities in pharmaceuticals mean that further development of local manufacturing has the potential to positively impact the health outcomes in developing countries, as well as adding to economic growth.

In sub-Saharan Africa (SSA), where the overall pharmaceutical market size is worth US$ 20 billion annually, the production of life-saving medicines is furthermore concentrated in very few countries: 50 per cent of pharmaceutical manufacturing takes place in South Africa and an additional 40 per cent in Nigeria, Ghana, Kenya and Uganda combined.

These pharmaceutical markets are expected to have a compound annual growth rate of 12 per cent in 2018 according to IMS Health Reports. The Sub-Saharan Africa Pharmaceutical Yearbook (July 2011) also notes that pharmaceuticals alleviating chronic conditions such as hypertension and diabetes represent lucrative growth opportunities, as do those for the therapeutic segments including anti-infectives, cardiovascular, diabetes, respiratory, oncology and central nervous system medicines. The anti-infective pharmaceutical market, which comprises antiretrovirals, antimalarials and antibiotics, is expected to represent close to 45 per cent of sales, remaining the primary market due to the high malaria burden. The cardiovascular segment represents 11.8 per cent of sales, and the central nervous system and oncology 4.3 per cent and 3.3 per cent respectively. However, oncology medicine is forecast to generate growth of 12.9 per cent per annum, driven primarily by an expanding middle class and underlying strong economic growth.

Therefore, Africa remains one of the fastest growing economies in the world. The recent signing of the African Continental Free Trade Area (AfCFTA) in Kigali this March will boost intra-Africa trading with a combined GDP of US$ 2.5 trillion; where 44 out of 55 countries have already signed the treaty.

The overall African Pharmaceutical sector is worth US$ 30 billion per annum and is expected to be worth US$ 65 billion by 2020. However, the pharmaceutical manufacturing sector in Africa contributes to only 25-30 per cent of the continent’s needs. The continent depends largely on imports from Asia, frequently with long lead times. The pharmaceutical sector is seen as a strategic sector, and high dependency on imports of essential medicines have raised security concern about the continuity of supply. 

Countering Counterfeits
In addition to the low pharmaceutical production capacity, the African continent is confronted to an even bigger problem – counterfeits. Counterfeited medicines represent a US$ 1 billion industry worldwide where over 30 per cent of those medicines are sold in parts of Africa, Asia and Latin America. According to the World Health Organization (WHO), substandard and counterfeited anti-malarial medicines cause about 120,000 deaths every year in Africa. 

African governments have become increasingly aware of the problems posed by counterfeiting and several initiatives have come to exist including the Anti-counterfeit Network Africa, which was launched in Uganda in February 2016. Also, a Customs Watch system, a surveillance request system that involves the recording of trade marks with Customs, is becoming more popular in Africa with countries such as Algeria, Côte D’Ivoire, Egypt, Kenya, Mauritius, Morocco, South Africa, Sudan and Tunisia already participating in the programme, while countries like Ghana and Egypt are providing an informal Customs Watch service. In 2008, the Anti-Counterfeit Act was passed by Kenyan lawmakers establishing an Anti-Counterfeit Agency.

In East Africa, the access to quality medicines is limited by the existence of a few pharmaceutical plants whereby a lesser number are WHO pre-qualified. This creates reliance in imported medicines with high prices.

The combined Pharmaceutical market size of the East African Community (EAC) in 2017 was about US$ 4 billion with a big volume spent on essential medicines, particularly Antibiotics, Antimalarials, Anthelmintics, Disinfectants, Analgesics and Anti-Retroviral medicines. Another challenge for the African continent is the non-uniform registration requirements. The East African Community has come up with harmonised registration and inspection guidelines.

The African Medicine Regulatory Harmonization (AMRH) initiative aims to accelerate the access of medicines by improving the fragmented system of product registration in Africa, and in the East African Community in particular. The EAC was the first Regional Economic Community (REC) in Africa to launch Medicine Regulatory Harmonization (MRH) project in March 2012 with the purpose of harmonising medicines registration in the East African Community Partner States in order to increase the rapid availability of essential medicines in the region and to enable free movement of medicines within the region; with the ultimate goal to have a harmonised and functioning medicines registration system within the East Africa Community in accordance with nationally and internationally recognised best practices.

In 2012, the EAC designed a Regional Pharmaceutical Manufacturing Plan of Action (EACRPMPoA) to guide partner states of the EAC towards collective and synergistic evolution of an efficient and effective pharmaceutical production sector, capable of making significant contributions to meeting national, regional and international demand for medicinal products until 2027 and beyond. The action plan is closely aligned to the short, medium and long-term goals and policies of the EAC and individual member states and serves to complement past and present regional economic community and pan-African strategies.

The plan recommends strategic interventions to be applied at firm, institutional, national and regional levels to improve the business environment for pharmaceutical manufacturing, strengthen associated regulatory capacity and further develop human resource capacity through a programmatic approach. Specifically, the plan has set out the following primary strategic objectives:

1. Promotion of competitive and efficient pharmaceutical production regionally; Through usage of incentives such as preferences of up to 15 per cent on tenders for locally manufactured products 
2. Facilitation of increased investment in pharmaceutical production regionally; this is through restricting certain imported products that can be locally (regionally) manufactured 
3. Strengthening of pharmaceutical regulatory capacity in the region;
4. Development of appropriate skills and knowledge on pharmaceutical production in the region;
5. Utilisation of TRIPS flexibilities towards improved local production of pharmaceuticals, and
6. Mainstreaming innovation, research and development within regional pharmaceutical industry.

The key ingredients to the successful medicine regulation harmonisation are:

– Strong leadership of the Regional Economic Community and prompt decision making exemplified by the East African Community
– Partner States expertise harnessed for capacity enhancement
– Strong Public Private Partnership
– Private sector engagement at all levels of the harmonisation process
– Training in regulatory skills
– Government commitment for continued participation of National Medicines Regulatory Authorities’ staff in harmonisation activities and beyond
– Advocacy by The New Partnership for Africa’s Development (NEPAD), the World Health Organization (WHO) and other partners

As of today, domestication and implementation of processes have commenced in the Partner States; the expansion to other regulatory functions such as Pharmacovigilance and Post Market Surveillance (PMS); the regulatory requirements are harmonised, joint inspections are conducted and decision making are streamlined among Partner States’ National Medicine Regulatory Authorities, which is ultimately an asset for investment.

Development of Regional Pharmaceutical Policy, Legal and Regulatory Frameworks and establishment of Central Agency are underway, which will lead to the establishment of a single regional Regulatory Agency. 

In reality, a brand is much more than that. Branding as a concept encompasses the entire soul, fibre and character of the company. Brand has a wider scope and it is relevant to the entire operations, support and strategic planning functions in the organisation.

Globally, there is a lot to be learnt as far as strategic brand management in healthcare is concerned. Different regions will have different challenges. But the fact that the gaps need to be addressed still remains. Are healthcare systems learning enough from other global brands like Mercedes, Pepsi, Apple, Toyota, etc.? Well, the answer is no.

To provide clarity on what an effective brand building would entail in a hospital, the following points have been listed below: 

Brand Values: Branding starts with the inherent values of a firm. These values are more often than not, given by the founders and top leaders of the organisation. It is imperative for everyone to take a step back and see what the organisation stands for. In case of hospitals, it could be philanthropy, enhancing the quality of life, bringing world-class services to the area, etc. Whatever the philosophy, it needs to be discovered, articulated and used to form the basis for the brand to be created.

The idea is to find the uniqueness in the inherent fibre of the brand. Every human being is unique in some way or the other, and so is every brand. One only has to dig deep enough to discover what the uniqueness is.

Brand Positioning: Once it is clear what the branding is for, one needs to look at how this will be positioned in the market. Needless to say, it cannot be the same as anyone else as each hospital will need their own unique position. 

Many hospitals make the mistake of positioning themselves on the ‘features’ that they have to offer. As a result, they are unable to connect to the end user. It would be more relevant for the target audience if they positioned themselves on the benefit that the features would translate into. For example, JCI accreditation is a feature which translates into better treatment outcomes as a benefit. So, focusing on the accreditation rather than the benefit will not resonate with the target group.

Not to forget, the positioning of a brand is a matter of perception. In branding, perception is reality. A brand is positioned by the image it creates for itself in the minds of the people.

Brand Identity: This is where the name, logo and tagline come into the picture. We can add house colours, font type, etc. to the list. The identity has to be consistent to the unique position that we want to create. In some parts of the world, most hospitals, till recently, had green colour as part of its branding. Whereas, it is acceptable that there are ample reasons for green being allocated to healthcare, it is also contradictory to the concept of branding that green colour should be used by every brand. 

Of late, we have been seeing non-green branding for hospitals, which makes the hospital brand more visible in the marketplace. If a colour is being decided for a hospital brand, it will make sense to choose something that is not being used by others.

The identity [name, logo and tagline] has to be appealing enough so that the image of the brand can be created with ease. The recall will be good and the preference will be favourable for the brands that have likeable and unique identities.

Brand Personality: This is a concept which is very closely linked to the identity. Every brand has a personality. It may sound strange, but leading brands work hard at creating a persona out of their brands. For instance, the overall personality of a brand like Virgin Atlantic is distinct from a brand like Lufthansa. These differences are created by planning the colours, words, images and other attributes carefully. Similarly, the hospital brand can be a modern male doctor, or a caring mother, etc. Whatever one needs to create, it has to be crafted deliberately and must augment the brand position.

Brand Promise Delivery: Once the brand’s unique position, identity and persona are in place, the time comes to deliver whatever will be promised. Many hospitals boast of high quality, but their clinical outcomes are not up to the mark. Many hospitals boast of great doctors, but most of their doctors operate as islands of excellence without seeing eye to eye with each other. Similarly waiting times, interiors, staff attitude and a lot of other things needs to be diligently worked at in order to create a consistent brand experience. It is fundamental to the success of a brand, that the promise and its delivery should be consistent every single day.

One of the key factors that determine the delivery the brand promises is the staff behaviour and outlook. A premium hospital promising a great patient experience with all the frills cannot afford to have a staff that is badly dressed. A hospital that promises utmost care and concern for its patients cannot have a grumpy looking front office person. Staff outlook and attitude plays a vital role in delivering the brand. One may be surprised to see how many hospitals have never communicated to their staff about what the brand has promised to the outside world. 

There is absolutely no thinking through or training of the staff about delivering the brand promise. No wonder many healthcare providers are unable to figure out why the branding efforts have failed in spite of a hefty sum being paid for designing of adverts. Sometimes, healthcare providers make the mistake of going ahead with the advertising blitz without ensuring that the expectations they create will be met at the ground level. This shooting in the foot results in lost reputation over a period of time.

Brand Communication: A healthcare brand communicates with its audience on multiple platforms. It speaks to them primarily through advertisements and press and media and other philanthropic initiatives. For each communication there must be an objective. It is imperative that each communication talks about the uniqueness of the brand. This uniqueness needs to be relevant to the audience it is speaking to.

A judicious mix of each kind of communication vehicle is a must. The number of newspaper ads and outdoor hoardings have to be determined based on certain organised facts and data. Press and media play a vital role in building healthcare brands. The brand can get its initiatives endorsed and liked by the popular press and create a favourable image for itself. In the modern times, online media and social networking also plays a very significant role in shaping the opinion for a brand. Healthcare providers can overlook media [including web media] on its own peril.

Brand Loyalty: No discussion on branding is complete until we talk about brand loyalty. In healthcare, brand loyalty is a peculiar concept. Providers cannot [and mostly do not] wish for the patients to get sick and come back again. In such a scenario, how can a hospital talk about loyalty? The answer is — people can refer the hospital/provider to their friends in case they ever need the services. This can be done by brand advocates who can swear by the capabilities of the brand to deliver what it promises.

Another form of loyalty in healthcare arises with patients who need to visit the facility repeatedly for their medical condition. This is true for chronic ailments or for conditions like pregnancy, physiotherapy, etc. Brands serious about loyalty will not only want to retain the patients for the entire cycle of care that they can provide but would also like to monitor the number of new patients who came as a result of reference given by this existing patient. I have not seen many brands doing that in healthcare, even though there have been calculations proving that a five per cent increase in loyalty can push up the sales by up to 20 per cent!

There is so much more that can be said about branding for healthcare services. However, as a starting point, if whatever is mentioned above can be incorporated in building the healthcare brand, one will stand a fair chance of creating a sound platform for robust growth.