Partnering Overseas: Opportunities and Cautions

The explosive growth in U.S. healthcare spending may be slowing, but in other regions of the world it's just revving up. Economists predict that the annual GDP growth rate of developing economies, for example, will average about 60 percent higher than in highly industrialized nations. Along with becoming more affluent, populations in these countries are becoming more egalitarian, and gaining larger, better-educated middle classes with access to all the information riches of the Internet. The result is that more people around the world are craving ready access to better healthcare, and are willing and able to pay to get it or are demanding it from their governments.

But the governments and private organizations looking to provide these improvements often find it difficult to gather enough local expertise to meet such a large-scale need and, therefore, seek help from those who have done it before. This reality opens the door for highly rewarding opportunities for U.S. hospital systems to partner with overseas counterparts on ambitious healthcare projects.

Johns Hopkins Medicine has for 15 years been engaging in these sorts of partnerships in more than a dozen countries in every region of the world. It has been a rewarding endeavor, serving as a way to further our mission of improving health by sharing knowledge acquired here over more than a century. On the other hand, being involved in global healthcare collaboration has also presented us with significant challenges, and any U.S. hospital planning to enter this complex marketplace should be fully aware not just of the potential rewards, but also of the risks and difficulties.

A wide range of opportunities

There are many types of overseas partners and projects that could benefit from collaborations with U.S. hospitals, ranging from simply adding more beds to an existing hospital, to opening new clinics and developing new clinical specialties, to upgrading the quality and safety of patient care, all the way to developing entirely new medical center campuses. Johns Hopkins Medicine International, for example, is heavily involved in a project in Malaysia that will see the development not only of a U.S.-style graduate medical school, but also a large teaching hospital and other related facilities. Among the types of local partners that drive these projects are national or regional governments, existing private hospital systems, private payor organizations, and non-profit foundations. Increasingly, public-private partnerships are becoming an important part of the mix.

The nature of the partnership can vary widely from project to project as well. In some cases, Hopkins has contracted not only to help oversee the development of major new facilities and programs, but also to manage them for many years. In others, we have more advisory and consultative roles that may or may not be long-term. We may be intimately involved in every aspect of a new facility for a decade or more, or we may simply help out for a few years to get a relatively focused new clinical or research program off the ground. In rare cases we are asked to become equity partners in planned new facilities.

These emerging marketplaces offer a range of opportunities. For example, we are closely involved with local partners in developing and operating a major medical center outside of Istanbul, Turkey. In Trinidad and Tobago, we are spearheading a public health effort to map the spread of diabetes and training healthcare providers to build capacity in cardiology, while in the United Arab Emirates, we clinically operate a molecular imaging center and manage three public hospitals.

But while Hopkins has ultimately proven successful in forging these partnerships and realizing a large number of ambitious projects, getting to this point has not been easy. In fact, we faced some setbacks and daunting challenges early on, and had to learn a lot — often, the hard way — about why this field isn't for everyone and why any organization that plans to enter the market should be aware of what it's likely to encounter.

Preparing for challenges

The first question a prospective player in this business needs to ask is: What value can I offer a potential partner? While, in theory, almost any well-regarded healthcare organization in the U.S. could theoretically provide valuable clinical and administrative expertise to a planned international project in an emerging market, a number of leading U.S. medical centers and healthcare management consultants have already established themselves as leaders in providing these services. An organization's ability to effectively "export" this capability is often a key differentiator. Accordingly, any hospital hoping to win a contract overseas has to make a compelling case to potential partners as to why it should be selected over others.

Then, there are a number of unique, complex social, operational and financial challenges to be navigated in global healthcare collaboration, and they can differ substantially from those U.S. hospitals are used to encountering.

At the top of these challenges is the need to adapt to local and regional cultures and constraints. That's a lot trickier than it sounds. In spite of all our experience in the field, every single time Hopkins enters a new project we encounter challenges that seem daunting at first. When we started out in overseas collaborations, we assumed that our partners would want to do things the way we ourselves do it in Baltimore — after all, they chose us for our expertise. But as it turns out, what works for us here may not work exactly the same way somewhere else, and that's true on both the clinical and administrative sides.

For example, U.S. hospitals have long since empowered nurses, junior physicians and other care providers to challenge the decisions of senior physicians when a patient's health may be at risk. But in some of the countries in which we work, challenging a senior physician is regarded as a serious breach of civility and protocol.

Learning to adapt

Experience has taught us that such differences cannot simply be overruled by fiat. We learned over time that medical practices are closely tied to a region's unique traditions, beliefs, aspirations and experiences, and they can be deeply ingrained. There is only one way to deal with these differences: Learn what they are, understand where they come from, respect them and then customize your work to accommodate them. Doing so can require placing staff on the ground and being highly creative in figuring out ways to adapt existing U.S. models to other cultures.

Hopkins never compromises on issues related to patient safety, but we've learned to be open-minded about almost everything else. We used to worry that quality of care might suffer when our collaborations strayed from our Baltimore models, but we've come to see that an intimate part of delivering great care involves being able to do so in the proper cultural context. If a U.S. hospital isn't prepared up front to rethink the way it does things when working overseas, then it would be wise to remain focused on domestic healthcare.

Another big potential stumbling block involves finding the personnel needed to manage and staff new overseas facilities. In the U.S., hospitals may struggle with the costs of top-notch personnel, but at least the people are available. Many countries, however, don't have the sort of existing healthcare infrastructure — be it leading-edge hospitals, great medical and nursing schools, or executive education programs — that produce a steady pipeline of highly qualified personnel. Nursing shortages in particular, while a problem in the U.S., are acute in many countries. Trying to fill top leadership positions, both clinical and administrative, can also be a special challenge.

The easy-sounding solution is to bring in personnel from the U.S. However, getting a number of successful U.S. clinicians and administrators, as well as technical staff, to move overseas for years or even just months can be difficult. It has taken Hopkins many years to establish a culture in Baltimore that encourages and rewards these sorts of seemingly risky moves on the part of our staff. And while we have cultivated a number of people who are willing and even eager to take overseas positions, often for extended periods of time, we are still heavily dependent on our ability to recruit people internationally for most of our overseas projects. In addition, we now work whenever possible to try to bolster local education and experiential opportunities, so as to establish longer-term pipelines in the countries in which we work. We've also established routine mentorship programs that bring local clinicians and administrators to Baltimore to spend weeks or months observing and learning how we do things here.

Is it worth it?

There's no question — global healthcare is a daunting prospect. It requires an institution to demonstrate a willingness to initially fail — probably more than once — to succeed at global collaborative healthcare in the long term. But for leading U.S. hospitals that are willing to step up and rethink many of their basic approaches to providing healthcare, all in a spirit of deep respect for partners and better outcomes for patients, the results can more than justify the effort.

Even aside from potential financial returns, the opportunity to contribute to raising healthcare standards and accessibility on a global scale is extraordinarily satisfying and energizing and provides useful new perspective on how healthcare is delivered here in the United States. Organizations driven by a passionate mission to take care of patients can ultimately find a way to overcome the many obstacles to partnering overseas and will likely be glad they did.

Steven J. Thompson, MBA, has more than 25 years experience in various positions within academic medicine and academic health centers. Mr. Thompson is the founding chief executive officer of Johns Hopkins Medicine International, a position he currently holds. After six years as senior vice president of Johns Hopkins Medicine, he returned to the helm of JHI in 2011. Johns Hopkins Medicine International was established as the arm of Johns Hopkins Medicine that provides a focus for all international activities. Mr. Thompson has a particular interest in identifying innovative ways for Johns Hopkins to collaborate with a wide range of affiliates to work towards the common objective of improving health and healthcare delivery around the world.

More Articles Featuring Johns Hopkins Medicine International:

Medical Tourism and Travel: What it Means for Your Hospital
Johns Hopkins Medicine International Completes Planning Phase for Malaysian Health System
Johns Hopkins Enters Into Agreement to Improve Kuwait Hospitals

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