NHS international intelligence scanning service

Identifying and curating key international reports, research and conversations that provide insight and lessons for NHS leaders.

26 November 2021

We provide a monthly international intelligence-scanning service on this page, and available via our monthly newsletter.

November 2021

  • Led by Dr Abi Sriharan, Director of the System Leadership and Innovation programme at the University of Toronto, researchers in Canada, Australia and the UK have developed a conceptual framework for leadership during a public health crisis, based on over 8,000 pandemic research studies from 2003 until now. 

    In the face of a rapidly changing environment and a requirement to make decisions with little or constantly changing evidence, Dr Sriharan noted that adaptability has become the key to successful leadership, more so than in other public health crises. Additionally, due to the need to consider healthcare, social wellbeing, and economic impacts, Dr Sriharan also highlighted that leaders are now required to demonstrate cultural humility and collaboration in order to be successful. 

    The framework is now undergoing field-based testing studies. A full paper outlining the study is available. 

  • Though no one common definition exists, frugal Innovation can loosely be defined as “developing quality solutions in a resource-constrained environment that are affordable to low-income consumers". As such, their implementation into the delivery of NHS services presents opportunities for more financially sustainable services, with comparable or improved effectiveness and safety when compared to standard methods. However, this potential is limited by numerous barriers that stifle uptake. 

    In the latest paper on the topic, published in BMJ Innovations, researchers at Imperial College London have examined the uptake of Kangaroo Mother Care (KMC) vs incubator use for newborns into the NHS. KMC was originally developed in Columbia during the 1970’s and makes use of prolonged skin-to-skin contact, early discharge, regular follow-up and exclusive breastfeeding, and has been shown as effective for stable babies in low-income settings. Despite this evidence and uptake in other high-income countries (Sweden and the USA), it has struggled to be widely adopted into the NHS. 

    From the outset, the barrier of research paucity was identified as an issue. Such is the lack of research into KMC in the UK, the research team were required to use the Kangaroo Care (KC) and Skin-on-Skin contact models as proxy’s for KMC. 

    Overall, the team identified barriers falling into three broad categories: 

    • Research, evidence and guidance
    • Education and training
    • Cultural attitudes 

    Greater investment needs to be made to develop the UK specific evidence base to enable the implementation of national guidance, whilst education and training, incorporated into standard programmes of training and professional development for a broad range of healthcare professionals would enable the confident delivery of services and the delivery appropriate educational support for parents to feel comfortable. 

    These are not factors limited to the implementation of KMC, as they run through many frugal innovation projects in the NHS. As such, anyone interested in the benefits of adopting frugal innovations into the NHS will find value in this work. 

  • The COVID-19 pandemic represents a health system shock of an unprecedented scale. Health systems resilience – defined as the ability to absorb, adapt, and transform to cope with shocks – is necessary to ensure sustained performance of health system functions (governance, financing, resource generation, and service delivery) so that the ultimate health system goals, especially that of improving health of the population, can be achieved.

    As we have witnessed, few countries could achieve this goal and even fewer could do so in a sustained way, leaving all countries with important lessons to learn. The lessons derived in this study can inform both the ongoing efforts, while countries are still grappling with the pandemic, as well as help to ensure these efforts also incorporate a longer-term perspective, thus improving preparedness to any future health system shocks.

    While there is no ‘one-size-fits-all’ response that all countries could replicate, the study identifies 20 key strategies, grouped according to the health systems' functions, that have been found as enhancing health systems resilience in the face of COVID-19. They have strong interlinkages and do not work in isolation, and this study also considers how the health system operates in the context of other systems, and broader political and governance structures.

  • The OECD has released their biennial Health at a Glance report that examines indicators on population health and health system performance across the OECD member states and other emerging economies. This edition has a special focus on the impact of COVID-19, including the direct impact of deaths and illness related to the virus, as well as the indirect impact on access and quality of care, and on mental ill-health. 

    Since the last report in 2019, the UK has continued to perform well in the quality of care delivered and spending on health and care as a percentage of GDP, which now stands at 12.8%. 
    However, the report highlights the impact that COVID-19 has had on the health and wellbeing of the nation. Life expectancy has dropped by over a full year (81.4 vs 80.4) and the prevalence of depression has doubled to 21%.  In this regard, Chile, Canada and Australia are all noted for their interventions to improve mental health. Chile has increased mental health spending as a percentage of overall health spending by 310%, Canada introduced free self-assessment, support and phone counselling through Wellness Together Canada, and Australia doubled reimbursement entitlements for talking therapies. 

  • The New Zealand Ministry of Youth Development (MYP) has commissioned research to understand the experiences of takatāpui - queer, gender diverse, and intersex young people (16-24), collectively referred to as Rainbow young people - through the highest stages of the COVID restrictions (Levels 3 and 4) and the pandemic more generally. 

    The research, which included online surveys, focus groups and interviews, found that Rainbow young people were impacted to a far greater extent, with only on third of young people reporting that they were managing the pandemic well, compared to just over half in the wider 16-24 non-rainbow demographic.

    The report makes a total of six recommendations including: 

    • Prioritisation of free and accessible provision of mental health support 
    • The development of anti-discrimination policies 
    • Equitable access to gender affirming healthcare 
    • Addressing the barriers to young people not seeking testing or healthcare 
    • Designation of Rainbow communities as priority populations across all of government
  • Writing in Lancet Global Health, several organisations advocating for LGBTQIA+ rights in healthcare have discussed the process of decolonising gender in Indian healthcare. The authors describe the process of removing rigid notions of gender and sexuality introduced to India during colonial rule and the subsequent entrenching into Indian law and cultural norms, ultimately resulting in discrimination and marginalisation of sexual and gender minorities not seen before British colonial rule.

    The authors describe the challenges associated with changing the law to overcome this marginalisation, and some of the innovations being introduced by grassroots organisations – such as the development and introduction of a new birth certificate into delivery rooms that won’t assume gender at birth and the inclusion of clinical education and support dedicated to LGBTQIA+ health in India’s first All India Institute of Medical Sciences. 

  • Many plaudits have been given to the technological approaches taken by South Korean to restrict the spread of COVID-19 through one of the most densely populated countries in the world. However, writing in The Conversation, Choon Key Chekar, Joshua Moon and Michael Hopkins of Lancaster and Sussex Universities argue that more recognition should be paid to the use of social policies as major drivers behind South Korea's success.

    Referencing the recently released House of Commons report on the UK’s pandemic response, they argue that too greater emphasis is placed on high-tech solutions that ignore the value of traditional methods of contact tracing, isolation and quarantine of which South Korea has made extensive use. 

    A prime example of this is the assignment of a case officer employed by the local council to all those required to isolate. The case officer is able to provide advice and guidance, deliver tailored support packages and is a two-way point of contact for support for services all the way through to pet care. This comprehensive and personalised package of service is inherently trust building and has led to high compliance from those required to undertake the 14-day isolation period. 

  • Throughout 2021, The Tropical Health Education Trust (THET) and the African Centre for Global Health and Social Transformation (ACHEST) conducted three symposia examining the role of the UK in relation to the recruitment of health professionals from Low- and Middle-Income countries.

    With representation from 11 countries by 36 experts and with support from the UK government via the Department of Health and Social Care (DHSC) and Health Education England (HEE), the symposia have provided a place for a diverse range of stakeholders to collaborate to advance the UK’s leadership in ethical recruitment. 

    Examples central to this are the adherence to the WHO Code on the International Recruitment of Health Workers and the further development of bilateral agreements between HICs and LMICs. 

    The final symposium in the series explored new ideas for participation, including the SCALE programme, developed by the Ugandan Ministry of Health and Health Education England, which uses virtual learning between UK and Ugandan participants, alongside bi-directional temporary movement. 

    Beyond the symposia, THET and ACHEST will continue to work together in a number of ways: 

    • Promoting and advocating for awareness of approaches to migration that are mutually beneficial
    • Working in close partnership with WHO to increase the number of countries applying the principles of the WHO Code
    • Offering a continued partnership with the UK Government to look at how UK ODA can be used as a basis for up-skilling workforces in partner countries
    • Contributing to the evaluation of approaches that aim to support mutually beneficial migration 
    • Engaging the private companies that facilitate global migration, so that they go beyond the WHO Code and look to how they can benefit health systems as well as individuals. 


  • The latest edition of The Health Advocate, the monthly publication from the Australian Hospitals and Healthcare Association, focusses on workforce wellbeing this month. Recognising the catalytic effect that the COVID-19 pandemic has had on pre-existing wellbeing issues among healthcare professionals, which include burnout, depression and insomnia, the authors of various articles present potential solutions. 

    Among these are a distributed model of leadership that promotes inter-professional collaborative practice; a re-prioritisation of clinical supervisions as a means of delivering professional and emotional support; and the work of Macquarie University to provide their nursing workforce with a broad suite of education and training opportunities so that they can continue to support professional development opportunities during the pandemic. 

October 2021

  • 18-months into the COVID-19 pandemic, the WHO European Region, European Public Health Alliance, and EuroHealthNet collaborated to undertake a rapid survey to assess the engagement of governments with community and civil society groups when developing their responses to the pandemic in Europe.  

    Despite the continued COVID -19 response from civil society and community groups and their ability to fill gaps in government reach, the survey's findings highlight that government engagement across two thirds of the 18 countries' surveyed remains sporadic and unsystematic, with 50% reporting that there had been no improvement in engagement at all since the onset of the pandemic.

    The authors argue that this continued failure to engage community and civil society organisations will inhibit efforts to ‘build forward better’.  

    Two key recommendations to enable a more regular and systematised government-civil society engagement that is needed to underpin more inclusive health governance are:  

    • Investing in training so that government professionals have the technical skill set and experience required to conduct meaningful engagement. 
    • Including community organisations and civil society into health system operations at national level who can be leveraged in an emergency response.  
  • A new article in the Israel Journal of Health Policy Research examines the Israeli Ministry of Health’s (MoH) programme to shorten waiting times for MRIs in response to growing waiting times for services and inefficient use of available capacity in comparison to other OECD countries.  

    The program focused on six core strategies that together could reduce waiting times. These can be grouped across three categories: economic (financial incentives for providers), workforce (additional personnel, and training programs for radiographers and fellowships for radiologist) and infrastructure (additional scanners in underserved locations, greater use of underused services, and a computerised monitoring system).   

    In the four years between implementation and evaluation, waiting times for adult neurology MRI scans decreased from an average of 52 days in 2015 to 24 days in 2016/2017 and 26 and 32 days in 2018 and 2019 respectively.

    The authors emphasise throughout their analysis that the key point of importance for other health systems is the need to recognise that it was a combination of approaches which resulted in the reduction in waiting times, not the success of any single intervention.  

  • Common across the US and UK is an insufficient collection of race and ethnicity data. The US Centre for Disease Control and Prevention reports that there is no race and ethnicity data for nearly 40% of those testing positive for COVID-19 or receiving vaccination.  

    In both the US and UK, the problem extends far beyond COVID-19 data. The US think-tank the Commonwealth Fund has published an article summarising the recent work of Grantmakers in Health and the National Committee for Quality Assurance which identifies opportunities for immediate action, based on available literature and interviews across health care organisations, state and local health officials, actuaries, and consumers.  

    The report identifies two of the biggest reasons healthcare programs do not have accurate data as being:  

    • Competing standards of recording race and ethnicity data and
    • Fear and misconceptions among professionals and the public about the appropriateness of collecting and divulging this information.  

    The report makes a total of 11 recommendations for overcoming barriers to high-quality, complete data on race and ethnicity. These include:

    • Updating the standards and requirements for equity reporting  
    • The need for Federal Government to develop resources to support data collection and sharing by state and local agencies and healthcare organisations
    • Extending the involvement of communities in the development of data standards and materials and
    • Improved regulation to address concerns around data sharing 

    This report will be followed by a second report detailing intermediate and long-term recommendations for states and federal policymakers. 

  • The continued expansion of digital tools in the delivery of our health services presents significant opportunities and limitations in relation to integrated care.  Whilst digital tools present an opportunity for increased patient-centredness and care coordination, the rapid expansion in the proliferation of these tools also risks exacerbating existing inequalities.  

    A new paper published in the International Journal of Integrated Care evaluates these opportunities and threats in light of the COVID-19 pandemic. The authors highlight that many of the pros and cons are two sides of the same coin. On the one hand where digital tools have enabled the shift to predominantly remote care delivery throughout the pandemic, a significant challenge remains for those organisations that lack the infrastructure to support remote care delivery efficiently, leading to a fragmentation of their services.  

    One example considers the Toronto University Health Network Phone-Connect program that distributed mobile phones to vulnerable individuals so that they could stay in contact with their services. The authors highlight that in circumstances where digital literacy is low, the effectiveness of such interventions is limited and therefore worsens health inequalities if not paired with additional support for service users. 

    A final point of consideration is the concern that a reductionist view is taken towards the use of digital technologies where they are only seen as tools for information sharing and communication, and their wider influence on the integration of services is missed.   

    In response to these potential limitations, the authors recommend three strategies for ensuring that digital health tools are supportive of efforts towards integrated health and care services:

    • Make interfaces and workflows simply and easy to follow 
    • Bring on digital “liaisons” to assist newer users as they adapt to new tools 
    • Have marginalised communities drive implementation through engagement and evaluation.
  • A new special issue of British Medical Journal Innovations looks at frugal innovations and how high-income countries can adopt these cost-effective and high-quality innovations, often more widely associated with development in the resource constrained health systems of low- and middle-income countries.  

    Articles in the issue explore individual examples of innovation, which include remote collection of dementia risk factors and conduction of cognitive testing by Mindset4Dementia; the development of an electronic stethoscope by the All India Institute for Medical Sciences; and the use of smartphones for virtual teaching and ward rounds by London Northwest University Healthcare NHS Trust.  

    The publication also includes two reviews, one exploring the expansion in use of tele-medicine during surgery, and the other examining the variation in use and interpretation of the term ‘frugal innovations’ across academia and practice, and how this variation is hindering adoption more widely across the healthcare systems of high-income nations.

  • The impact on mental health of the COVID-19 pandemic is well documented, with one Australian survey indicating increases in mild to moderate symptoms of depression (26.5%), anxiety (24.5%) and suicidal thoughts and behaviour (10%).   

    With the goal of supporting these patients into the correct care from the outset, a new ‘direct to customer’ triage system has been developed and piloted in the North Coast NSW Primary Health Network (PHN), with the hope that it will reduce demand for Australian mental health services in the wake of Covid-19. The system works by acting as the single point of contact for guiding citizens to the right mental healthcare prior to their first clinical presentation, a redesign on the original service delivery model that saw GP’s act as the ‘gatekeeper’, but importantly doesn’t remove GP’s, AHP’s and other agencies' ability to refer individuals onto mental health care.  

    From a technical perspective, citizens seeking mental health care will complete a self-reported assessment, the results of which are made immediately available by the platform's dashboard which shows a multi-dimensional profile of the person’s mental health and well-being and the recommended most appropriate care pathway, ranging from direction to self-management support, through to immediate clinical assessment for potential triage or hospitalisation. 

September 2021

  • Based on the Institute for Healthcare Improvement's work with partners in hundreds of US health care organisations and communities, this article distils five critical takeaways to guide health care leaders in working with community partners to improve health. It suggests that successful strategies for improving health require: 

    • Understanding the needs and assets of the community
    • Joining existing efforts and community-level coalitions
    • Establishing shared aims and interventions
    • Leveraging potentially shared financing best practices within the community.
  • This special publication of EuroHealth, the monthly magazine from the European Observatory on Health Systems and Policies, examines how to enhance public health and health systems' resilience during pandemics, through addressing governance issues. 

    The publication examines a range of topics from Workforce to Community Engagement, Leadership to Public-Private Partnerships. 

    Articles of particular interest to the NHS include: 

    • Health system resilience during the pandemic 
    • Centralisation and decentralisation in a crisis 
    • Governing health workforce responses during COVID-19 
  • The World Health Organization defines an infodemic as “an overabundance of information and the rapid spread of misleading or fabricated news, images, and videos”. 

    This recently published article discusses methods for countering misinformation and disinformation among the population, including:

    • Providing expert information 
    • Empowering citizens 
    • Boosting knowledge 

    Across all three of these domains, individual NHS providers and the systems in which they operate can, should and do provide valuable input. 

    An example of this could be working alongside other expert organisations (such as fact checking charities and public health agencies) to provide information that has been translated and adapted to regional contexts. Doing so provides citizens with information from a widely trusted source, empowers citizens to challenge disinformation when they are confronted by it, and reduces the chances of disinformation taking hold in the first place, as research during the pandemic has shown that individuals are less likely to believe and share disinformation when their knowledge about an issue has been increased. 

  • As digital solutions take an ever greater role in the delivery of healthcare services, their successful implementation continues to take on greater importance. However, despite this importance, there is a historically high and persistent failure rate among large, complex and well-funded digital health programmes across North America, Europe and Australasia. 

    Projects are affected by various technical, functional, information and user-related factors; however, in the majority of circumstances (up to 65%), poor project management is cited as a reason for these failures. Despite this commonality, little is understood about optimal project management approaches. 

    In this article from the University of Queensland, researchers attempted to evaluate the evidence underpinning current project management approaches used when implementing commercial, off-the-shelf healthcare information technology solutions, including complex healthcare software in large digital health programmes in hospitals or across health systems.

    And this policy brief from the European Observatory on Health Systems and Policies, takes stock of how digital health tools have been used during the COVID-19 pandemic so as to assess how uptake and use of these tools has been facilitated, and learn lessons for the longer term to support the sustained use of digital health tools.

    Prior to the pandemic, both technical and non-technical barriers to implementation existed across European health systems, but non-technical barriers were the main obstacles to greater adoption. These included: 

    • Insufficient investment
    • lack of supportive and clear legal frameworks
    • concerns from health professionals
    • gaps in planning and support for implementation

    Since the onset of Covid-19, these barriers have all lessened to some degree, permitting the use of digital tools to support the delivery of health services during the pandemic, and more recently the various vaccine development and roll-out programmes. 

    The report highlights that to maintain the current momentum and sustain the use of digital tools after the pandemic, clear legal and financial frameworks at policy level, including scope for local adaptation and co-creation of solutions, along with monitoring and evaluation embedded throughout local solutions, will be needed. 

  • Networks of providers, defined as the formal collaboration of 3 or more independent providers, is an increasingly common method for facilitating inter-organisational collaboration across various health systems. Despite their increasing popularity and evidence of success, a substantial number of these networks fail. 

    To better understand why this is, in 2019, researchers from Uppsala University, Sweden, began studying a Network in southern Sweden which had been in operation for 5 years and was designed to support the sustainable collaboration of organisations working across healthcare delivery and elder care. 

    Through observation of Network meetings and individual interviews, the researchers established that pragmatism, ‘the need to get things done’, was a key driver of success in the Network, as it maintained interest amongst the voluntary network members. Additionally, this pragmatism had a positive influence on the sustainability of the network as collaboration on projects, especially through smaller working groups, improved trust between members. 

  • As a result of COVID-19 and the recent attempted launch of ‘GP Data for Planning and Research’ (GPDPR), more of us in the UK are aware of the current and potential uses of patient data for the improvement of services, as well as the potential drawbacks. 

    A new report from the North American Observatory on Health Systems and Policies has examined this from the perspective of the Canadian health system to determine the current and potential uses of Electronic Medical Records (EMR) for primary care performance measurement. 

    The researchers determined that the current utilisation of EMR for primary care is focused at the individual physician level, with some inter-physician sharing possible to facilitate comparable data and research. However, the possibility for data to be used at an organisational level to drive system level quality improvement, is less well established. 

    While the NHS is currently more advanced in its use of data, the challenges identified in its adoption and implementation are similar across the NHS and Canadian systems, with governance and funding for implementation projects highlighted as key factors limiting greater use of EMR data. 

    To avoid unnecessarily slow progress in the utilisation of data, researchers recommended improvements to pan-Canadian data and privacy standards and renewed performance intelligence competencies and core PHC indicators.

August 2021

  • Published in the Australian Health review, researchers at Monash University (Melbourne, Australia) have investigated the self-reported impact of COVID-19 on the professional and personal lives of Australian healthcare professionals.

    Using an anonymous survey of healthcare professionals at a large tertiary health centre, the researchers were able to highlight concerns almost identically aligned with those of NHS healthcare professionals throughout the pandemic. These included the fear of contracting the virus and the associated potential for passing this onto family and patients; the ability to provide high quality care to patients; and the challenges of being redeployed.

    The researchers highlighted that despite support services being introduced for health professionals by health service providers and the state government, interventions can and should go further. One such development would be a more discipline/profession targeting of support.

    As the Covid-19 pandemic continues over the long-term it will be important to maintain an accurate understanding of the impact on health professionals mental health and wellbeing. To this end, researchers at the University of Milan and the Occupational Health Unit at the University Hospital of Milan have developed an observational longitudinal study to examine the psychological wellbeing of all employees.

    The survey was designed to capture sociodemographic characteristics, personal and occupational exposure to covid, worries and concerns, general psychological discomfort, PTSD symptoms and anxiety.

    It was offered to all 550 hospital employees and had a 90% uptake, with those scoring above a predetermined cut-off being offered a second level of questions that would determine if more specialist treatments needed to be offered.

    It is intended that the process will be repeated to monitor symptoms and determine if the impacts of the pandemic are leading to chronic effects.  

  • The North American Observatory on Health Systems and Policies (NAO) has published a comparison of the health policy response to COVID-19 in Canada, Ireland, the United States and the United Kingdom, between January and November 2020.

    Analysis showed that all countries faced common challenges during the pandemic, including difficulties in scaling-up testing capacity, implementing timely and appropriate containment measures amid much uncertainty, and shortages of health and social care workers, personal protective equipment and other medical technologies.

  • Healthcare managers are key to the delivery of integrated care. Reflecting this, the latest edition of the ‘European Health Management in Transition’ book series focuses on the contributions healthcare managers make to integrated care.

    Spread over 8 chapters and with contributions from 25 authors, the book covers topics ranging from funding to patient involvement and finding common ground and motivators with stakeholder to digital health.

  • Since the covid-19 pandemic started the COVID-19 Health Systems Response Monitor has collected national level responses. Recent analysis has sought to determine the primary health care (PHC) specific examples collected.

    Analysis has demonstrated three common themes across European PHC systems:

    • Multi-disciplinary primary care teams coordinating with public health to deliver the emergency response and essential services
    • PHC providers defining and identifying vulnerable populations for medical and social outreach
    • PHC providers employing digital solutions for remote triage, consultation, monitoring and prescriptions to avoid unnecessary contact.

    Particular examples comes from Spain where PHC providers worked with hospitals to provide separate routes for essential services that didn’t require co-location with conformed covid-19 cases; France and Israel where new digital platforms were developed to support all PHC appointments; and the establishment of ‘corona care centres’ in the Netherlands to enable daily remote monitoring of patients in the community.

  • As part of World Breastfeeding Week, WHO/Europe showcases Sweden’s experience in gathering data to understand the reasons behind declining breastfeeding rates in the country.

    Despite relatively high rates of breastfeeding in comparison to other countries in the WHO European Region, only 11% of mothers met the WHO’s standard recommendation of exclusive breastfeeding for the child's first 6 months. Whilst there has been an overall decline since the 1990s.

    In response to this, two surveys were conducted in the Skåne regions. One aimed to evaluate the current status of breastfeeding in health facilities, whilst the second aimed to explore breastfeeding attitudes and knowledge among the local population and to gain a deeper understanding about the underlying factors that influence whether and how Scanian women choose to breastfeed.

    The survey identified the following negative influences:

    • Widespread uncertainty remains about the health benefits for both the child and mother with only 3 out of 10 aware that it reduces the risk of breast cancer.
    • Currently, there is no regional coordinating body to support breastfeeding in Skåne. Health workers reported that policies they can refer to are insufficient.
    • Violations of the International Code of Marketing of Breast-milk Substitutes are common in healthcare facilities. 91% of nurses working in child health care services reported being contacted by representatives from the baby food industry during the last year; with 80% being given free formula samples to distribute to families.
    • Since pre-service education, only 32% of healthcare professionals who responded to the survey completed further training in breastfeeding counselling, and the majority considered themselves in need of further training on how to counsel women to breastfeed.
  • A new analysis of US health care spending reveals stark disparities across racial and ethnic lines, with White Americans benefiting from an outsized share of health care dollars relative to their proportion of the population. The study was conducted by researchers from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington School of Medicine.

    IHME’s analysis shows that the differences in spending are driven by inequities in how Americans utilize health care, with minority patients less likely to receive outpatient services or prescription drugs.

    The study reveals that in 2016 non-Hispanic White Americans received health services representing 72% of all health care spending, despite comprising only 61% of the population. On the other hand, Hispanic and Asian Americans received the least spending relative to their proportion of the population: Hispanic patients benefited from 11% of health care spending despite accounting for 18% of the population, while Asian, Native Hawaiian, and Pacific Islander individuals received 3% of spending while making up 6% of the population.

    While spending on African Americans was roughly equal to their share of the population – they received 11% of health care spending, while making up 12% of the population – it was skewed significantly toward emergency and inpatient care, suggesting that they do not receive care until they are experiencing advanced illness. Specifically, they received 26% less spending on outpatient care, but 12% more spending on emergency department care.