I attended the TTWUD launch event yesterday, which was hosted by Nigel Crisp to mark the launch of his

new site for spreading innovation in global health and organised by the current Medsin director Jonny Meldrum, who had been working on the site for a number of months. Having found it a thoughtprovoking event, I decided to write up some of the discussion and some of my reflections when I got home. One of the best things about the talks was the simple point often made, but one that I think can never be repeated enough that global health is all about equity. Its why Im interested in global health, and its also something thats increasingly under siege right on our doorstep here in the UK, with the current erosion of social safety nets and current threats to equity in healthcare delivery thats going on. As I understand it, TTWUDs primary emphasis is on facilitating mutual teaching and learning a route towards co-development as Nigel Crisp so eloquently puts it - by global health professionals and stakeholders from high, low and middle income countries alike. To illustrate what this means, the first of the many case study examples presented was that of Brazils system of primary healthcare and community health workers (CHWs). Each of the 250,000-strong army of CHWs has personal responsibility to visit each of ~150 households at least once per month, and is responsible for a wide range of preventative and integrated healthcare and environmental health roles. Whats particularly amazing about it is not only its success and cost-effectiveness, but also that there are plans afoot to pilot the system in North Wales. The system and plans for reverse innovation to Wales are described further in the full case study here. Given his influential role as Chairman of the National Association of Primary Care and of the NHS Clinical Commissioners, Charles Alessis evident enthusiasm for a pilot in England was very encouraging, although his thoughts about dinosaurs sitting on two separate drainpipes as a metaphor for the resistance of the NHS establishment to change, and Fiona Godlees comments about patients expectations in the UK, perhaps hint at the extent of the challenge in translating such eminently sensible, cost-effective schemes to higher-income contexts such as the UK. Three particular themes that came up in discussion were those of establishment inertia and the value of disruption, of creative, cost-effective changes to practice often resulting from necessity or adversity, and - linked to the first point - the importance of youth in this agenda. All three resonated strongly with my interests, and many of the more specific points also struck a chord with my own experiences, such as that about the importance of a clear organisational direction and purpose which was made by the African Health Policy Networks Francis Kaikumba. One other recurrent theme during the discussion was that of personalised care and patient empowerment being likely to emerge as the next big revolution in healthcare, in the wake of evidence based medicine. There was a lot of talk about the value of context-specific approaches to healthcare delivery and service improvement, which treat the patient as a unique whole rather than a set of biological components. At its core, I think that's what good care is all about and it doesnt hurt that its often better value and more resource efficient too. Sustainability and what it means for healthcare is something Im particularly interested in, having previously been involved in work on the subject at the Centre for Sustainable Healthcare. Paul Farmer at one point spoke about the 'fetishisation of the quantifiable' when it comes to peer-reviewed journals, and the missed opportunity in global health that disciplines like sociology and anthropology bring to the table. This I could thoroughly relate to; Im studying public health this year and although I recognise the importance of quantitative approaches, I do think that their dominance in policy and priority-setting may at times be more of a hindrance than a help, given that certain genres of problem and intervention - especially upstream, policy-based interventions - are inherently much harder to evaluate fully or effectively in a quantitative way. This is particularly true when it comes to certain more abstract concepts relavant to healthcare and health system improvement: patient engagement, self care, social capital, sustainability and resilience. They are difficult to pin down on a neat scale, but at present - in the face of rising costs due to ageing populations and the NCD epidemic, climate change, energy insecurity and increasing resource scarcity - they are perhaps some of the most important dimensions of innovation in healthcare. In one of the examples discussed, about a USAID-funded pilot project to reduce neonatal mortality in Russia, it was thanks to further funding not being awarded that the true effectiveness of scaling up and spreading innovations using local capacity and resources was highlighted, resulting in markedly better health outcomes (see http://www.hciproject.org/improvement_tools/improvement_methods/spreading and http://www.hciproject.org/node/3563 for more info) After a great presentation on an integrated and home-based palliative care scheme in India by exMedsin presidents Felicity Jones and Dan Knights, Prof. Parveen Kumar (always strange to find out your textbooks were written by real people somehow...!) and the RSMs B Sethia pit ched their idea. Their proposed way to turn the world upside down involved medical student electives and to sum up a

much longer explanation, they want to make them into a two-way exchange, seeing this as an opportunity both to build capacity, to share ideas and to create long-term partnerships. They also made the case for such a scheme to be funded through aid given the newly announced increase in aid to 0.7% of GDP, quoting figures on the percentage of this which may not be spent effectively. In response to a (rather leading) question about support for the idea, one person in the room was brave enough to express qualms and this was the reason. Personally I felt the same; although broadly speaking I liked the idea, at least in principle, I can think of many things I would spend aid money on before paying for medical elective exchanges, especially given the huge extent of medical migration away from resource poor countries and the reasonable possibility of such a scheme even exacerbating it. I couldnt help wonder whether it might not be better perhaps to invest in scaling up schemes like MedicToMedic, which specifically invest in training health workers from rural backgrounds and poorer groups, who have been found to be much more likely to practice in or near their communities when they graduate than the urban middle class who are often the only students' whose parents can afford medical student fees. Or in the amazing and innovative technology to share experiences and build capacity, as exemplified by Alexander Finlayson and others' real-time clinical education website, described here. Paul Farmer's response to the idea centred on the need to be cognisant of the immense disparities in wealth between rich and poor settings, but he clearly recognised that this question wont have a simple answer. Also relevant is that a countrys status is very much a relative question: Brazil is lower inc ome than the UK or US, but to a country like Rwanda it seems rather like a colossal economic powerhouse whose primary care strategy it would be difficult if not impossible to emulate. Yet this article of his, quoted by Fiona Godlee at the start of the event, illustrates that health status in Rwanda has, in its very different context, improved by strides since the 1994 genocide, thanks largely to enlightened government policy with an emphasis on integrated care at the level of the patient and on health system strengthening. One of the key points of the whole event, which was brought up mainly in relation to the electives idea, is that exporting an - often flawed - way of delivering healthcare which has become the norm in the UK or US to developing countries is rarely what is needed or appropriate, and should be avoided as far as possible. At the same time, the West has a great deal to learn from lower income contexts who often achieve very good - and sometimes much better - health outcomes, with much less. The challenge lies in how to build mutual trust based on equity and respect in order to learn together, from one another, in such immensely different contexts. Now is the time to start turning the world upside down.