So What? Who Cares?

In Chapter 9, the closing chapter, the authors raise four “So what?” issues that our fellow learners and aspiring health system designers should address: getting good value for money while simultaneously satisfying individual consumers of care and guaranteeing that all citizens can access the health care their nation provides; understanding the system’s developmental life cycle and capitalizing on a zone of innovation available in existing health system design; comprehending what reconceptualization means and giving some examples of what it might look like; and appreciating that a high-value health system needs to be owned by all and requires each and every citizen to do their part in preserving, protecting, and sustaining it.

How Did We Get Here?

Chapter 3 traces the development of health systems in middle- and high-income countries since the Second World War and notes the trends that have led to the development of contemporary health systems. The authors summarize the major trends in healthcare—the benefits, costs, public attitudes and beliefs, and consumer responses to medical care. Health has improved, more citizens are able to access healthcare, standards of care have risen, and the advance of scientific medicine is stunning. The authors reflect on the forces that have led to the current successes and raise upcoming challenges in improving health and healthcare. Foremost among these are concerns about rising costs and value-for-money of health systems, which pose sustainability challenges to health systems in all countries.

Developing Plans for Change

Chapter 5 presents a semi-structured plan for each work group to produce one system intervention plan (SIP) for their country. Taking the components of their health system, its underlying system problems, and their formulation of its vision and goals, the students individually and then in their small group take a stab at identifying gaps and constructing a system improvement plan. This chapter will present various techniques and exercises to help students come up with interventions that work. The process of idea-generating is designed to generate a solution to fix one or more of their chosen system performance gaps. The students’ work product is to agree on and propose one intervention to achieve the goals, objectives, and targets they have selected for their chosen country in Chapter 4.

Testing the Change, Improving the Plan

Chapter 6 introduces the students to a proprietary framework and tools to test, refine, and prepare each student’s system improvement plan (SIP) for implementation. The students revisit their country SIP to refine its constituent process steps and to produce a process flow map of their plan. The flow map illustrates a logical chain that links the proposed inputs through sequential action steps for implementation of the plan to produce the outputs that enable the SIP to attain the projected goals. The authors introduce the proprietary D3A3 model that consists of six interlinked steps: D1—design the intervention plan; D2—determine the measures of success; D3—deliver; A1—assess; A2—analyze; and A3—act. The D3A3 model is used to guide iterative development and agile implementation of system improvement plans. The students will use the D3A3 model to conduct one or more test runs to improve their SIP and increase their confidence that it will deliver the outputs they need. In complex dynamic systems, it is hard to predict the results of change and plans should be subjected to iterative cycles of testing. For this the authors introduce a process called a model for improvement that helps designers to understand the potential impact, effort, feasibility, and risks of implementing their SIP and to progressively test and strengthen plan design and prepare it for implementation.

Introduction to the Health of a Population

Chapter 1 conceptualizes a health system as a collection of interacting elements that are designed to produce outputs that lead to better population health. A system’s elements both “hang together” as a whole and continually interact and affect each other as they interoperate to produce their final result. Systems thinking is one of the most important disciplines enabling one to understand and characterize systems that display dynamic complexity. Systems thinking in health is a framework for seeing interrelationships and repeated events rather than individual activities, for discerning patterns of change, understanding responses to policies, and for deciphering human behavior within health systems and over time.

Developing a Vision and Goals

Chapter 4 presents methods to examine the performance of a health system and to assess, define, and choose the vision, specific goals, and objectives for a health system. The authors discuss approaches to understand the performance of a country’s health system and present indicators that could be used to assess the performance of health systems. They present methodology to examine the opportunities and threats faced by a country health system and the strengths and weaknesses of the health system based on the performance achieved. They show how the results of this examination are used for a strengths and weakness, opportunities and threats (SWOT) analysis. They discuss how the SWOT analysis can be used to identify gaps in system performance and consider those that need addressing. The SWOT analysis informs the beginning of the goal-setting process and the development of an improvement plan to redesign the health system to achieve set goals.

Implementing a Change—Adoption and Diffusion

In Chapter 8, the authors discuss in detail factors that might influence the introduction and scale-up of the system improvement plan (SIP). Successfully maneuvering an SIP in a complicated health system is a challenge. It requires considering the multiple interlinked factors that individually and collectively influence the adoption and diffusion process. They discuss the potential enablers and barriers that may facilitate or hinder the adoption and diffusion of the SIP and the change it is designed to produce. They introduce a proprietary framework, the 7Cs model, to group these factors into categories. This framework is designed to enable students to clarify the many interconnected elements that will influence the implementation of their SIP and organize the interventions that are needed to effectively manage these factors. The 7Cs model encompasses seven factors that need to be considered in relation to the implementation strategic change and of the SIP: (i) challenge, (ii) content, (iii) context, (iv) coalitions, (v) communication, (vi) capacity, and (vii) cohesiveness.

Assessing the Health System of a Country

Chapter 2 describes different definitions and conceptualizations of health systems. It presents a proprietary framework that adopts a systems view of health systems. In the authors’ framework they conceptualize health systems as a collection of functions that interact to produce outputs that in turn are used to produce outcomes. Health systems functions consist of organization and governance, financing, and resource management. These functions are used to produce health system outputs, namely public health services and personal healthcare services. Policymakers use policies to ensure the health system outputs are effective, efficient, equitable, and responsive to achieve the right level and distribution of health system outcomes, namely population health, financial protection, and user satisfaction. The health system is situated in a dynamic and changing context with which it interacts and is influenced by it. The context is shaped by demographic, epidemiological, political, legal and regulatory, economic, sociocultural, ecological, and technological changes and shifts that create opportunities and threats to which the health system must respond. Policymakers need to consider how to design health systems to ensure that they are not only responsive and resilient to the opportunities and threats created by contextual changes and shifts but also that they ensure the right balance of effectiveness, efficiency, equity, and responsiveness for the system outputs to achieve desired level and distribution of outcomes.

Insights From Systems Thinking

Chapter 7 presents three high-level insights that can be drawn from this book’s look at a health system from a systems thinking perspective. First, all health systems suffer from one of systems theory’s classic descriptive models called The Tragedy of the Commons, in which a scarce resource is consumed when a collective benefit (e.g., health insurance) is subsidized and its price to the user is less than the cost to produce it. Second, when viewed from a systems perspective of value-for-money, most health systems face competing objectives—satisfying individual’s demands for maximizing their own medical care and providing healthcare as a fundamental right of all citizens regardless of ability to pay. Third, to integrate these goals requires re-framing the way societies think about each. The authors describe double-loop learning, which is required when confronting second-order change. The latter term describes problems where it is necessary to redesign human perceptions for change to lead to improvement. Complex changes require double-loop learning, in which underlying interpretive conflicts and differing values and beliefs are surfaced and managed.