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Building a High-​Value Health System
ii
Building a High-​V alue
Health System
Rifat Atun and Gordon Moore

1
iv

1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.

Published in the United States of America by Oxford University Press

198 Madison Avenue, New York, NY 10016, United States of America.

© Oxford University Press 2021

All rights reserved. No part of this publication may be reproduced, stored in

a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by license, or under terms agreed with the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.

You must not circulate this work in any other form

and you must impose this same condition on any acquirer.

Library of Congress Cataloging-​in-​Publication Data

Names: Atun, Rifat, editor. | Moore, Gordon, editor.
Title: Building a high-​value health system /​[edited by] Professor Rifat Atun and
Professor Gordon Moore.
Description: New York, NY : Oxford University Press, [2021] |
Includes bibliographical references and index.
Identifiers: LCCN 2020049688 (print) | LCCN 2020049689 (ebook) |
ISBN 9780197528549 (paperback) | ISBN 9780197528563 (epub) |
ISBN 9780197528570 (online)
Subjects: MESH: Delivery of Health Care—​methods | Systems Analysis |
Health Planning—​methods | Organizational Innovation
Classification: LCC RA418 (print) | LCC RA418 (ebook) | NLM W 84.1 |
DDC 362.1—​dc23
LC record available at https://​lccn.loc.gov/​2020049688
LC ebook record available at https://​lccn.loc.gov/​2020049689

DOI: 10.1093/med/9780197528549.001.0001

This material is not intended to be, and should not be considered, a substitute for medical or
other professional advice. Treatment for the conditions described in this material is highly
dependent on the individual circumstances. And, while this material is designed to offer accurate
information with respect to the subject matter covered and to be current as of the time it was
written, research and knowledge about medical and health issues is constantly evolving and
dose schedules for medications are being revised continually, with new side effects recognized
and accounted for regularly. Readers must therefore always check the product information and
clinical procedures with the most up-​to-​date published product information and data sheets
provided by the manufacturers and the most recent codes of conduct and safety regulation.
The publisher and the authors make no representations or warranties to readers, express or
implied, as to the accuracy or completeness of this material. Without limiting the foregoing, the
publisher and the authors make no representations or warranties as to the accuracy or efficacy
of the drug dosages mentioned in the material. The authors and the publisher do not accept,
and expressly disclaim, any responsibility for any liability, loss, or risk that may be claimed or
incurred as a consequence of the use and/​or application of any of the contents of this material.

9 8 7 6 5 4 3 2 1
Printed by Marquis, Canada
CONTENTS

Preface  vii
Acknowledgments  xi

1. Introduction to the Health of a Population   1

2. Assessing the Health System of a Country   15
3. How Did We Get Here? Historical Megatrends in Health
and Medical Care   53
4. Developing a Vision and Goals   74
5. Developing Plans for Change: A Framework for Designing a
High-​Value Health System   97
6. Testing the Change, Improving the Plan   122
7. Insights From Systems Thinking   146
8. Implementing a Change—​Adoption and Diffusion   167
9. So What? Who Cares? The Wrap-​Up   193

References  217
Index  225
vi
P R E FA C E

A growing challenge to all population-​based health systems—​whether na-

tions or large organizations—​is how to make healthcare delivery effective,
efficient, equitable, satisfying, and, especially, affordable. The size of the
task is clear. In the past 50 years, healthcare expenditures in the countries
of the Organization for Economic Cooperation and Development coun-
tries have doubled to reach an average of around 10% of the gross domestic
product (GDP) while that in the United States has trebled to reach above
18% of GDP, in excess of $3.5 trillion each year. Through 2040, projected
per capita expenditure on healthcare in developed countries is estimated
to exceed the rate of GDP growth. Who bears this increasing cost, and how,
varies considerably among countries.
Delivery of healthcare services differs widely across the world. Benefits,
results, and popular acceptance are markedly different. Countries have
different mixes of public health services, high-​quality medical care, level
of personal financial risk protection and affordability, and national satis-
faction. Most countries and businesses are struggling to find an equilib-
rium between benefits that are optimal for them and their constituents
and the best value-​for-​money. No country would claim to have successfully
achieved the perfect balance.
All health systems are in flux. Science is advancing our understandings of
biology and, with it, the need will increase for health system reform to en-
sure their optimal use. New treatments, diagnostics, health technologies,
and medicines will become available, contributing to rising medical care
costs. Confronted by these costs, every population-​based health system
will seek to be more effective and efficient, while maintaining its accepta-
bility to the population it serves. Inevitably, however, nations and organi-
zations will be forced to face the fact that costs of health care will continue
to increase and ultimately become unsustainable; countries will need to
choose between other health and societal priorities and the extent and
vi

scope of medical care provided to citizens. Our hope in this workbook is to

help decision makers learn to do this well.
Our goal in Building a High-​Value Population Health System is to teach how
a population can get better health for the amount it spends. The learning
objectives are to prepare readers to understand a health system, create a
strategic plan to improve it, and design actions to build a better system
that improves care for populations. The educational process will provide
tools and help readers to acquire skills and knowledge. Throughout, we treat
population health as complex systems and show that using systems theory
approaches can stimulate deep learning and transformative innovation.
Our population targets for health system improvement are middle-​
and high-​income nations with adequate organizational and economic ca-
pacity to build a full-​service health system. Despite the magnitude of the
health system design challenge, there is no how-​to book that describes and
teaches a practical, general approach to designing anew or improving upon
a current health system. We hope this workbook can meet that need.
This educational workbook focuses primarily on national systems of
health care for populations and individuals. We recognize that public health
and social determinants of health also have profound effects on the health
of populations and must be considered part of achieving a high quality,
equitable, and affordable health system. Public health can rightly claim
equal or greater causality in global trends in health and disease in the past
100 years than the contribution of medical care. Social determinants such
as economic success have been major factors in improving health. How
much improvement each has contributed to the current state of health in
developed countries has not been computed convincingly. For sure, public
health and social determinants are important. But because individual
healthcare services are high cost and have grown fastest, they have been
more prominent in politics and government policy. Since medical care has
directly consumed much more of countries’ national resources, it is our
primary concern in this workbook about policy development, change, and
implementation.
The book’s targeted audience is health system learners at all levels.
Primary among them are teachers and students at medical, allied health
professions, and public health school levels. Educators can use this work-
book to teach their students how any health system works and how to im-
prove it. It is designed to be used in classroom settings as the basis for a
general course on teaching how to understand and improve healthcare. To
make the book easy-​to-​use for educational purposes, we have highlighted
educational instructions for students and teachers throughout. These
sections are featured in italics.

[ viii ] Preface
 This book will be of interest to other audiences as well, including busi-
ness managers, delivery system leaders, politicians and their staff, and
policymakers. Because the book is structured to catalyze strategic action,
it will assist organizational change agents in designing and implementing
plans to improve the cost, quality, and outcomes of their health system. For
all readers, we hope that the book will be useful as a primer to enable them
to plan and deliver a health system that works for them.
Using an active, learner-​directed teaching method, the workbook sys-
tematically leads the reader through the steps of designing a system to fit
a population’s needs. The book lays out a general approach to analyzing
a country’s or organization’s health system performance, evaluating the
needs of the population to be served, assessing the key capacities avail-
able, and determining how to develop and implement health system design
options that fit and are feasible. Students engage in a real planning process.
The book will use case examples from across the globe to illustrate how all
health systems are constructed, operate, and succeed or fail.
In Chapter 1, we present a definition of a health system. Following
this, a distinction is drawn between a descriptive view of a system as a set
of elements comprising the inputs, structure, and processes that deliver
health outputs to a defined population and a systems analytical approach
by which we examine, interpret, and seek to understand the complex in-
terdependent, interactive, dynamic complexity of the system-​in-​action to
produce the outcomes predetermined by its deep structure.
We introduce our framework for analyzing a health system in Chapter 2.
The framework enables students to dissect the context, functions,
outputs, and outcomes of a national health system. The students select
a country that they will work on for the remainder of the course. They
join a small group that shares the target country. In individual and small
group work, they start a descriptive analysis of the health system of their
selected country. Their work culminates in a presentation of the struc-
ture, goals, and results of each selected country to the entire group of
students.
In Chapter 3, the students are presented with a historical perspective of
health system development. We describe four major trends in healthcare
globally over past 60 years to understand how we got to where we are today
and to identify some of the challenges that await us.
In Chapter 4, the students formulate a vision and high-​level goals for
their country. In the process, they examine gaps between desired and ac-
tual outcomes in their country. By identifying strengths and weaknesses,
opportunities and threats and by putting their country through an analysis
of 12 parameters of performance, the students create a map demonstrating

Preface [ ix ]
x

the largest performance gaps, which in turn leads them to identify the
values, goals, and tentative objectives of their chosen country.
The students identify areas for change in Chapter 5. Returning to a sys-
tems thinking approach, each student identifies, describes, and justifies
a policy, structure, or process change whose projected output is an im-
provement toward a desired health system goal. The students present and
critique their ideas and identify one proposal to be carried forward collec-
tively by their small group.
Chapter 6 guides each student through a number of tests to assess their
plan’s rationale, feasibility, and likely impact. The students present their
ideas for group critique and collectively finalize one proposal that their group
will take forward for implementation.
Chapter 7 reviews major learning insights generated in the workbook
by the use of a systems thinking approach to analysis and planning. The
systems archetype called ‘The Tragedy of the Commons’ is described, and
value-​for-​money is redefined and enriched. Examples are given of health
system interventions that represent three change models: single-​and
double-​loop learning and fundamental reconceptualization.
Chapter 8 asks each student group to develop a proposed implemen-
tation plan. They examine their proposed change for its rationale, likely
outcomes, and risks and consider how to achieve strategic change to en-
sure implementation happens. This process culminates in a presentation
to the entire group, in which each small group argues for funding for their
idea. Students will act as individual policymakers and select the proposals
in which they would invest.
Chapter 9 concludes the book with a summary of the major challenges
to all health systems in middle-​and high-​income countries and an integra-
tion of the interventional themes available to improve them. It ends with
a summary of some suggestions of reconceptualized health systems and
the skills, tools, and roles of design leaders in improving health systems to
ensure their sustainability in the future.

[x] Preface
ACKNOWLEDGMENTS

We would like to thank our publisher, Oxford University Press, and our
editors, Sarah Humphreville and Emma Hodgdon, for helping us move
our manuscript through to publication. In addition, we greatly appreciate
the support of Harvard University’s T. H. Chan School of Public Health,
Harvard Medical School, and the Harvard Pilgrim Healthcare Institute. We
are grateful for our many students, whose study with us over the years
has stimulated the underlying educational methods in this workbook and
improved our teaching. Thank you to our colleagues who have encouraged,
participated, and critiqued our work, leading to and improving many of
the ideas and methods in this workbook. We are grateful for the many
researchers, healthcare organizations, and thought leaders who have
shared insights with us and told their stories. We especially want to thank
England’s NHS and New England’s Harvard Pilgrim Health Care, Atrius
Health, and Harvard Vanguard Medical Associates for enabling each author
to directly experience the satisfaction and tribulations of delivering primary
care services to real people. Finally, we give special thanks to Mary Ellis, a
recent honors graduate of the College of Arts and Sciences at Washington
University in St. Louis, whose diligent review, critical comments, and valu-
able insights have made this a better book.
CHAPTER 1

Introduction to the Health

of a Population

If I had one hour to save the world, I would spend fifty-​five minutes defining the problem
and only five minutes finding the solution.
—​Albert Einstein

T he purpose of this chapter is to help the reader understand the physi-

ology of health systems as dynamic systems. We describe two ways we
will view a health system.
First, we discuss health systems: how health systems are defined,
depicted, and analyzed. We use the term system in this book to describe an
interconnected set of component parts that form a dynamic whole. Each el-
ement has particular properties and characteristics, as does the whole. We
present a high-​level framework for understanding the component parts of
a nation’s health system.
Second, we introduce the idea of looking at health systems through
the approach of systems thinking. In particular, in this chapter we present
health systems as complex dynamic systems. In this view, a health system
is examined as a complex set of interacting and interdependent processes.
2

THE HEALTH OF A NATION

What Determines Health?

The overall health of a population is the result of the interaction of many

variables, of which healthcare services is but one. Health and well-​being
are influenced by many other factors—​culture, education, income levels,
gender, social behaviors, the environment, and economics, to name but a
few. The model in Figure 1.1 categorizes these multiple drivers of health.
Modern societies have developed many interventions to improve
the health and function of their constituents. Among the most visible
influences on health are health services. These range from those pro-
vided to the entire population to those targeting individuals and families.
Foremost among these are public health services and medical care. We also
refer to the latter as medical services, individual healthcare services, or per-
sonal healthcare services. These two types of services—​public health and
medical care—​have developed over time, energized by the specific intent to
improve the health of the population.
At the population level, health systems have provided public health
programs and services. These services target individual and collective
health, usually through functions complementary to medical care. Public
health programs are whole-​population interventions that address health-​
related factors such as the environment (e.g., water and shelter), nutrition
(healthy eating), and social factors (like violence and substance abuse), in

Health System

Healthcare
Social Services
Determinants Public
of Health Health

Medical
Care

Doing Your
Part – Healthy
Behaviors and
Stewardship

Figure 1.1 Determinants of health.

[2] Building a High-Value Health System

addition to providing general prevention strategies (such as vaccination and
health education). Public health programs have had major impacts through
managing epidemics, curbing substance abuse and smoking, promoting
automobile safety, and educating the public about physical abuse and
gun violence. In addition, public health has made the environment safer
through clean water, adequate food and shelter, and safety in workplaces.
In complementing medical care, public health has promoted prevention and
early detection, vaccination, health education, and public policy changes
(such as laws about smoking cessation or seatbelts) to encourage individuals
to practice healthy behaviors and to protect their health.
Public health is the most cost-​effective of health interventions. It is our
view that public health has not only contributed mightily to the levels of
health in all countries but that it also represents the most value-​added way
to improve health in the future for all nations. We see whole-​population
threats as the most significant future risks to health in middle-​and high-​
income countries. Most important among these are lifestyle-​ related
damage, violence and armed conflict, poverty, and climate change. The
latter is, in our view, the most important future threat to the health of
all nations through its direct effects influencing the physical environment,
and causing severe weather events like flooding, drought, and fires. The
consequent impact on natural ecosystems reduces food production and
stimulates mass migration as well as triggering epidemics through the
widening range of transmittable disease vectors.
Medical care is delivered to individuals and directed to their specific
needs. Medical services consist of interventions that provide detection, di-
agnosis, and treatment of individual disease as well as those that aim to
enhance wellness and well-​being and prevent the development of illness.
Middle-​and high-​income countries have all sought to provide some level
of personal medical care.
In virtually all health systems, medical care is based on the Western
model called “allopathic medicine.” This model is science-​based and is often
referred to as “modern medicine,” to contrast with homeopathy, folk, or
traditional medicine. Allopathic medicine utilizes doctors, nurses, and
other healthcare professionals to deliver modern surgery, medical diag-
nosis, treatment, and care in a variety of delivery modalities, ranging from
primary care offices to telemedicine to technically sophisticated hospitals.
Individual healthcare services have not been limited to medical care.
Multiple independent entities deliver individual healthcare services
ranging from support services to Alcoholics Anonymous for alcoholics and
other addictions, and lay support groups for mental health. However, our
primary focus is on the formal structures of the medical care in middle-​and

I n t r o d u c t i o n t o t h e H e a lt h of a P op u l at i o n [3]
4

high-​income countries, comprising doctors, nurses, other healthcare

professionals, hospitals, primary healthcare, insurers, payers, and those
organized interventions that are designed to care for individuals.
Three categories of factors outside healthcare delivery also have signif-
icant effects on health. First, social determinants of health, such as edu-
cation, housing, income, food access, employment, and work conditions,
are broad societal factors that affect health status. Second, as shown in our
model, we point out the important category of each individual’s responsi-
bility for their own and the collective health of the nation. Individual re-
sponsibility is significantly influenced by social determinants of health, as
personal agency over one’s health can vary with societal values, political
milieu, socioeconomic status, racial background, geographic location, and
other factors. However, individuals do bear some personal responsibility
for their lifestyle behaviors, as well as for the appropriate use and stew-
ardship of the medical and public health systems in which they partici-
pate. Third, environmental factors in the built environment or worsening
natural habitats for humans, animals, and plants affect health. These are
mediated by factors such as climate change and human-​mediated events
like pollution. Conversely, good design of cities—​enhancing exercise and
safety, for example—​can create health-​inducing environments.
Despite the obvious importance of public health and broad social, ec-
onomic, and environmental impacts on the health of a nation, we will
mostly focus in this workbook on designing changes in the organization,
financing and delivery of individual healthcare services. We have chosen to
emphasize individual healthcare services because of its importance to na-
tional economies, high costs, popularity, and political prominence, and, as
we will argue, its unstoppable expansion and opportunity costs if medical
care cannot be redesigned and improved.

Health, Economic Growth, and Development

The relationship between health and the economy is a two-​way street.

On the one hand, the interaction of health and the economy can be a vir-
tuous cycle (Figure 1.2). A strong economy is a powerful predictor of good
health. Economic growth, with the right policies, enhances health; indi-
vidual health improves as socioeconomic status rises, A robust economy
enables countries to invest in health systems that play important roles in
improving health and social well-​being of individuals and populations.

[4] Building a High-Value Health System

 Good Less illness and
Health premature
death

Sustainable Healthier and greater

development human capital

Higher
Economic productivity
growth and less
absence from
work

Figure 1.2 Health, economic growth, and development.

In addition to its benefits for individuals, families, and communities,

health is a critical ingredient supporting economic growth and sustainable
development of countries. Better health contributes to economic growth
by producing healthy and productive human capital. The prospect of
better health and longer lives incentivizes people to invest more in devel-
oping their human and social capital. Because healthy citizens have better
chances to realize future benefits in employment and income, they are
willing to commit upfront to more years of schooling for themselves and
their children. For children, good health translates into high attendance at
school and superior cognitive functioning. For adults, good health means
less absence from work and greater ability to fulfill work duties, leading to
higher productivity.
On the other hand, health and the economy can interact in a vicious
cycle. A struggling economy can increase poverty and illness. Poor health
leads to further reduced productivity and loss of human capital. These
factors then hinder economic growth and produce more poverty, which in
turn drives ill health, creating a vicious cycle. Moreover, the surge of ill-
ness can strain healthcare delivery and raise costs, sapping the economy
of investments needed to recover from the economic downturn. Until they
can control the costs of medical care, nations will have less available for
other national priorities, including public health and stimulating economic
growth.

I n t r o d u c t i o n t o t h e H e a lt h of a P op u l at i o n [5]
6

What Is a High-​P erforming Health System?

It is self-​evident that a high-​performing health system should deliver value-​

for-​money. It should generate the greatest possible health of its popula-
tion for whatever financial inputs it dedicates to health. Well-​functioning
health systems use available resources efficiently and effectively to pro-
duce good health. They respond to legitimate expectations of citizens and
satisfy them.
But what is good health? How would one know that their country
achieved it? Measuring the health of a nation is complicated. Generic
definitions of health vary widely, ranging from the idealistic aspirations of
the World Health Organization (WHO) charter, which states “health is a
state of complete physical, mental and social well-​being and not merely the
absence of disease or infirmity”1 to the more modest and conditional def-
inition expressed as the vision of the US Healthy People 2030 Framework
that health is “a society in which all people can achieve their full potential
for health and well-​being across the lifespan.”2
A high-​performing health system and good health, as an expectation
and objective of a nation, are in the eye of the beholder. Each nation has its
own idea of good health. Beyond the general use of longevity as a measure
of good health, countries differ in what they want to get from their health
system. What a country wants in the way of good health and what it is
willing to give up to achieve it reflect unique priorities. Understanding
what an individual nation views as good health is key to assessing how well
the output of their health system is doing the job.
Health is deeply intertwined with other factors that influence what cit-
izens want and expect from their nation. Individuals want to live free of
disease, disability, and death. But they also want to be safe, sheltered, and
fed. Health systems are important for the productive economy and security
of countries. Well-​functioning health systems are critical in mounting ef-
fective responses to emerging public health emergencies, such as epidemics
and pandemics from infectious diseases,3 and in addressing burden of di-
sease from other conditions, such as noncommunicable diseases and
cancers.4
In practice, linking performance of health systems directly to good
health has been challenging.5 Many well-​intentioned policies and mana-
gerial decisions aimed at improving health systems do not achieve desired
outcomes and instead lead to unexpected or unintended consequences.
One explanation for this phenomenon is that too often the tools used to
conceptualize and analyze health systems and the heuristics used to gen-
erate managerial decisions are too simplistic for health systems that are

[6] Building a High-Value Health System

complex. As a result, decision makers have limited understandings of how
best to design a health system and translate it into policy.6
Several obvious factors influence the ways in which a country achieves
good health efficiently, effectively, and equitably. The health system suc-
cess factors include, among others, a vision for what they country wants,
an excellent design of structures and processes in their health system, the
capacity of individuals to make appropriate decisions in relation to their
health, good management of healthcare institutions, and effective political
leadership. These factors are influenced by contextual characteristics of the
setting in which a country is situated, such as history of the country, soci-
ocultural norms, economic characteristics, ability to introduce and scale up
new technologies, and good doctors and hospitals.

SYSTEMS THINKING AND THE HEALTH SYSTEMS

The Evolution to a Systems Thinking Model for Health

Defining and describing a health system is difficult. A system is a collec-

tion of interacting elements that produce outputs that lead to outcomes.
A system’s elements hang together as a whole because they are linked,
continually interact and affect each other and operate toward a common
purpose.
A health system is a means to an end—​a collection of activities designed
to achieve societal goals. In simplistic terms, a health system uses inputs
(money and other resources) to build and operate institutions that deliver
healthcare services with structural and process characteristics that produce
results that aim to meet citizen expectations about maintaining health,
overcoming disease and illness, alleviating suffering, enhancing well-​being,
supporting shared national values, and creating good value-​for-​money.
Early attempts to conceptualize health systems described them in terms
of the actors within them, economic relationships among the participants,
or flows of funds. As an example of the first, systems were defined in terms
of the main sets of actors needed for the population to be served: health-
care providers, third-​party payers, and government as regulator.7
Later, a health system was conceived of as the economic relationship
between demand, supply, and intermediary agencies that influence the
supply–​demand relationship.8,9 The demand side refers to individuals,
households, and populations whose actions influence health outcomes,
and the supply side to institutions that produce the human and material
resources to provide healthcare. The agencies refer to the state or govern-
ment institutions responsible for financing, regulation, and purchasing

I n t r o d u c t i o n t o t h e H e a lt h of a P op u l at i o n [7]
8

of healthcare and other institutional purchasers (such as private insurers,

public insurance funds, district health authorities, and health maintenance
organizations).
Others have defined health systems in terms of archetypes of financing
and healthcare delivery models.10 In this formulation, a health system is
characterized as a set of relationships between an array of components (fi-
nancing, macro-​organization of provision, payments, regulations, and per-
suasion [of behavior], referred to as control knobs11) or as a set of functions12
that can be modified by policymakers to achieve health system goals.
Descriptions of health systems have expanded upon these three
definitions. The WHO in 2000, for example, described a health system as
comprising all the activities whose primary purpose is to promote, restore
or maintain health.13 They extended this definition in 2007 to include the
people, institutions, and resources engaged in a variety of activities in ac-
cordance with established policies to improve the health of the popula-
tion they serve, while responding to people’s legitimate expectations and
protecting them against the cost of ill-​health.14
Most recently, however, health systems have come to be viewed as com-
plex systems shaped by interacting functions, dynamic complexity, and
contextual factors distinctive to each country.15
This way of describing a health system has been named systems thinking
and is the approach we use in this workbook.

From Static Description to Dynamic Formulation

The daunting job of understanding systems is complicated by the way people

try to portray them. Over the years, many theories and tools, ranging from
relatively simple to complex, have been developed to describe, understand,
and inform actions in systems.
One way to view a system is mechanistically, describing it primarily
in terms of the types and number of variables involved and their cause–​
effect connections. Peter Senge, in his book The Fifth Discipline, calls this
detail complexity.16 The tools used to understand and take action from this
systems perspective are familiar to designers—​identifying elements and
processes, mapping and diagramming them, analyzing their connections
and flow, and redesigning the elements and their relationships. Such tools
are built on the notion of cause–​effect relationships between and among
the system’s variables.
In problems displaying straightforward detail complexity, cause–​
effect models can be simple and effective. In general, these problems are

[8] Building a High-Value Health System

characterized not only by a manageable number of variables, but they are
also comparatively free of personal interactions, disparate aims, conflicts
of interests, differences in mental maps, and know-​ how among the
participants.
However, some systems, such as health systems, are dynamic and
complex. They are made up of many interconnected and interdependent
elements that form extensive networks of feedback loops with time delays
and nonlinear relationships. A system’s activity is the result of the influ-
ence of one element on another through feedback. This interconnectedness
and these interactions mean that a system response to a stimulus, pertur-
bation, or intervention occurs as a result of the interactions between the
system’s elements, rather than the result of a change in one component.
With higher levels of detail complexity, simple analysis and decision-​
making often fail. The human mind takes shortcuts and makes errors, of
which individuals are often unaware. When faced with configural problems,
the human brain, in most cases, resorts to linear decision-​making models.
In such systems, the limits to information processing capability of the
human mind means that feedback structures, nonlinearities, and the
time-​delays between actions and their consequences are ignored by tools
designed for simple detail complexity. Faced with too many variables, we
first make assumptions that reduce the amount of information used in
understanding a situation. However, by simplifying mental cause–​effect
maps, ignoring time delays and feedback loops, and assuming there are
no interpersonal conflicts and misunderstandings between actors in the
system, analysts usually generate static options when making decisions.
Senge concludes that this simplifying and reductionist approach “create(s)
a snapshot showing how the system works at a moment in time.”17p31
Making so many simplifying assumptions leads to explanatory
conclusions or modeling that have such a high uncertainty or error that
the answers are as likely to be wrong as right. Using such reductionist and
linear approaches in decision-​making in health systems creates bounded
rationality.18 This term refers to explanatory cause–​effect models that fail
to provide an accurate representation of the real world because they ig-
nore possible wider impacts of policies and decisions, as well as unintended
consequences of policies. Such simplistic analyses miss or overlook impor-
tant sources of the problem. This leads to misperception of feedback, so that
even when such information is available, consequences of interactions
cannot be deduced rapidly and correctly. In such instances, inadequately
considered interventions aimed at eliminating the problems do not pro-
duce expected results but lead to further unintended consequences and
produce policy resistance.19,20

I n t r o d u c t i o n t o t h e H e a lt h of a P op u l at i o n [9]
01

Senge defines a second type of system complexity.17 He calls this dynamic

complexity, where cause and effect are subtle and where the effects over
time of interventions are not obvious. Conventional forecasting, planning
and analysis methods are not equipped to deal with dynamic complexity.17
The perspective needed to understand, design, and take action in systems
with dynamic complexity is called systems thinking.

What Is Systems Thinking?

Systems thinking is a way of describing and thinking about a system. There

are patterns of interrelationships between key components of the system.
These interactions operate over time. Systems thinking is a tool to under-
stand such a complex system. Its basis is a type of analytic frame called
systems theory, which was invented a century ago to enable designers to
understand a system in dynamic motion, rather than merely as a set of
component parts. Systems thinking is a way of thinking about the forces
and inter-​relationships that shape the behavior of systems.17
The essence of systems thinking is a way of looking that facilitates un-
derstanding the interconnectedness and behavior that characterizes the
system as a whole rather than its individual component parts. With sys-
tems thinking, a designer can visualize patterns of change in systems and
their movement over time, rather than as static snapshots.16 It is akin to
watching a video that shows all the moving parts of a system while they are
in dynamic action producing their outputs.

Systems Thinking Is Needed to Understand Health Systems

Why is a systems approach necessary in improving health? Decision-​

making in health systems is characterized by detail complexity. To under-
stand systems, a designer decision maker must have a way to understand
its moving parts, interactions, interdependencies, timing delays, external
influences, and feedback from outside the boundaries of the system it-
self. For simple systems, linear flow models offer easy ways to charac-
terize inputs, structures and processes, and outputs. As systems increase
in complexity, such models no longer suffice. They suffer from the limits
of information processing capability of the human mind, which adapts to
complexity by reducing the amount of information used, creating simple
cause–​effect mental maps, and generating a number of static options
when making decisions. This limitation means that feedback structures,

[ 10 ] Building a High-Value Health System

nonlinearities in systems, and the delays between actions and their
consequences are ignored.
A functioning health system is more than the sum of its parts; it is a col-
lection of stakeholders that form moving parts in a dynamic, interacting
process. Systems thinking reveals the dynamic complexity of systems that
are characterized by networks of relations, feedback loops, and nonlin-
earity.21 Systems thinking fosters the ability to see the world as a complex
system comprising many interconnected and interdependent parts.22 It
encourages looking at organizational dynamics and the interrelationships
in the system, instead of getting overinvolved in the details of a situation.
It helps anticipate rather than react to events and thus to prepare better for
emerging challenges.
Dynamic complexity has important policy implications for health sys-
tems. If a health system’s complexities are not understood, its policies may
not lead to intended results and may even produce results that are counter-
intuitive or even the opposite of what was intended. One has to consider
the effects of a policy not just on a component part but also on the system
as a whole and anticipate the system’s response.

Introduction to Health Systems

A health system is a system in a special sense of the word. When we

use the term system in this workbook, we mean it as a general descrip-
tive term that refers to the way that an enterprise functions as a whole.
Systems are a collection of elements interacting and joined together by
a web of interrelationships. What a system produces is the result of the
workings of its design, elements, people, processes, interconnections, and
interactions. All its outputs are latent in the structure of the system. It is
an interactive collection of activities whose design determines—​and even
predetermines—​its behavior. In other words, systems generate their own
behavior.
Every enterprise is a system with a structure organized according to a
set of principles and rules. Systems produce something. Each system is
designed to produce the results it gets; its performance potential is de-
termined by its design and structure, while its actual outputs are further
modified by its level of efficiency and effectiveness. Using a common ex-
ample, imagine a racing car that has a potential top speed of 170 miles per
hour. This speed is achievable because of the design of the car, its motor, its
drivetrain, and other structural features. To achieve its full potential per-
formance, however, it needs a skilled driver who must be effective—​that

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21

is, doing all the right things in steering, braking, and throttling up and
down—​and it must be efficient: potential performance is lost when parts
are worn, the transmission does not work efficiently, and tuning is not
optimal.
Like all systems, health systems are built in such a way that its under-
lying structure determines how it generates and expresses its results; the
health system releases its performance in a way that is latent in its struc-
ture. Someone designed parts of it, science advanced its capacities, and it
evolved through many large and small iterations to its current complex set
of people, processes, and things.

Systems Thinking and Systems Theory to the Rescue

Systems thinking is a discipline that consists of broad concepts that help

one to understand and characterize systems that experience dynamic com-
plexity (and higher levels of detail complexity as well). Systems thinking is
a framework for seeing interrelationships and repeated events rather than
a specific activity, for seeing patterns of change, and for considering human
behavior within systems and over time. It facilitates an understanding of
organizational dynamics and the interrelationships in the system, instead
of getting bogged down in the mechanical details of a situation.
In systems thinking, an organization and its respective context is
viewed as a complex whole. The core of systems thinking is the ability to
see the world as a complex system, comprising many interconnected and
interdependent parts.22 It enables an observer to see the whole as well as
its component parts: simultaneously seeing the tree and the woods, so to
speak. Understanding interconnectedness and complexity is the essence of
systems thinking.
Systems theory, on which systems thinking is based, originated in the
1920s within several disciplines, including biology and engineering, as a re-
sponse to growing technological complexities that confronted engineering
and science. It evolved further with the field of system dynamics, developed
in 1950s by Jay Forrester at the Massachusetts Institute of Technology,
who recognized the need for better methods of testing new ideas in social
systems.23
In practice, systems thinking entails careful consideration of pos-
sible consequences of policies and actions. This involves generation of
scenarios through group work and joint thinking and discussing the pos-
sible implications of each scenario. Finding ways to mitigate unintended
consequences of polices or interventions—​taking into account interactions

[ 12 ] Building a High-Value Health System

between health system elements and its context—​is also an essential com-
ponent of systems thinking.
Systems thinking can help overcome the limitations of linear and reduc-
tionist approaches in policymaking by enabling testing of new ideas in so-
cial systems.23 In practice, shifting to systems thinking means considering
the interlinkages between system elements and the interactions between
the systems and the context within which the system is situated. One has
to consider the effects of a policy, not just on a component part but also on
the environment as a whole and anticipate the context’s response. This places
greater emphasis on fostering collaboration, careful thinking through of
possible consequences of actions, and generating scenarios through group
working.
Systems thinking involves collaboration across disciplines, sectors,
and organizations with ongoing learning that recognizes that the con-
text and health system interactions are continuously changing, and that
policymakers need to adapt, learn, and apply new knowledge to evolving
challenges. It considers organizational structures, patterns of interaction,
and events as components of larger structures, helping to anticipate rather
than react to events, which in turns allows policymakers to better prepare
for emerging challenges.

Health Systems and Systems Thinking

A health system is no different than other complex dynamic systems.

A health system evolved as a response to an immediate threat or to ful-
fill societal or political ambitions (e.g., the development of the Bismarck
model of health systems that established welfare systems in Prussia and
central Europe or the predominantly tax-​funded national health systems as
characterized by the United Kingdom (UK) and Nordic countries in Europe).
The resulting health system responded by producing outputs: health, relief
from the effects of illness, reassurance, satisfaction, and hope.
Complex systems can only be changed by understanding their internal
dynamics and making targeted interventions at high leverage points that
catalyze transformative change. It is the first objective of organizations
and systems to achieve the inherent capacity of the system’s design by
improving efficiency and effectiveness through design and management.
In general, efficiency is achieved through understanding and modifying
feedback loops internal to the system. Effectiveness, on the other hand,
depends also on feedback from, understanding of, and adjustment to the
context external to the system. When the limits of improvements from

I n t r o d u c t i o n t o t h e H e a lt h of a P op u l at i o n [ 13 ]
41

efficiency and effectiveness are reached, the relative cost of managing

inputs and delivering results begins to rise, and when this point is reached
in a system, it is time to improve the system’s inherent capacity to pro-
duce outputs that make it more effective in achieving its desired outcomes
and goals.

[ 14 ] Building a High-Value Health System

CHAPTER 2

Assessing the Health System

of a Country

C hapter 2 presents an approach to understanding and analyzing health

systems. The chapter is structured as a teaching plan and workbook.
First, it presents a health system analytic framework (Figure 2.1) that will
be used throughout the book. Each of the model’s elements is explained,
and suggestions made about what is included and how observational data
for these elements can be found. Second, following the introduction of
this framework, we describe how the model will be used as the basis of a
student’s independent study of one country that they select for their work
during the course.
After working independently, students will break into groups of four to six
and will meet for about two hours (in person or virtually) to discuss and ana-
lyze contextual factors and how they are changing and how these changes are
creating opportunities for and threats to health systems. The groups will then
undertake another period of independent study to characterize functions of the
country’s existing health system, the health service outputs it produces, and
national goals. This study will be followed by another small team exercise, in
which each group will use the framework for health system analysis described
later in the chapter to analyze this second tranche of information about their
chosen country (although the model can be applied to any population with its
own healthcare program, such as a union, a military veterans’ system, or a large
business). The group will also formulate a presentation of their conclusions.
This chapter’s teaching and learning plan, which may take two to three weeks
to complete, ideally culminates in a whole-​course group meeting, where each
subgroup presents their analysis to other students and faculty for comment and
 61

Epidemiological
Demographic Political

Governance and
organisation

Equity Efficiency Health

Public Health
Services
Financial Legal/
Technological Financing
protection Regulatory

Personal Health
Services
User
Effectiveness Responsiveness satisfaction

Resource
management

Economic
Ecological
Sociocultural

Figure 2.1 A framework for analyzing health systems.

Source: Atun R, Aydin S, Chakraborty S, et al. Universal health coverage in Turkey: enhancement of equity. Lancet. 2013;382(9886):65–​99; supplementary
appendix: http://​download.thelancet.com/​mmcs/​journals/​lancet/​PIIS014067361361051X/​mmc1.pdf?id=eaa9nRX05fcXdhZf5ODCu
critique. The presentation, which should be written up in summary form, will
cover the context of the country studied, the organizational design and govern-
ance of the health system, how resources are managed, how the health system
is financed, major features of its healthcare delivery, performance of the health
systems, and one policy or structural change the country has undertaken. The
presenting group will identify and describe its first impressions of any major
shortfalls in achieving health system goals and will present its preliminary view
of the gaps in health systems achievements in relation to outcomes or outputs,
and their impact on the health and well-​being of the population.

HEALTH SYSTEMS: DEFINITIONS AND CONCEPTUALIZATIONS

A health system is a means to an end—​a system designed to achieve so-

cietal goals regarding health and well-​being. Recent definitions, such as
that by the World Health Organization (WHO) in 2000, describe a health
system as all the activities whose primary purpose is to promote, restore,
or maintain health.1 The WHO extended this definition in 2007 to include
the people, institutions, and resources, arranged together in accordance
with established policies, to improve the health of the population they
serve, while responding to people’s legitimate expectations and protecting
them against the cost of ill health through a variety of activities whose pri-
mary intent is to improve health.2
Earlier definitions conceptualized and described health systems from
a specific viewpoint. These have included descriptions from the perspec-
tive of the range of actors within them, economic relationships, or flows
of funds. For example, Evans defined health systems in terms of the main
sets of actors comprising the population to be served: healthcare providers,
third-​party payers, and government as regulator.3
Others have described a health system in terms of the economic rela-
tionship between demand, supply, and intermediary agencies that in-
fluence the supply–​ demand relationship. The demand side refers to
individuals, households, and populations whose actions drive the choices
and outcomes of health services and outcomes. The supply side denotes
the institutions that produce human and material resources for healthcare,
providers of healthcare services, individuals, and informal unpaid carers.
The agencies refer to the state or government institutions responsible for
financing, regulation, and purchasing of healthcare and other institutional
purchasers (such as private insurers, public insurance funds, district health
authorities, and health maintenance organizations).4

A s s e s s i n g t h e H e a lt h S y s t e m of a C o u n t r y [ 17 ]
81

Others have defined health systems in terms of archetypes of financing

and delivery of healthcare, describing them as an array of relationships be-
tween a set of components such as financing, macro-​organization of provi-
sion, payments, regulations, and persuasion (of behavior). The components
have been named by Roberts and others as control knobs5 and by Frenk as
a set of functions6 that can be modified by policymakers to achieve health
system goals.
More recently, health systems have been conceptualized as complex sys-
tems characterized by interacting functions and dynamic complexity and
shaped by contextual factors in each country.7 This way of describing a
health system is called systems thinking and is the approach we use in this
workbook (see Box 2.1).

Box 2.1: USING SYSTEMS THINKING TO UNDERSTAND

HEALTH SYSTEMS AS COMPLEX SYSTEMS

For simple systems, flow models offer easy ways to characterize inputs,
structures and processes, and outputs. Such flow diagrams are like
snapshots of the parts of a system. As systems increase in complexity,
such models no longer suffice. They suffer from the limits of information
processing capability of the human mind, which adapts to complexity by
reducing the amount of information used, creating simple cause–​effect
mental maps, and generating a number of static options when making
decisions. This limitation means that feedback structures, nonlinearities
in systems, and the delays between actions and their consequences are
ignored.
Decision-​making in health systems is characterized by detail com-
plexity. To understand systems, a designer decision maker must have a way
to understand its moving parts, interactions, interdependencies, timing
delays, external influences, and feedback from outside the boundaries of
the system itself.
Systems thinking is a tool to understand a complex system. Its basis is
a type of analytic frame called systems theory, which was invented a cen-
tury ago to enable designers to understand a system in dynamic motion,
rather than merely as a set of component parts. Systems thinking is “a
way of thinking about, and a language for describing and understanding,
the forces and inter-​relationships that shape the behavior of systems.”8p6
The essence of systems thinking is a way of looking that facilitates un-
derstanding the interconnectedness and behavior that characterizes the
system as a whole rather than its individual component parts. With sys-
tems thinking, a designer can visualize patterns of change in systems and

[ 18 ] Building a High-Value Health System

 their movement over time, rather than as static snapshots.9 It is akin to
watching a video that shows all the moving parts of a system while they
are in dynamic action producing their outputs.
System thinking reveals the dynamic complexity of systems that are
characterized by networks of relations, feedback loops, and nonline-
arity. Systems thinking enables one to see the world as a complex system
that consists of many interconnected and interdependent parts.10 It
encourages looking at organizational dynamics and the interrelationships
in the system, instead of getting overinvolved in the details of a situation.
It helps anticipate rather than react to events and thus to prepare better
for emerging challenges.
Dynamic complexity has important policy implications for health sys-
tems. If a health system’s complexities are not understood, its policies
may not lead to intended results and may even produce results that are
the opposite of what was intended. One has to consider the effects of a
policy not just on a component part but also on the system as a whole and
anticipate the system’s response.

FRAMEWORK FOR CONCEPTUALIZING AND ANALYZING

HEALTH SYSTEMS

We have developed a holistic framework (Figure 2.1) that extends earlier

approaches used to analyze health systems11,12 by adopting a systems view
of health systems and in incorporating context as an integral part of an all-​
encompassing analysis.13 In this view, health systems are conceptualized
as comprising a set of interlinked functions: (i) governance and organiza-
tion, (ii) financing, and (iii) resource generation and management. These
functions can be modified by policies and interact in a dynamic way to
produce a set of outputs in the form of public health and personal health-
care services for citizens. Public health and healthcare services operate
with varied levels of effectiveness, efficiency, equity, and responsiveness
to achieve health system outcomes of health, financial protection, and
user satisfaction. The nature and functioning of the health system, and the
outputs and outcomes it produces, are shaped by the context within which
the system is situated and with which it interacts in a dynamic fashion.14,15
Using this systems perspective, one can explore contextual factors and
health systems functions that interact to influence health system perfor-
mance and the achievement of health system goals and objectives. The
model conceptualizes health systems as comprising a set of interlinked
functions (governance and organization, financing, resource generation
and management), which operate in a contextual milieu and produce a

A s s e s s i n g t h e H e a lt h S y s t e m of a C o u n t r y [ 19 ]
02

range of outputs. Those functions, and the structural design in which they
operate, can be modified by policies. They also interact in a dynamic manner
to produce a set of outputs in the form of public health and personal health-
care services for citizens, with varied levels of effectiveness, efficiency, eq-
uity, and responsiveness. These outputs, in turn, produce population-​level
outcomes of health, financial protection, and user satisfaction.
The framework used in this chapter can be used to understand and ex-
amine how a health system works. It enables analysis of health systems
from contextual factors affecting health system functions to health system
outputs (public health and personal health service delivery) and outcomes
(population health, financial protection and user satisfaction). This frame-
work can also be used as a tool to analyze a health system’s performance, as
an evaluative instrument to assess effects of enacted policies or changes in
health system functions, or as a formative tool to develop and test future
policies or scenarios. The analytical framework has been used in single-​
country and multicountry analyses and to inform health system reforms.16

Individual Assignment

Each student should pick a country from the following list. The best choice will
blend three criteria: a country with which you are familiar, one that you are es-
pecially interested in learning about, and a country that you share with at least
one other small group of students.* You will still have an opportunity to switch
your choice after the small group meeting, coming up next in this chapter. The
country choices are

• Brazil
• Germany
• South Africa
• South Korea
• The Netherlands
• Turkey
• United Kingdom
• United States of America

Prior to the first small group meeting, each student will work independently
to apply the framework to the country of their choice. Table 2.1 provides a format
for keeping track of your observations and initial impressions. As you apply the
framework to your selected country, your first impressions of its strengths and
problems are useful. Use Table 2.1 as instructed to make notes prior to the small

[ 20 ] Building a High-Value Health System

 Table 2.1 FORMAT FOR RECORDING COUNTRY ANALYSIS AND INITIAL
IMPRESSIONS

Impressions of
Strengths and
Notes Weaknesses

Context

Functions

Governance/​organization

Financing

Resource management

Objectives

Equity

Efficiency

Effectiveness

Responsiveness

Goals

Health

Financial Protection

National satisfaction

Context abbreviations, in order: D, demographic; E, epidemiological; P, political; L, legal and regulatory; E, eco-
nomic; S, sociocultural; E, ecological, T, technological
2

group meeting. You will return to this chart, or a copy, at several points in later
chapters.

Context

When introducing health system reforms, the context of the existing health
system is vitally important for reformers, policymakers, and change-​makers
to consider. Even when there is ample evidence of the benefits of a policy
or an intervention, contextual factors influence these policies and affect
their introduction and scale-​up. Specifically, analysis and understanding of
context can help provide legitimacy to new policies, reveal important his-
torical antecedents, offer insight into political systems, and provide an un-
derstanding of the influence of sociocultural norms (which affect cognitive
and normative legitimacy of policies). Technological innovations (such as
digital social media for mass communication) can create new possibilities
for interventions into health systems and influence the introduction and
scale-​up of policies. Critical events (such as regime change in governments,
economic crisis, rapid economic growth, natural disasters, and epidemics)
create external shocks on health systems that may facilitate or hamper
change.
In our framework, we define context in terms of factors that individ-
ually and through their interactions influence the trajectory of change in
health systems for better or for worse. For example, ecological changes
can lead to adverse health effects from generation of environments con-
ducive to emergence of new infections, floods, heatwaves, water shortage,
landslides, and exposure to ultraviolet radiation or pollutants. Ecological
changes can also lead to ecosystem-​mediated health effects such as altered
infectious disease risk (e.g., emergence of zoonoses—​infectious diseases
that are transmissible from animals to humans through direct contact
or though food, water, and the environment), reduced food yields that
lead to undernutrition and stunting, depletion of natural medicines, and
worsening mental health. Further, ecological changes can produce indirect
health effects such as those due to population displacement from injudi-
cious deforestation, conflict, and forced migration.
Some contextual factors are facilitators of positive change. As an ex-
ample, technological changes create major opportunities for health sys-
tems to achieve systems goals and objectives. For example, digital data
have made it possible to collect large amounts of clinical, socioeconomic,
demographic, lifestyle, health behavior, and genetic data on individuals
and populations and to create large data sets from such multiple sources.

[ 22 ] Building a High-Value Health System

It has also facilitated new communication technologies that transfer and
pool these data in large databases. Advances in fast-​computing, data sci-
ence, artificial intelligence, and machine learning and the development of
new investigational and evaluative methods have made possible the anal-
ysis of large amounts of data. Using these novel analytic approaches, anal-
ysis of such information makes it possible to identify which individuals in
different populations are at greater risk of developing certain illnesses, to
estimate potential benefit of interventions, and to compute relative risk of
death from certain diseases with or without an intervention. The ability to
analyze such large data sets to identify individual characteristics and their
propensity to illness or death has enabled risk stratification and classifica-
tion of individuals or population groups into risk categories. Risk stratifica-
tion of individuals or population groups and information about their ability
to benefit from an intervention has enabled the development of precision
medicine for individuals and precision health for populations, both of which
offer the opportunity to precisely target treatments and interventions.
The interplay of contextual factors influences the trajectory of change in
health systems and delineates what change seems possible. Changes in each
contextual factor and major contextual shifts—​which can create external
shocks—​and their interplay create opportunities or threats for health sys-
tems in the short-​or long-​term to influence its performance, outputs, and
outcomes. The analysis of context can identify opportunities that are con-
ducive to attaining desired health system goals and objectives in line with
the values embraced by stakeholders. In relation to threats, the analysis
can identify contextual changes that may hinder the attainment of desired
health system outcomes or may worsen health system performance.
As you consider the different contextual elements of your chosen
country’s health system, you should be identifying and weighing their im-
pact on the health system. Your analysis will seek to identify and map con-
textual factors to ascertain which of the changes create opportunities and
which create threats to the health system now and in the future. Analyzing
your country’s context aims to answer six questions:

1. What are the most important changes, positive or negative, among the
eight context categories?
2. How are these changes affecting the health system?
3. What is the likely magnitude of these changes on the health system?
4. How and when will these changes impact the health system?
5. How certain is the likely impact?
6. Which of these changes create opportunities and which create threats
to the health system?

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42

Table 2.2 COVID-​1 9—​T HE INTERPL AY OF CONTEXT AND HEALTH SYSTEMS

Context Contextual Changes

Demographic Aging—​vulnerable populations with multimorbidity

Epidemiological Emerging infections, SARS-CoV-2, and climate change’s effect on

disease vectors

Political Leadership and attitudes toward command and control

Legal The delays from existing rules and regulations at a time of national
urgency

Economic Globalization—​interdependence and supply chains’ impact on world

economy and trade of good and services

Sociocultural norms Attitudes toward death and dying and the value of intensive
medicine for the old and frail

Ecological changes Destruction of animal natural habitats—​leading to mixing of

human and animal ecosystems—​emergence of new infections (e.g.,
coronaviruses)

Technology Travel; digital data; data analysis and modeling; social media;
communications; new diagnostics; technology-​enabled testing and
tracing systems; integrated supply chains

In our framework, we define context by a set of descriptive categories

that are continually changing and influencing each other. These factors
include demographic, epidemiological, political, legal and regulatory, ec-
onomic, sociocultural, ecological, and technological factors. Changes in
these contextual factors strongly affect health systems. In turn, perfor-
mance of health systems influences the context. See Table 2.2 for an il-
lustrative example of how changes in context shape health systems and
how health system responses to these changes shape context in different
countries.

Context Categories

We discuss in more detail each of the contextual factors in our framework

with a series of questions aimed at assessing the contextual factor. Table
2.3 summarizes key descriptive parameters and some suggested available
measurements to estimate contextual factors.

[ 24 ] Building a High-Value Health System

 Table 2.3 KEY DESCRIPTIVE PARAMETERS AND EXAMPLES
OF CONTEXTUAL FACTORS

Contextual
Factors Descriptive Parameters Examples of Parameters Used

Demographic Population • Aging

dynamics: population growth • Migration
and structure • Urbanization

Epidemiological Trends for risk, morbidity, and • Noncommunicable diseases

mortality • Multimorbidity
• Emerging infections

Political Political economy • Government values

Institutional configuration • Government stability
Citizen engagement • Civil society role in decision-​
making and accountability

Legal and International agreements • Trade agreements

regulatory National laws

Economic Economic growth • Fiscal space

Favorability of economic • Gross domestic product growth
environment • Unemployment levels
• Inflation trends

Sociocultural Public attitudes and beliefs • Citizen values and expectations

related to health • Social networks
Social norms
Lifestyles

Ecological Human and urban ecology • Natural disasters

Physical environment • Climate change

Technological Technologies for health and • Technological adoption

health technologies (communication, computing, data
science)

Demographics

Demographic characterization refers to the status and trends in age struc-

ture, gender, and geographic distribution of the population. Demographic
patterns can be stable or vary over time, in relation to factors such as fer-
tility, mortality, immigration, and migration. For example, the speed and
extent of demographic transition reflects the dynamics between changes
in population, fertility, and mortality levels in a country. Demographic

A s s e s s i n g t h e H e a lt h S y s t e m of a C o u n t r y [ 25 ]
62

transition in a country occurs with a decline in mortality rates, followed—​

after a lag—​by a reduction in total fertility rate, bringing about an initial
transitional period of high population growth (as more children and adults
survive and live longer) before fertility levels adjust to longer life span
and the population stabilizes. With demographic transition, increased
longevity and reduced total fertility cause a swing in the population age
profile, leading to a shift toward an aging population and a declining pro-
portion of younger and working age individuals.

Key Questions

How does the nation’s demographic profile affect the health system?
How are the general population dynamics changing in the country of
analysis in relation to infant mortality rate and total fertility rate?
How are the general population dynamics changing in relation to
average life expectancy at birth, population age structure, and
population size?
What are the levels of urban and rural populations? What are the ur-
banization trends?
What are the trends in relation to immigration and emigration in and
out of the country?
What are the implications of the demographic transition on the
health system?

Epidemiological Factors

Epidemiological factors refer to the pattern of health and disease in the

country. An epidemiologic transition typically follows a demographic tran-
sition; falling mortality and fertility level and increased longevity lead to an
aging population and consequent change in the population age structure.
Epidemiologic transition creates new patterns of risk factors, ill-
ness, and causes of death. Patterns dominated by infectious diseases
and conditions affecting children and pregnant women shift to those in
which chronic diseases, cancer, and mental health conditions increasingly
predominate. Demographic and epidemiological transitions bring about
major changes in population age structure and the burden of disease,
and the stage countries are in during these transitions will determine the
types of policies needed to improve health and benefit countries econom-
ically and socially.

[ 26 ] Building a High-Value Health System

Key Questions

What is the epidemiologic profile of the nation and how does it im-
pact the country and its health system?
How is the epidemiologic profile changing?
How are mortality levels changing in the population and population
subsegments (infant mortality, maternal mortality, mortality
levels of major chronic diseases)?
Which conditions are rising or falling in incidence or prevalence (for
key noncommunicable and communicable diseases)?
How is the prevalence of risk factors for chronic diseases changing
(e.g., smoking and obesity) in the population or in population
groups?
How are social determinants of health changing in the population or
in population subgroups?

Political Environment

These characteristics describe the inclusiveness, continuity, effectiveness,

and values of government. Features include political stability, government
structures, and political inclusion of citizens and civil society. The political
environment also relates, among others, to the political economy in terms
of decisions related to health. Politics in a country reveals the prevailing
values of the citizens and government that shape societal goals and broad
policy objectives, especially those related to social sectors. The political en-
vironment delimits readiness for change.

Key Questions

How effective and stable is the political environment?

How trusted is the government’s leadership?
Who makes political decisions?
What are the values of the government?
How do these values influence policies on health?
What is the balance of power between the executive, legislative, and
judiciary?
How does this balance influence the decision-​making process in the
country in relation to health?
How important is health as an issue for politicians?

A s s e s s i n g t h e H e a lt h S y s t e m of a C o u n t r y [ 27 ]
82

What is the capacity of the political system for innovation and change
in health systems?
At what level are decisions affecting health made (e.g., national, state,
province, municipality, city, institution)?

Legal and Regulatory Environment

These factors describe the national or international legal and regulatory

rules (beyond those health polices or regulations that directly guide the
activities in the health system) that constrain or support the structure,
function, and financing of health systems. These include, for example,
data privacy laws, binding international legal agreements in areas such
as climate change, international accords governing human rights, inter-
national treaties governing trade (such as, for example, the World Trade
Organization), bilateral trade agreements, and multicountry or regional
trade agreements.

Key Questions

What important laws of the country affect the health system (e.g.,
laws on data privacy, anticompetitive marketplace interference,
and workforce accreditation)?
What international treaties to which the country is signatory
are likely to affect the health system or health policies (e.g.,
the United Nations’ treaties on human rights, the Framework
Convention on Tobacco Control, treaties governing the World
Trade Organization)?
What bilateral, multicountry, or regional trade agreements has the
country entered into that may affect health?

Economy

Economic factors relate to the economic strength of a country—​including

economic policies, economic growth, economic stability, economic sustain-
ability, and the way that individuals and businesses benefit from the cur-
rent economy and its success and weakness.

[ 28 ] Building a High-Value Health System

Exploring the Variety of Random
Documents with Different Content
ultimately involved. Local examination will reveal the existence of
pelvic conditions, in whose absence there may be justification for
inferring that the trouble has not originated in that cavity.
Ruptured extra-uterine pregnancy has been in numerous cases
mistaken for acute appendicitis. It usually begins with violent pain
and pronounced muscle spasm, with more or less shock. I have
repeatedly been called to operate for appendicitis and found the
other condition present. The operator may be prepared to find it if
he elicit a suggestive history or if a vaginal examination reveals a
pelvis more or less filled with semisolid material. Amenorrhea does
not always signify ectopic gestation, yet when doubt arises it would
be advisable to inquire carefully into the menstrual habit of the
patient. On the other hand it is known that acute appendicitis may
bring on uterine hemorrhage. When, however, the possibility of
pregnancy exists, along with a history of menstrual irregularity, or of
hemorrhages unaccounted for, and one finds within the pelvis the
uterus pushed forward or displaced, or perhaps an irregular tumor,
he may suspect the condition if not actually diagnosticate it.
A peculiarly unfortunate combination is that of acute appendicitis
occurring during pregnancy, or still worse, as I have seen it, e. g., in
a woman with a large uterine myoma, gone to about the seventh
month of pregnancy, and then suffering from an acute peri-
appendicular abscess, the whole proving more than she could
withstand.
With an appendix placed behind the cecum it will usually rest
upon the psoas muscle, where it may be disturbed by violent
exercise, or where it may lead to mistaken diagnosis either in case of
acute inflammation of the muscle itself or of acute appendicitis.
When the right limb is drawn up, and especially when all motions of
the limb give pain, we may believe at least in the participation of the
muscle in the inflammatory activity. On the other hand, an insidious
psoas abscess may give rise to a certain degree of tenderness in the
right iliac fossa, with flexion of the thigh, and gradual development
of tumor, which may be mistaken for chronic appendicitis.
The possibility of appendicitis occurring during typhoid has been
mentioned. Differential diagnosis between the two conditions will
ordinarily not be difficult when one can obtain an accurate history. In
classical appendicitis pain is always the first symptom, and
temperature rarely rises until a number of hours at least after the
first attack of pain. Even the milder typhoid cases may show
tenderness in the right iliac fossa, but one should look for the
characteristic eruption and make a Widal test. The presence of
splenic enlargement would point to typhoid, as would also the
occurrence of bronchitis, epistaxis, or headache, with perhaps
albuminuria. The most perplexing cases will be those of perforation,
perhaps even of typhoid ulcer of the appendix. In these cases acute
pain will usually indicate perforation.
Intrathoracic affections sometimes begin with or are accompanied
by severe pains which are referred to various parts of the abdomen
and cause great confusion. Thus I have repeatedly seen pneumonia,
even on the left side, regarded at least at first as acute appendicitis,
because patients referred most of their pain to the abdomen rather
than to the chest, while the abdominal muscles participated to such
an extent as to produce pronounced rigidity. Here a blood count
would scarcely help, but careful physical examination of the chest
would reveal the difficulty. Such examinations should be made when
respirations become irregular, or when the breathing is evidently in
any way embarrassed. Acute pneumonia and acute pleurisy,
especially diaphragmatic, may have then to be differentiated from
acute appendicitis.
Finally, hysteria is an element not to be disregarded in some of
these cases; not that it is likely often, if ever, to lead to serious
doubt, but that patients with the hysterical or neurotic temperament
are constantly tempted to so seriously exaggerate their complaints
as to lead to at least a more serious view regarding themselves than
circumstances justify. Thus a mild appendicular colic in a neurotic
patient may produce a disproportionate complaint, and one must be
ready to assign to hyperesthesia or exaggerated complaints their
proper value.
The symptomatology of appendicitis may then be summarized
briefly as follows: When pain comes on suddenly and is referred to
the lower part of the abdomen, or even its central region, becoming
perhaps more localized as the hours go by, is shortly followed by
nausea or vomiting, and this by general abdominal sensitiveness,
with an increasing degree of rigidity; and when temperature, which
at first is not elevated, begins to rise in from twelve to twenty hours,
then it may be held that this is a classical picture of an attack of
acute appendicitis. So strongly does Murphy, for instance, hold to
this order of events that he even questions diagnosis when
symptoms are not thus timed, and especially if vomiting precede
pain.
When pain which has been severe subsides, and comes on afresh
after an interval of perhaps thirty-six hours, it is to be regarded as
due to fresh peri-appendicular involvement, and is an unfavorable
feature. In fact the subsidence of pain and apparent improvement
often noted do not always mean actual improvement, but may be
the forerunners of a still more dangerous condition. Thus the
“perilous calm” of appendicitis should hasten operation, or at least
increase watchfulness, rather than beget confidence. Should one rely
too much upon them and procrastinate he will find that his mortality
rate will rise accordingly. The statement elsewhere quoted in this
work that “the resources of surgery are rarely successful when
practised upon the dying,” will apply here.
There is scarcely any equally limited area of the body in which as
many varied and widely different pathological conditions may be
exemplified as in the appendix and the space immediately around it.
The mildest degree of hyperemia or vascular engorgement, the most
destructive form of inflammation, with fulminating necrosis, may
here be observed. Moreover, conditions commencing under one type
may quickly change and the whole type of an attack may within a
short time be merged from the mildest into the most severe.
In catarrhal or endo-appendicitis it is mainly the mucosa which
suffers. This may undergo merely a congestion, with increase of
discharge, and, so long as the outlet be not completely obstructed,
may be a purely temporary matter of but a few hours’ duration, or it
may extend over a few days. The purulent or more destructive forms
may commence in either of the coats of the appendix. It is no
uncommon thing to find a necrotic mucosa with a still unbroken
serosa, or a perforation of the outer coats and a hernial protrusion
of the inner, perhaps just ready to give way. In location and extent
the suppurative and destructive process may also vary. Whereas
ordinarily the distal portion, being less supplied with blood, will
suffer first, it is not uncommon to find perforation at the junction of
the appendix with the cecum, or even gangrene of a limited area of
the cecal wall itself. Again, at times, the trouble seems limited to
accumulation of pus within the appendix, i. e., an empyema of the
appendix, without great tendency to involve the structures adjoining,
and an appendix may be found containing a few drops of pus or
distended almost to its bursting point still free or but slightly
attached by exudate. In the milder cases there may be found
strictures indicating the site of previous lesions. Again, aside from
pus, there may be more or less fluid or semisolid fecal matter or
dense concretions, in addition to the possible foreign bodies whose
presence has been elsewhere considered. In the more subacute or
chronic forms there will be found relics of previous rather than active
expressions of present trouble, such as strictures, thickenings,
contortions, old adhesions, sometimes quite dense, and contained
concretions, or other foreign bodies, or one may find appendices
shrivelled up or more or less obliterated (appendicitis obliterans).
The role of the omentum has elsewhere been mentioned, but
must be alluded to again at this point, since it participates more or
less in almost every case of acute appendicitis. The moment the
appendix is acutely inflamed the omentum tends to shift itself over
toward it and finally around it, and it is not uncommon to find a
gangrenous appendix wrapped in a roll of this kindly disposed fatty
apron. In fact this may constitute the tumor which may have been
already discovered and found to be fixed or movable. The inner
surface at least of the omentum thus applied will nearly always have
sacrificed itself and one has need usually to remove a considerable
area of gangrenous omentum, as well as the appendix itself, feeling
as he does it that he is necessarily sacrificing the best friend that the
incriminated appendix has had.
Aside from what may concern the appendix itself the two most
serious complicating local conditions are abscess and gangrene with
perforation. Abscess is not necessarily the result of perforation, at
least at first, but may be due to infection by continuity, the sequence
of events being acute appendicitis, with exudation, fixation, and
adhesion of surrounding tissues, followed by pus formation, perhaps
first within the appendix and then perforating, or perhaps having its
origin in the infected exudate exterior to it. So long as this process is
localized by a protective barrier of surrounding lymph, with intestinal
adhesions and the assistance of the omentum, there is to be dealt
with a more or less complicated peri-appendicular abscess, such as
in the past was frequently seen and spoken of as perityphlitic.
Concerning the frequency of perityphlitic abscess in days gone by
the literature of the previous century will afford ample illustration,
but in spite of the surgical acumen and advice of Willard Parker, who
taught the profession how to deal with it, its proper explanation did
not come until the researches of Fitz, alluded to at the beginning of
this chapter. Even now it is perhaps not quite correct to say that
every typhlitic abscess, i. e., every collection of pus around the
typhlon or head of the large intestine, is of appendicular origin, for
the tendency has been to forget the possibility of phlegmonous
cellulitis about any part of the bowel without reference to the
appendix.
Such a peri-appendicular abscess may be small, containing but a
few drops of pus, or extensive, even to the degree of holding a pint
or more. The pus is usually offensive and sometimes one will find
floating in it shreds of tissue, or even a completely separated and
sloughed-off gangrenous appendix. According to the original location
of the appendix, and the disposition of the adjoining parts, such a
collection of pus may form a tumor in the iliac fossa, which may also
fill the pelvis, or may present in the loin, closely simulating a
perinephritic abscess.
It is unfortunate when the natural walling off process has failed
and we have to deal with a spreading, generalized, septic peritonitis.
A partial compromise between these conditions sometimes appears
as a widespread yet practically localized peritonitis, in which several
loops of bowel have become affixed, and, what is worse, infected to
such an extent that they are themselves breaking down, so that
there may be impending or actual gangrene of the intestine. Such a
condition bespeaks the intensity of the infection and the
destructiveness of the infectious process, and produces a condition
which may appall the operator. The result is not only acute
obstruction of the bowel but such a local condition that one scarcely
knows where to begin or terminate his operative efforts. It was in
such a case as this that I removed eight feet and nine inches of
bowel, the last nine inches including the colon, turning in both ends
and making a lateral anastomosis, because of multiple gangrenous
patches, each of which taken alone would have required a distinct
and laborious intestinal resection, it seeming better to remove the
entire amount involved. This patient recovered and was well years
after the operation. Still other complications may disturb the
surgeon’s calculations. Thus fecal fistula may have already occurred,
or suppurative thrombophlebitis may have already produced the
beginnings or an hepatic abscess, while septic expressions within the
lungs, the heart, or elsewhere may have also occurred. In addition
to this general peritonitis, with all of its terrors, may put a hopeless
aspect upon the case.
Treatment.—Viewed in the above light it will be seen that
appendicitis is essentially a surgical disease, and that while mild
attacks may at times be successfully conducted to resolution, or tend
in that direction without treatment, the danger of spreading infection
with all its possible disasters is ever present, and even a mild case is
at no moment free from the danger of becoming acute. Considering
its widest relations, and believing in the greatest good to the
greatest number, the surgeon may easily maintain that, save when it
is too late, it is never a mistake to operate, providing operation be
properly performed. This, however, is sometimes out of the question,
and the laity occasionally assume responsibility for a decision against
the better judgment of the profession. We have to accept, then, the
fact that, no matter what the theory may be, we are not always
allowed to operate when we desire. Nevertheless if a universal rule
could be established it could be laid down in terms such as these,
that more lives would be saved by operating upon every case of
appendicitis as soon as the diagnosis has been made or even in the
presence of good reason for suspicion.
With conditions such as they are, and the fact that these cases are
usually first seen by general practitioners whose surgical judgment
has not been cultivated, and whose prejudices often actuate them, it
may be said that every case should be seen early by a surgeon, no
layman and no ordinary practitioner of small experience being in
position to assume responsibility for delay. It then remains for the
judicious and competent operator who may see such a case early, as
thus advised, to study it carefully in order to convince himself
whether there be about it good and sufficient reasons for not
operating. The most honest operator does not gainsay the possibility
of mild cases recovering without operation. He does, however,
question by which course they run greater risk.
The following may serve as a brief summary of conditions which
justify waiting:
1. When symptoms are mild and not increasing in severity;
2. When pain and tenderness are not pronounced and
gradually subside;
3. When the pulse rate does not exceed 100;
4. When temperature is not rising nor showing abrupt
changes, especially if during the first thirty-six hours there
have been no rise. (Murphy states that if there has been no
temperature during the first thirty-six hours he begins to
doubt the diagnosis.)
5. When the belly is not distending;
6. When rigidity is not increasing and there is no evidence of
peritonitis;
7. When nausea is not increasing;
8. When neither in facial expression nor elsewhere are there
evidences of septic infection;
9. When there is no perceptible tumor in the right iliac fossa.
Under the above conditions the conservative surgeon will be
justified in waiting; being prompt, however, to intervene, should
there be change for the worse in any one of the features specified.
Even here it may be said that with conditions all as favorable as
above represented pus may be present (in small quantity) and the
whole picture may suddenly change into one of local disaster.
Finally it may be summed up in these words: When there is no
doubt as to the advisability of waiting, then wait; but in case of
doubt operate, i. e., give the patient the benefit of the doubt, which
he in this way the more certainly obtains.
Non-operative Treatment.—While thus waiting in cases which justify
it, what should be done? Absolute rest in bed, even to the extent of
using bedpan instead of commode, is the first essential. The second
comprises abstention from all food, and practically the temporary
starvation of the patient, who may be allowed water in abundance
and nothing else. Altogether too much stress has been placed upon
the so-called starvation treatment as “saving patients from
operation.” Active therapeutic treatment is limited mainly to the use
of cathartics and of anodynes, according to reason therefor. On one
hand it is not advisable to rudely stir up the large intestine, one part
of whose structure is already involved in a serious and questionable
inflammatory process; on the other hand it is not for the general
welfare of the patient to permit him to continue with a condition of
coprostasis and the ever-increasing stercoremia which it encourages.
On the whole it would seem better to clean out the lower bowel at
the earliest possible moment, after which if the patient be properly
starved there will be less necessity for subsequent active catharsis.
The question of anodynes is one of equal importance. Those who
bear pain badly, or those who suffer intensely, will demand
anodynes, which every physician knows both help to mask the
symptoms and interfere with elimination; but such cases seem to be
of themselves so violent that the extreme expression of pain should
of itself be regarded as an indication for operation. It should be held,
then, that cases which demand opiates for relief of pain demand
operation even more strongly. In the mild cases, expectantly treated,
the local application of ice may be of some value. In effect these
cases are to be treated expectantly, and, while expectant treatment
is a confession of weakness or of ignorance, it may be unavoidable
because early operation is flatly refused.
Indications for Operation.
—Sufficient reasons for not operating being absent or having passed,
the following may be considered among the more urgent indications
for immediate surgical attack:
1. Continued and especially increasing pain and tenderness;
2. A rapid pulse (110 or over) tending to increase in rapidity;
3. Any rapid change in the temperature, either a sudden rise
or a drop to the normal or subnormal, without
corresponding improvement in every other particular;
4. Increasing or widespread abdominal rigidity; when the
right side of the abdomen of a sensible and non-neurotic
subject is rigid this of itself should be sufficient to justify
operation;
5. The appearance of tumor in the right iliac fossa;
6. Recurring and especially constant vomiting;
7. Any indication of septic infection, local or general.
Such are the indications by which the surgeon may say upon the
instant of their recognition that a given case requires immediate
operation. Fortunate are both he and the patient if the case be seen
early, when these conditions have but lately shown themselves, and
before it be too late. It has been said that almost every death from
appendicitis means the loss of a life that might have been saved and
for which someone is responsible, this responsibility being divisible
among the patient, the parents or family, and the general
practitioner who first saw the case and was tardy in recognizing its
essential features. While patients die after late operations the
surgeon himself is rarely censurable, it not being his fault that he
was called in too late, and the patient dying of the progress of the
disease in spite of an operation and not because of it.
Operation for appendicitis may be one of the simplest and easiest
of the abdominal operations, especially when the acutely infectious
element be not present, or it may be one of the most trying and
difficult of all possible surgical procedures, taxing alike the judgment
of the experienced operator and the resources of the clinic. Much
will depend upon the time at which it is performed. If within the first
forty-eight hours the surgeon may expect to find but a small amount
of pus; if from the second to the fifth day, he may find a well-
marked collection, while later he may have not only localized abscess
but extensive complications. Again, he who operates between
attacks, during the interval or interim stage, will find conditions of
adhesion and results of old disease rather than its active products.
These operations should then be considered under these different
headings:
1. Early operations in acute cases, where there is little or no
tumor;
2. Operations in cases where abscess is present;
3. Operations in cases of more or less peritoneal involvement,
with obstruction;
4. Interval operations.
Under the above headings conditions vary so widely that they can
scarcely be spoken of or described under the same name. The seat
of the disease should first be approached. Here there is wide range
for choice of location of incision and even the method of its
performance. Some prefer the outer border of the rectus, others go
through the rectus muscle proper by an incision parallel to its fibers,
which when exposed are separated, its sheath both anteriorly and
posteriorly being divided separately. Others go through the
abdominal wall by incisions more or less oblique, and made near the
anterior superior spine, where are found the different layers of the
abdominal muscles arranged in proper order, their fibers being
disposed at right angles to each other. That incision is best in each
case which affords the shortest and easiest route to the site of the
lesion when it can be located. If tumor be present it is ordinarily best
to go in directly over it. In the absence of tumor the point of
greatest tenderness is the best guide. The possibility of subsequent
hernia at the site which is weakened by operation should be taken
into account. If it be possible to avoid drainage hernia may usually
be avoided. When drainage is necessary hernia is sometimes
unavoidable. The advantage of operation through the rectus is that
the muscle fibers can be separated without dividing them. Incision
here may, however, carry the operator so far from the site of the
appendix that he must necessarily disturb the interior arrangement
more than is advisable, and thus increase the danger of infection.
The oblique exterior incisions near the ilium always permit of
separation of the fibers of the external oblique. The deeper muscle
fibers which cross at nearly a right angle may sometimes be nicked
and widely separated by firm traction, as in the so-called “gridiron
method,” or they may require division. A short external incision is
desirable when it suffices for the purpose. Considerations of safety
(i. e., the better exposure and easier removal of the appendix) may
call in some instances for long incisions, and they should be made
sufficiently long for his purpose.
It will often happen that as the surgeon passes more deeply
toward the peritoneum he will find the tissues more or less
edematous. This is a reliable indication of the presence of pus
beneath, and should make him open the peritoneum with care and
then use extreme caution in his further manipulation, lest by
separating recent adhesions he permit pus to escape. The
peritoneum being opened sufficiently the finger is gently insinuated,
and thus the first orientation concerning internal conditions is
obtained. With the exploring finger there should be ascertained,
first, the existence of any adhesions; second, their location and
relative firmness, and, third, in a general way, the amount of
surrounding disturbance. With an appendix placed anteriorly we may
thus come directly upon it, while when placed deeply and posteriorly
we may have much to do before reaching it. After the first general
exploration the next procedure should be to protect and wall off the
region involved from the rest of the abdominal cavity by strips of
gauze. These should be long and so secured that none may be lost
by being left within the abdomen. The introduction of gauze for this
purpose will sometimes increase depression and decrease blood
pressure, but it is a necessary procedure in nearly every instance.
Moreover, several strips may be needed, and the incision may have
to be extended to a limit of two or three inches, according as further
exploration reveals a more complicated situation. The fluid pus
which may escape should be gently removed with dry gauze, or, if
present in considerable amount, be carefully conducted toward the
surface. Loops of bowel or tissue bound together by lymph should
be gently separated, as they may easily tear, or since imprisoned
between them there may be found small collections of pus. If found
gangrenous the situation is thereby seriously complicated, and it is
advisable not to restore such a loop to the abdominal cavity.
The omentum, as already indicated, may serve as a valuable guide
to the location of the appendix, which may be found wrapped within
it. It should be handled with great caution, while, at the same time,
it is made to reveal the desired information. When the omentum is
infiltrated, contorted, and adherent we may be sure of finding pus
concealed within the cavity which it helps to wall off. That which is
already gangrenous should be removed, with use of sutures in such
a way that there shall be no subsequent bleeding. It may be found
easily, or not until many other details have been mastered. The
involved appendix, when found, may be in one of the conditions
described above, all of which demand its removal save those where
this has been already accomplished by violence of the disease, in
which case the opening in the cecum may have to be closed, or one
may employ it for the purpose of an artificial anus. The appendix is
often so hard to find that any reliable guide will be welcomed. Such
a guide may be found, first, in the location and relation of the
omentum, and, secondly, in the cecum if this can be exposed, or in
either one of its firm, longitudinal, white tissue bands, which, leading
down on either side of the colon, meet and blend at the point of
origin of the appendix. Either of these followed in the right direction
leads to this spot. Conditions may be such, however, as to obscure
both of these guides, and then the colon should be followed
downward toward the ileocecal valve, or the small intestine up
toward it, in the belief that in this vicinity, and probably in the centre
of the tumor, the appendix will be found. What the surgeon shall
next do depends on the details of each case. He has not only to
remove the diseased appendix, but to ligate and separate from it its
mesentery; furthermore to separate either or both of these from
surrounding tissues or organs, e. g., the wall of the pelvis, the ovary,
the bladder, the retroperitoneal tissue above the sacrum, or from the
lateral or anterior abdominal wall. This separation may be easy, or in
its performance the tube may rupture and both pus and fecal matter
escape; or perforation may have already occurred and the operator
will be conducted into a cavity containing matter, pus and fecal
mixed, in which perhaps fecal concretions of considerable size will be
found loose. He is fortunate who, finding a condition of this kind,
finds at the same time that he is still within a circumscribed cavity.
This he should respect, and, while endeavoring to clean it thoroughly
and drain it, he will avoid doing further harm by breaking down its
walls.
Another condition which may arise after the peritoneum is opened
is that of escape of a quantity of seropurulent fluid or of almost clear
pus which is free within the abdominal cavity. There may be little or
much of this. When present it should be removed by gentle
sponging before the gauze packing is introduced. Some operators
are inclined to irrigate freely and endeavor to wash out all this
contained fluid. Others are opposed to this method and believe that
gentle dry sponging is preferable. When the appendix is found free
and movable, and when the tissues in previous contact with it are
free from evidences of destructive infection (as, for instance, when
peritoneal surfaces have not lost all their glimmer or sheen), one
should carefully remove it, cauterizing its stump, burying it beneath
the surrounding peritoneum, and close the abdomen without
drainage. In spite, however, of the assertions and actions of some
operators, I believe it to be the wisest rule to lay down for general
application that it is safer to drain in every case where free pus or
breaking down exudate is discovered.
The question of drainage thus raised is as important as any
connected with this subject. When and how shall one drain is a
question upon which hundreds of pages have been written by
various operators, and one which, while settled for individuals, can
hardly be settled for the profession at large by any brief statement.
Inefficient drainage is almost as bad as none. Efficient drainage may
call for the insertion of a tube into the depths of the pelvis, even for
counteropening in the cul-de-sac, or for additional opening in the
loin, or for the employment of two or three tubes and drains of
various kinds. A large tube loosely packed with gauze, perhaps split
through its length and abundantly provided with openings, is
probably the most effectual drain for most purposes. The cigarette
drain, of gauze wrapped in oiled silk, or a few folds of oiled silk
loosely tied together, along which fluid may percolate, may be
sufficient for cases of lesser extent. Large foul cavities are better left
more widely open, and abundantly drained with gauze packing, in
spite of the humorous stigma which has been cast upon some of
these methods by Morris with his expression “committing taxidermy
upon patients.” The depressing reflex influence of such packing
being readily conceded it may be regarded as the lesser of two evils.
Another almost equally important question is that of treatment of
the peritoneal cavity when involved. Here methods and opinions
have varied widely. A peritoneal cavity once inflamed cannot be
made absolutely clean in any way, and much reliance should be
placed on the properties of the membrane itself, which, to a large
extent, should act as its own scavenger. When, however, by
removing the parts evidently diseased we have taken away the main
source of infection we may feel like relying upon the natural
protective forces of the human body; still even here opinions differ.
Thus some would flush the abdomen with hot saline solution and
even leave some portion of it there, closing the external wound,
while others would carefully avoid the introduction of anything by
which infectious material may be spread; and while each method
has much to justify it one is scarcely found preferable to the other. I
believe, however, in thoroughly cleaning out any distinct abscess
cavity, and if the pelvis be such then I would irrigate it. I would also
thoroughly drain it.
The attention of the reader is here directed to the general
considerations found earlier in this work concerning the general
technique of abdominal operations, and the matters of drainage and
after-care, it being scarcely necessary to reiterate what has been
there said regarding the general use of saline solution locally and by
the rectum, the advantage of the Fowler position, or of Murphy’s
method of slow and gentle introduction of saline solution into the
rectum, providing for its continuous absorption, etc.
The possibility of appendicitis leading to general peritonitis, this to
acute obstruction of the bowel, and this possibly even to multiple
gangrene, has been mentioned. What should best be done under
these circumstances must depend upon the patient and upon the
surroundings. With a patient too much reduced to justify any
prolonged operation the surgeon would probably content himself
with evacuation of pus which may be readily reached, and then
perhaps by the formation of an artificial anus. Cases which will
justify such extensive operation as that above reported by myself in
this connection, where it was possible to successfully remove nearly
nine feet of intestine, will be exceedingly rare, as well as
impracticable in the ordinary private house.
A condition perhaps a little less serious but always perplexing is
that of gangrene of a limited area of cecum around a gangrenous
appendix. To remove the appendix alone in this condition is to
accomplish nothing, while to meet the indication may require the
exsection of a small area of cecal wall or the resection of the entire
cecum, or perhaps in cases of limited extent the enfolding of the
gangrenous area and the suture of its edges in such a manner that
when it sloughs it may slough into the bowel cavity.
When the surgeon sees a case of peri-appendicular (the old
perityphlitic) abscess late, and after it is easily recognized, he should
operate according to the local indication, making incision perhaps
short and placing it at a point where pus will apparently be most
easily reached and best drained. Most of these instances present
rather on the side or even in the loin behind the colon, and here a
posterior incision might be sufficient. This may here be more liberal,
since there is little danger of postoperative hernia, while through it
one may possibly expose the cecum freely and often reach even the
appendix itself. In making this opening it is well, if possible, to
separate the fibers of the transversalis by blunt dissection. Here, as
in all of the other incisions made toward the outer side of the body,
the opening should be made, if possible, obliquely and parallel to the
branches of the iliohypogastric nerves, which are thereby avoided
and loss of sensation thus prevented. In fact this posterior method is
sometimes even more rapid, and preferable in exceedingly fat
patients, while it will always cause less shock and abdominal distress
than does an anterior section; moreover, drainage takes place in the
most desirable direction.
 Fecal fistula is sometimes the immediate and unavoidable,
sometimes a more or less delayed and apparently inevitable, result
or complication of some of these operations. In the former instance
it will be because of more or less gangrene or the necessity for an
immediate enterostomy. In the latter case it results from conditions
which are concealed, but may be imagined, comprising the giving
way of tissues already compromised or else being a continuation of
the ulcerative or gangrenous process. These complications are
always unpleasant and untoward, though they rarely reflect upon
the method or judgment of the operator, being essentially inevitable.
If only the fecal outflow escape externally the condition may be
regarded as inconvenient and temporary. Only in those instances in
which the peritoneal cavity is contaminated does septic peritonitis
ensue. The majority of these fecal fistulas close spontaneously by
granulation tissue. Sometimes closure is rapid, sometimes delayed,
in which latter case it may be stimulated by the use of silver nitrate,
as already indicated above. In a few instances the condition is so
extensive or so permanent as to justify or require further operation,
which may be in the nature of a curettement of the fistulous tract, a
slight plastic procedure, including a buttonhole suture about the
opening, or possibly a complete intestinal resection. I have seen
small, fistulous tracts discharge occasionally, even for years, and
then finally close spontaneously, and have far oftener seen some
form of spontaneous closure than necessity for operative
intervention. The danger of infection around any such fistulous tract
is ever present, and when it has occurred the fact will be made
known by increase of edematous granulations, with swelling and
tendency to breaking down. In every such case active cauterization,
or, better still, the use of the curette, will be required.
A tuberculous form of chronic appendicitis, as well as tuberculous
infection of a subacute exudate, is possible, the case being
converted into one of greater chronicity, with more or less mild but
constant septic features (hectic). In any event, so soon as the
tuberculous element can be recognized radical measures should be
instituted.
 Fig. 583 Fig. 584

Omentum being gently lifted in order to Appendix delivered from the abdominal
uncover the appendix enclosed with its cavity and brought to view. (Lejars.)
fold. (Lejars.)
Fig. 585
 Separation of the meso-appendix. (Gosset.)

Operation for Chronic or Recurring Appendicitis; Internal Operations.

—Other things being equal the most favorable time at which to
remove the appendix is that when pathological processes are least
active. If, therefore, there be a choice the interval of quiescence
rather than the stage of active infection would be chosen. Interval
operations, so called, are usually comparatively simple, both in
principle and technique. There are times, however, when it is difficult
to find a partially obliterated appendix which has been covered up in
thickened peritoneum or partially organized exudate. In such a case
considerable blunt dissection or separation may have to be done
before it can be removed. In those instances is this particularly true
where it had originally a retroperitoneal location, and at no time a
free or movable position. When difficult of recognition we may be
unerringly led to it if we but follow the bands of white fibrous tissue
on either side of the cecum to their junction.
The opening by which the appendix should, under these
circumstances, be reached may again be made at the point of
election, and should best be located over the area of greatest
tenderness. Whatever incision is selected we should endeavor to
separate muscle bundles as much and incise as little as possible. The
appendix being delivered through the wound, either before or after
ligation of its mesentery, and being thus completely isolated, is
removed close to the large intestine, its base being tied and its
structure being seized within the blades of a forceps in such a way
that none of its contents may escape. The scissors with which it is
divided are contaminated by its contents and should not be used
again until cleansed. The stump on the proximal side may be
touched with the actual cautery, or scraped and then cauterized with
pure carbolic acid or formalin solution in order to thoroughly
disinfect it. Subsequent treatment of this stump differs with different
operators. Some are satisfied to leave it thus cauterized, while
others cover it with the adjoining peritoneum, which is brought
together over the stump end by either a purse-string or a continuous
suture. Yet others have been satisfied to invert the ends of the
stump into the cecum and thus leave it with or without further
protection. It seems to make really very little difference how the
stump is treated, providing only it be disinfected and prevented from
leaking. Nevertheless it would appear preferable to give it at least a
peritoneal covering to prevent adhesions (Figs. 583 to 588).

Fig. 586

The base of the appendix is tied with silk. The meso-appendix is being tied in
sections with the Cleveland needle. (Richardson.)
 Fig. 587 Fig. 588

Appendix surrounded with ligature at its Complete detachment of appendix.

base, after its isolation from its (Gosset.)
mesentery. Purse-string suture in place.
(Gosset.)

In the subsequent closure of the external wound drainage is not

made, there having been no pus to call for it; while the more
perfectly the wound layers be closed, each with a row of chromicized
catgut sutures, the peritoneal incision being first carefully
approximated and over it the muscle and aponeurotic layers, each
by itself, the less the tendency to subsequent postoperative hernia.
On general principles, also, the shorter the incision the less the
danger of this undesirable event. Nevertheless other considerations
should not be sacrificed to shortness and beauty of the cutaneous
scar.
The essentials of after-treatment of these cases have been already
summarized in the previous section, and to these little exception
may be taken in cases such as those above described. Every
precaution should be taken to prevent vomiting, as every muscular
effort involved in the act tends to disturb a freshly sutured wound.
While violent muscular efforts of defecation are also to be
deprecated, there is perhaps as much or more to be dreaded from
the abdominal distention which may result from inattention to free
intestinal elimination. Until the bowels have been moved it is best to
restrain the diet to the simplest fluid nourishment. So soon as
elimination becomes free more liberality in diet may be allowed.
There is the same liability to and danger from other possible
complications, such as postanesthetic pneumonia, anuria, or lack of
expulsive power of the bladder, which requires the use of the
catheter, in these as in other abdominal cases. Principles of
treatment, however, do not vary, and the reader is referred to the
previous section already indicated.
Paratyphlitic abscesses are to be distinguished from perityphlitic or
peri-appendicular abscesses in that they arise from a phlegmonous
process in the cellular tissue around the colon not due to intra-
appendicular infection. In consequence of such a cellulitis more or
less considerable collections of pus may form, which are most likely
to present either in the loin or just in front of the cecum, which may
burrow either upward or downward, or appear elsewhere. They are
mentioned here, not because they are to be differently treated or
surgically regarded, but because it is worth while to remember that
here about the cecum and ascending colon, as on the left side, such
pericolic abscesses may form without reference to the appendix.
 CHAPTER L.
THE LARGE INTESTINES AND THE RECTUM.

ANOMALIES OF THE LARGE INTESTINE.

The more common congenital anomalies of the various divisions of
the colon have to do mainly with the presence of diverticula and
atresiæ, or possibly total absence, due to defects in development.
Diverticula are much the more common. Some degree of constriction
is not particularly infrequent, but complete absence of even a
section of the colon is an extremely rare anomaly.
The acquired anomalies have to do with disease processes or
results of injury. Displacements may be the result of old adhesions
and distortions; of chronic constipation, i. e., fecal impaction and
resulting overloading, with sagging, stretching, and complete change
in shape and position; with displacement due to enlargement of
other organs, e. g., the liver, stomach, spleen, uterus, or, in milder
degree, with the gradual but inevitable and chronic results of tight
lacing. The causes which produce a gradual enteroptosis of the
transverse colon are not supposed to concern the surgeon, yet the
condition may precipitate acute obstruction which will necessitate his
urgent participation in its final treatment.
There are no diseases peculiar to the large which do not also
concern the small intestine, and no surgical diseases peculiar to it
which have not been considered in the foregoing pages. It is not,
therefore, necessary to make even a brief summary of the surgical
diseases peculiar to the large intestine. Of well-known lesions,
however, in this location there is perhaps a little worth emphasis in
this place. The most serious surgical conditions of the large bowel,
aside from the acutely obstructive, are those pertaining to
expressions of tuberculosis, syphilis, actinomycosis, dysentery in one
or other of its tropical forms, and cancer. There is a condition also of
either acute or chronic colitis or mucocolitis which may assume such
extreme degree as to necessitate a colostomy made at the cecum
(appendicostomy) for the purpose of more perfect irrigation and
physiological rest. The amount of suffering, as well as of toxemia,
which may proceed from a seriously inflamed colonic mucosa, must
be at least once seen in order to be fully appreciated. Such a
condition is characterized by local and general suffering, with septic
and copremic symptoms, as well as by tenesmus and the passage of
numerous small or larger and more infrequent amounts of blood-
stained mucus, sometimes of almost pure blood. As an illustration if
one recall what may be seen in case of a violently inflamed
conjunctiva or pharyngeal mucous membrane, and realize that this
condition is duplicated through a large portion of the colon, a more
vivid picture of what it actually represents can be afforded. When
exposed to inspection, as it may be when the rectum and the
sigmoid are involved, it will be found to bleed at the slightest touch
and to freely discharge large quantities of thick mucus. While such a
colitis is usually treated by non-operative methods an anesthetic is
sometimes required for its more perfect diagnosis and recognition,
as well as for such local applications as can scarcely be made
without it.

TUBERCULOUS AND SYPHILITIC ULCERATIONS OF THE

COLON.
Tuberculous and syphilitic ulcerations of the colon may be localized
and relatively insignificant, or numerous, disseminated, extensive,
and serious. In extreme cases of this kind the entire colonic mucosa
will be involved and the amount of distress thus occasioned be
scarcely controllable. These are the cases which, failing to yield to
ordinary therapeutic measures, justify colostomy at the cecum, for
the purpose of temporary exclusion of the large intestine and its
physiological rest, as well as its more perfect local treatment by the
irrigation and suitable local applications thus permitted.

STRICTURES OF THE LARGE INTESTINE.

 Strictures of the large bowel have the same etiology as those of
the small bowel, and are to be recognized by the same general
indications, of which increasing obstipation, perhaps with alternating
attacks of diarrhea and increasing difficulty in evacuation, are
unmistakable features. The nature of a stricture is not always to be
foretold before the exploration which it will necessitate. No stricture
of the large intestine which is above easy reach from the anus can
be successfully treated by any save operative methods, i. e., by
abdominal section and proper attention to whatever may be thereby
revealed. Thus at one time bands may be divided or some external
mass removed by pressing upon the bowel (e. g., a uterine myoma),
or there may be found an associated tumor, malignant or benign,
whose complete removal is both possible and permissible, or at
other times a malignant stricture so complicated that only an entero-
anastomosis, for temporary relief, can be effected.

CANCER OF THE LARGE INTESTINE.

Cancer of the large intestine spares no part of its length or lumen.
Primary cancer of the cecum may commence in the region of the
appendix, and has frequently been mistaken for a chronic
appendicitis. If the transverse bowel be involved there may be more
or less sagging or fixation, while at the flexures obstruction is more
easily produced. Such growths in time become sufficiently prominent
to be easily recognized from without, but then they have usually
gone beyond the time when radical operation can hold out much
promise. In the large, as in the small, intestine radical operations
are, however, often successful, and always in proportion as they are
made early and thoroughly. When extirpation is impossible
anastomosis will offer a temporary substitute (Fig. 589).

OBSTRUCTION OF THE LARGE INTESTINE.

Chronic obstruction of the large bowel is usually due to one of the
causes above considered. Acute obstruction of the colon is the result
either of precipitation of an acute condition upon the base of an old
chronic trouble, of Fig. 589
invagination, of
volvulus, or possibly
of one of the other
mechanical
contortions not
included in either of
these expressions.
Intussusception is
most likely to occur
either at the ileocecal
valve or in the region
of the sigmoid.
Volvulus is more
common in the latter
region. It is here due
to relaxation of
natural ligamentous
supports, to
overloading and
stretching, or is
possibly permitted by
some congenital
condition. Volvulus in
this section having
once occurred the
patient is liable to its
subsequent
recurrence. So well
known now is this
fact that surgeons
have endeavored to
take special
precautions against it,
which unfortunately
have not been
brilliantly successful. Cancer of cecum, showing ulcerating growth
It has been protruding interiorly and obstructing. (Dr. E. A.
Smith.)
suggested, for
example, to anchor
the sigmoid to the anterior abdominal wall, or to resect a portion of
it, to anastomose it with the cecum, as well as to reef the
mesosigmoid. Desirable as such operative relief may be, all of these
methods present inherent objections, while those which include
absolute fixation of the sigmoid perhaps predispose it to subsequent
obstruction from other causes. At present it would appear that a
sigmoidopexy is probably the best procedure, in order to prevent
local recurrence, in a sigmoid volvulus which has once been exposed
by operation, care being taken to fasten it well up to its outer side,
as well as posteriorly, in order that there may be no vacant spaces in
these directions.

THE RECTUM.

GENERAL CONSIDERATIONS.
The rectum was for too long a time relegated to the care and
almost sole interest of the itinerant charlatan, or the somewhat
ambitious, though scarcely more honest, specialist, who preyed alike
upon the suffering and ignorance of patients, until the practice of
rectal surgery was almost a mark of disgrace. From this unfortunate
condition it was rescued by the organized effort of honest men, until
now, in the light of their researches, the rectum has been shown to
be both the site of numerous, easily discernible, and serious, alike
mysterious and reflex lesions, all deserving careful study. The
connection between the sensory nerves with which its terminal inch
and a half are freely endowed and the vasomotor nerves throughout
the body is easily shown by their influence, for instance, upon the
respiration and the circulation, and in these respects some important
lessons have been learned from the charlatans. We have learned, for
example, that general vasomotor spasm, with its evidence in
coldness of the extremities and pallor of the surface, may often be
overcome by so simple a measure as stretching the sphincter; while
to cure lesions which produce more or less sphincteric spasm is to
frequently restore general circulatory tone. Again, what may be
accomplished in stimulating respiration by dilatation of the sphincter
has been shown to be of the greatest value in patients breathing
badly under an anesthetic.
The “orificialists,” then, while making absurd and impossible
claims, have nevertheless taught us considerable concerning the
value of recognizing the importance of sphincteric spasm. Their
claims concerning so-called “pockets” and “papillæ” are untenable
and absurd, and the expression which they have taught many of the
laity that they are sufferers from “rectal pathology” indicates alike
their ignorance of good English and good surgery. That papillæ do
become, under certain circumstances, exquisitely sensitive and are
occasionally in need of the cautery or the scissors, as well as of the
general relief afforded by stretching the sphincter, is undoubtedly
sometimes true.
The itinerant “pile-drivers” and charlatans of their class have done
more harm than good, and yet even from them the honest
practitioner has learned that “it pays” often to give attention to the
rectum. As a source of various disturbing and particularly distressing
reflexes there is scarcely any portion of the body of equivalent area
which can furnish so many. The relief to mental conditions,
amounting often to pronounced melancholia, which follows cure of
rectal lesions, is often astonishing, all of which shows that the
rectum is well worth the attention of the scientist, and especially of
investigation in every case where the slightest complaint is made.
All of which properly leads up to the subject of rectal examination
and how to make it complete. Much can be learned here by use of
the educated finger, as well as in the vagina, and the surgeon should
cultivate that tactile sense which will orient him so soon as the
finger-tip comes in contact with a morbid or diseased surface. In this
way it is possible to detect ulcers which are within reach by the
finger alone, without having to use the speculum, at least to make a
diagnosis sufficient to indicate what further procedure is required.
The rectum and lower bowel should be thoroughly emptied. It is
safe to assume that exquisite sensibility and pronounced sphincteric
spasm are the result of morbid conditions. The use of a local
anesthetic will in many instances be sufficient to permit at least of a
preliminary digital examination, the suggestive characteristics
especially sought being the general size of the rectal tube, infiltration
or fixation of its walls, and the presence of stricture, tumor, or other
impediment to insertion of the finger, including pronounced spasm at
the anus. The presence of bloody mucus or pus should also be
noted. In addition the rectal surroundings should be examined and
the presence of any phlegmon, fistula, sinus or other evidence of
present or past disease, including old scar, either of ulcer or incision,
should be noted. The degree of pain as well as of hypersensitiveness
produced should also be noted. With tact and gentleness satisfactory
knowledge of the condition of the parts within reach may be
obtained.
A rectal bougie may be used should suggestions of the presence
of stricture be present. Rectal bougies are usually made of soft
rubber of various sizes, with tips variously shaped, of which the
tapering and conical are the most useful. One of these may be
anointed and gently introduced, the endeavor being to guide it first
in the middle line along the course of the rectum and then gently
toward the left as the rectum swerves in this direction as it comes
down from above. With such a bougie the presence of a stricture
beyond reach of the finger may be detected. When recognized its
nature is, however, still left in doubt, to be decided by the history or
other features of the case. There is never excuse for roughness in
handling a rectal bougie, since perforation or serious injury might
result.
The next method of more complete examination of the rectum is
through one of the various forms of specula, from the so-called
rectal speculum, with its blades only a couple of inches long, to the
more formidable proctoscope or sigmoidoscope, with their
possibilities or artificial illumination, etc. According to the nature of
the lesion and the sensibility of the surface exposed various specula
may be used, with or without an anesthetic. For the majority of
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