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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.
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
References 217
Index 225
vi
P R E FA C E
[ 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
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
Health System
Healthcare
Social Services
Determinants Public
of Health Health
Medical
Care
Doing Your
Part – Healthy
Behaviors and
Stewardship
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]
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