How might we design health systems to promote health and wellbeing and not just treat illness and disease and manage infirmary and chronic conditions? What if health systems were about health?
If we were to apply design thinking to health systems, what might be do?
In a previous post, I suggested that knowledge translation is too important to be trusted solely to health professionals, partly because they have largely failed to take up the charge. Taking a step back — a systems thinking perspective — one realizes that to design better knowledge translation, we need to design better health systems.
Julio Frenk, Dean of the School of Public Health at Harvard, believes this too. In a 2010 paper published in PLOS Medicine, Frenk comments on the state of health systems and examines how we might re-think them in light of global health challenges.
Health systems are the main instrumentality to close the knowledge–action gap. To realize this potential, it will be necessary to mobilize the power of evidence to promote change. Yet all too often reform efforts are not evaluated adequately. Each innovation in health systems constitutes a learning opportunity.
Frenk’s article is an invitation to engage in systems and design thinking about health. Both approaches invite pause to consider what the problem is in the first place. For design thinkers, problem scoping is the first step.
For systems thinkers this is akin to setting the boundaries around the problem.
Once we set the boundaries and find the appropriate problem, we then frame it appropriately for design. Problem definition is something often over-looked or under appreciated, but is the core of effective problem solving and design.
If I had an hour to solve a problem I’d spend 55 minutes thinking about the problem and 5 minutes thinking about solutions – Albert Einstein
Health systems are typically defined in light of professional services and policies aimed at making the sick well. They are essentially illness and disease (sick care) systems. This conceptualization, still dominant in the professional and policy discourse in many Western countries, places medicine at the centre of health services with the allied disciplines working alongside, but rarely ventures its gaze beyond the institutions of care or the conditions such institutions are designed to treat.
Frenk, writing in PLOS Medicine, suggests its time to expand our view of what makes a health system if we are to truly promote and sustain global health and see three key points as provoking such re-thinking:
First, health has been increasingly recognized as a key element of sustainable economic development , global security, effective governance, and human rights promotion . Second, due to the growing perceived importance of health, unprecedented—albeit still insufficient—sums of funds are flowing into this sector . Third, there is a burst of new initiatives coming forth to strengthen national health systems as the core of the global health system and a fundamental strategy to achieve the health-related Millennium Development Goals.
In order to realize the opportunities offered by the conjunction of these unique circumstances, it is essential to have a clear conception of national health systems that may guide further progress in global health.
Frenk offers some suggestions:
Part of the problem with the health systems debate is that too often it has adopted a reductionist perspective that ignores important aspects. Developing a more comprehensive view requires that we expand our thinking in four main directions.
First, we should think of the health system not only in terms of its component elements (like human resources, financing, hospitals, clinics, technologies, etc.) but most importantly in terms of their interrelations. Second, we should include not only the institutional or supply side of the health system, but also the population. In a dynamic view, the population is not an external beneficiary of the system; it is an essential part of it.
It’s important to note the mention of the role of the population and its dynamical impact on the system. As populations change dramatically in their composition and form of residency within countries, including a greater movement to urbanization, so too will the myriad factors that influence health systems. The people are the system and thus it will change as populations change. While Frenk lists this as one point of many, it is a radical departure for reductionists or those who see health systems as being about care, not people.
A third expansion of our understanding of systems refers to their goals. Typically, we have limited the discussion to the goal of improving health. This is, indeed, the defining goal of a health system. However, we must look not only at the level of health, but also at its distribution, which gives equity a central place in assessing a health system. In addition, we must also include other goals that are intrinsically valued beyond the improvement of health. One of those goals is to enhance the responsiveness of the health system to the legitimate expectations of the population for care that respects the dignity of persons and promotes their satisfaction. The other goal is fair financing, so that the burden of supporting the system is distributed in an equitable manner and families are protected from the financial consequences of disease.
Frenk’s third challenge is to affirm the very point of health systems at all.
While not explicitly speaking of systems thinking or design thinking, there is much that both fields have in common with Frenk’s argument. Design thinkers might ask: What have we hired our health system to do?
Frenk argues that our health systems must go well beyond just making gains in measured health outcomes towards dignity, respect and social justice.
Finally, we should expand our view with respect to the functions that a health system must perform. Most global initiatives have been concerned mainly with one of those functions, namely, the direct provision of services, whether they are medical or public health services. This is, of course, an essential function, but for it to happen at all, health systems must perform other enabling functions, such as stewardship, financing, and resource generation, including what is probably the most complex of all challenges, the health workforce.
Frenk did not identify specific solutions, but did pose some key questions for health systems design.
If we were to take this challenge up as designers and systems thinkers, what might we do? Here are some suggestions for inquiry:
- Consider new definitions of health like the one posed in the British Medical Journal that emphasizes looking at the social and environmental influences on health beyond just the absence of physical symptoms. Further inclusion of a psychology of human flourishing might add to this definition.
- Map out a new system visually with people at the centre, not professionals or institutions. What does that look like? Tools like a Gigamap might provide the kind of multi-media, multi-sensory visual way to conceive of the interrelationships that make up health system. System dynamic models can help this out as well.
- Engage people across this system to validate this map and co-create possible future models that could serve to shape discussion at multiple levels and mobilize civil society to support healthy environments.
- Create small scale, safe-fail / fail-forward, prototypes of small-scale innovations that can be tested, developmentally designed, and rapidly re-developed as needed to start shifting the system as a whole.
Designing health requires designing health systems. Applying new thinking and envisioning a system that is dynamic, comprised of people and just institutions is a start.
Photo: Bartolomeo Eustachi: Peripheral Nervous System, c. 1722 shared by brain_blogger used under Creative Commons Licence
Design Thinking is trending is some educational circles. Edutopia recently ran a design thinking for educators workshop and I attended two great workshops at SXSWedu 2013 on Design Thinking:
Design Thinking is a great skill for students to acquire as part of their education. But it is one process like the problem-solving model or the scientific method.
It’s fair to imagine that one of the 2013 ‘words of the year‘ will be MOOC (which is not really a word, but an acronym that stands for Massive Open Online Course). It seems that everywhere you look in the higher education and professional development space we are seeing MOOC’s talked about and debated.
HBR editor Eric Hellwig, writing for the HBR blog, reported on a recent panel on MOOC’s held at the recent World Economic Forum in Davos with leaders like Bill Gates, Peter Thiel and Larry Summers. His report reflects the exuberance of the MOOC and the techno-deterministic spirit of much of the discourse on these tools:
The advent of massively open online classes (MOOCs) is the single most important technological development of the millennium so far. I say this for two main reasons. First, for the enormously transformative impact MOOCs can have on literally billions of people in the world. Second, for the equally disruptive effect MOOCs will inevitably have on the global education industry.
One of the panelists was Stanford professor Daphne Coller, the co-founder of Coursera, one of the largest MOOC providers offering more than 200 courses to millions of students worldwide. Coller has convinced top faculty at leading universities to provide high quality digital courses through Coursera for free and the result has surprised her.
We’re at 2.4 million students now. The biggest lesson I’ve learned on this is I underestimated the amount of impact this would have around the world. I really didn’t envision this scale and this impact this quickly.
Of these panelists, Peter Thiel may be the most controversial. He has spoken at length about the need to revamp education and sees technology and platforms like Facebook as a means to do it. (It’s worth noting that Theil was also an early investor in Facebook). He points to the multiple roles that education plays well beyond learning and suggests that when we go beyond that goal we start creating false economies of value within higher education:
You have to ask yourself, ‘What is the nature of education as a good?’ Ideally you want it to be learning. But it also functions as insurance. Parents will pay a lot of money for insurance against cracks in our society. Education as insurance has something to be said because it connects to the economy. You know computer science, you can get a job. But education also functions as a tournament. You do well if you go to a top school but for everyone else the diploma is a dunce hat in disguise. People need to understand what they’re trying to do? Is it insurance? A tournament? Learning?
Among Thiel’s biggest concerns is with the current educational system’s ability to support the kind of innovative thinking needed to make technological and scientific breakthroughs. So steadfast is he in the belief that some of the best minds are rotting in traditional classrooms that he founded the Thiel Fellowship, a scholarship fund to support promising young entrepreneurs in dropping out of school to pursue their ambitions of making social impact.
Thiel is disrupting education by taking learning away from the educational institutions charged with providing it. MOOC providers are seeking to develop a business model that puts them in the drivers seat of education and learning, drawing potential revenues away from traditional educational institutions. This will no doubt add to the pressures that universities and colleges are already facing as they rationalize ever more of what they do.
Education For All, Learning For Whom?
Free online learning of the calibre provided by Stanford University, Caltech, Harvard University, University of Toronto, MIT, and the Santa Fe Institute for anyone, anywhere sounds like a dream come true.
In some ways it is. In others, it’s an illusion.
It’s been suggested that less than 10 per cent of those enrolled in a MOOC complete it. And of this 10 per cent, it isn’t clear what they learn, how well they learn it, and what kind of application (if any) that content is made to issues away from the course. Online courses with video tutorials, self-organized learning and largely uni-directional teaching bring together the best of former teaching methods like instructional TV, self-help, and classroom lectures.
The problem is that this ‘best’ isn’t particularly effective. A 2000 meta-analysis of distance instructional methods found:
There does not appear to be a difference in achievement between distance and traditional learners. Of the ten instructional features that were analyzed, only three had an impact on student achievement. These three features were type of interaction available during a broadcast, type of course, and type of remote site. There was an insufficient number of studies to ascertain whether or not the education level of the distance learners effected their achievement in the course (Machtmes & Asher, 2000).
While this review was done before widespread Internet use, the methods included reflected the same list above with one- or two-way audio and video. The studies were also done on programs that were designed for credit, not voluntary non-credit courses. Research on motivation will show that optional programs are far less likely to engender behavioural shifts than those that are mandated.
So who then is benefitting from MOOC’s? We don’t yet know, but it is likely those with time to attend to the content, high levels of intrinsic motivation (< PDF), the technological tools to succeed, and the environment that is ready to support integration of content into practice. That’s a tall order.
We are in the early days of MOOC’s and its too soon to tell how successful they will be. However, theoretically there is relatively little reason to expect that they will produce the kind of results worthy of hyperbole — at east not with those already accustomed to alternatives. To offer a MOOC from a world-class university to a learner somewhere in the world where education is but a distant dream achieves a great deal. But to transfer MOOC’s to replace more interactive and engaging methods — usually face-to-face — and expect great learning is a bit implausible.
Yet, with what we are offering now to students in the form of large classes, disconnected curricula, and didactic instruction MOOC’s offer an attractive option. What it loses is the experience of learning that is not packaged in a class. This means a change to campus life, the informal and serendipitous learning that comes from being in the same physical space interacting with each other, and may seriously limit the use of thinking and creative tools that design thinking and applied creativity demand. (for a detailed look at MOOC’s and the modern university check out Nathan Harden’s essay in the American Interest).
There is much ado about MOOC’s, but is this a Shakespearian tragedy in the making for learners?
Photo credit: iStockPhoto used under license.