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 [1], global security, effective governance, and human rights promotion [2]. Second, due to the growing perceived importance of health, unprecedented—albeit still insufficient—sums of funds are flowing into this sector [3]. 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
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