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how things ought to be

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Health systems ought to be seamlessly integrated to meet any person’s health needs wherever they live, whenever they fall ill, and whatever the condition might be.

This view is slowly gaining acceptance, and this view is slowly being conceptualised within medical organisations like the WHO. There is a growing recognition that we ought to redesign our health systems around people/patient, and that our health services ought to deliver “good health” (however, what constitutes “good health” is often not defined).

The WHO-Europe has recognised:

  • That there are multiple pathways to good and poor health

  • That these pathways follow nonlinear patterns and therefore make health outcomes hard to predict

  • That health results from complex interactions between many different types of determinants

The literature, economic reality and political necessity consistently point to three key attributes that ought to be evident for a health and healthcare system to become seamlessly integrated:

  • Person-centredness

  • Equity

  • Sustainability

  • Person-centredness

Person-centredness is broader than just the focus on the person, it also requires a focus on his physical and social environments. While some might find the focus on the person, rather than the population, problematic, it ought to be recognised that many of the problems seen in the individual reflect the broader problems in his community.

Person-centred approaches to care embrace the person, his family and his community as interdependent. Therefore solutions to an individual’s issues frequently will require the input of professionals from different sources.

  • Equity

Equity in healthcare assures access to health (and social) services according to a person’s needs.

As Virchow already emphasised—health professionals have a responsibility to make the health system equitable. Fortunately health professional organisations increasingly recognise this responsibility and advocate for equity measures in their policy agendas.

Equity needs to be distinguished from equality. Equity in healthcare “does not mean that everyone receives the same care. Instead, it means that care aims to achieve optimal outcomes for all groups of patients, even if achieving optimal outcomes means that care differs from person to person, and group to group.”

Healthcare needs are nonlinearly distributed across the community—most people are healthy most of the time without the need for any form of healthcare. However, healthcare delivery in most countries remains grossly inequitable. Tudor Hart described it as the “inverse care law”—the availability of good medical care tends to vary inversely with the need of the population served.

  • Sustainability

Achieving sustainability of the health and healthcare system has become an imperative; Nobel laureate economist Robert Fogel predicts that the expenditure on health will reach 20–25% of GDP by the year 2025.

Prevailing tendencies to achieve sustainability by limiting services or redistributing costs for healthcare on those in need of care will ultimately be counter-productive. Sustainability has been defined as the balance between social, environmental and economic concerns. Hence, sustainable solutions must be affordable to individuals and society, acceptable to all constituents and adaptable as needs change over the life trajectory.

Person-centredness and equity have been identified as two key approaches that make health and healthcare systems sustainable.

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Fig. 12.1
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  1. 1.

    What Zsuzsanna Jakab really means here is the more narrow “ healthcare system”.

  2. 2.

    Despite all the rhetoric about “patient-centred care”, the patient is not at the centre of things.—David Rosenthal and Abraham Verghese [2].

  3. 3.

    It becomes absolutely clear that the established biotechnical means at our disposal must be supplemented by biographical understanding.—Iona Heath [3].

  4. 4.

    Given the importance of the psychological, social, cultural, behavioural, and economic factors of each person, it seems only fitting that “personomics” be added to the precision medicine toolkit, and that it be used to refer to an individual’s unique life circumstances that influence disease susceptibility, phenotype, and response to treatment.—Ray Ziegelstein [4].

  5. 5.

    …the reason why poverty is unacceptable is not that the lives of the poor are shorter, but that poverty is demeaning, cruel and unjust. People should be entitled to decent living conditions not because it would make them live longer (which would be a welcome by-product) but because in a humane society the principle of fairness and justice is paramount.—Petr Skrabanek [5].

  6. 6.

    Health systems promote health equity when their design and management specifically consider the circumstances and needs of socially disadvantaged and marginalised populations, including women, the poor and groups who experience stigma and discrimination, enabling social action by these groups and the civil society organisations supporting them.—Lucy Gilson [6].

  7. 7.

    A sustainable health system also has three key attributes: affordability, for patients and families, employers, and the government …; acceptability to key constituents, including patients and health professionals; and adaptability, because health and health care needs are not static ….—Harvey Fineberg [7].

  8. 8.

    Person-centredness at an instrumental level entails: easy access to care, continuity of care preferably with a single provider, coordination of care, bidirectional communication and caring attitudes.

  9. 9.

    For more detail on the contribution and societal benefits of the healthcare system see: Suhrcke et al. (2005) The contribution of health to the economy in the European Union. Luxembourg: Office for Official Publications of the European Communities (

  10. 10.

    For the distinction between needs and wants see Chap. 5

  11. 11.

  12. 12.

    GDP-spending on health 2014 (The World Bank—for more details see

    high income countries 12.3%; low and middle income countries 5.8%, the World average 9.9%

    US 17.1%, Maldives 13.7%, Germany 11.3%, Cuba 11.1%, Canada 10.4%, Australia 9.4%, Ecuador 9.2%, UK 9.1%, South Africa 8.8%, Brazil 8.3%, Chile 7.8%, Russia 7.1%, Luxemburg 6.9%, Kenya 5.7%, Singapore 4.9%, Senegal 4.7%, Fiji 4.5%, UAE 3.6%, Madagascar 3.0%.


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Addendum 1

Equity Principles Shape the Design of Healthcare Systems

Gilson L, Doherty J, Loewenson R, Francis V. Challenging inequity through health systems. Final report, Knowledge Network on Health Systems 2007. Geneva: WHO Commission on the Social Determinants of Health, 2007. [6]

Why health systems matter to the social determinants of health inequity
1. Health systems offer general population benefits that go beyond preventing and treating illness. Appropriately designed and managed, they:
   • provide a vehicle to improve people’s lives, protecting them from the vulnerability of sickness, generating a sense of life security, and building common purpose within society
   • ensure that all population groups are included in the processes and benefits of socioeconomic development and
   • generate the political support needed to sustain them over time
2. Health systems promote health equity when their design and management specifically consider the circumstances and needs of socially disadvantaged and marginalised populations, including women, the poor and groups who experience stigma and discrimination, enabling social action by these groups and the civil society organisations supporting them.
3. Health systems can, when appropriately designed and managed, contribute to achieving the Millennium Development Goals.
Critical health system features that address health inequity
1. The key overarching features of health systems that generate preferential health benefits for socially disadvantaged and marginalised groups, as well as general population gains, are:
   • the leadership, processes, and mechanisms that leverage intersectoral action across government departments to promote population health; organisational arrangements and practices that involve population groups and civil society organisations, particularly those working with socially disadvantaged and marginalised groups, in decisions and actions that identify, address, and allocate resources to health needs
   • health care financing and provision arrangements that aim at universal coverage and offer particular benefits for socially disadvantaged and marginalised groups (specifically: improved access to health care
   • better protection against the impoverishing costs of illness; and the redistribution of resources towards poorer groups with greater health needs) and
   • the revitalisation of the comprehensive primary health care approach, as a strategy that reinforces and integrates the other health equity-promoting features identified above

Addendum 2

Factors That Entrench Inequity followed by a red fragment

These factors are known for more than 50 years but so far have been neglected in health and social system improvement efforts (first highlighted by Tudor Hart in 1971 [24])

Limiting the Role of Government in Health and Social Services Personal—Neoliberal/Libetarian Doctrine
“…the function of the State is, in general, to do those things which the individual cannot do and to assist him to do things better. It is not to do for the individual what he can well do for himself. …I should like to see reform of the Health Service in the years ahead which is based on the assumption of individual responsibility for personal health, with the State’s function limited to the prevention of real hardship and the encouragement of personal responsibility.” John Seale [25]
The Psychology of the Human Double Standard—Thinking about Oneself in Favourable and about Society in Unfavourable Terms
“…we think of our individual patterns of use in the favourable terms of spending and satisfaction, but of our social patterns of use in the unfavourable terms of deprivation and taxation [emphasis added]. It seems a fundamental defect of our society that social purposes are largely financed out of individual incomes, by a method of rates and taxes which makes it very easy for us to feel that society is a thing that continually deprives and limits us - without this we could all be profitably spending. …We think of ‘my money’ …in these naive terms, because parts of our very idea of society are withered at root. We can hardly have any conception, in our present system, of the financing of social purposes from the social product …” Raymond Williams [26]
Market Mechanisms are the only Way to Achieve Intelligent Planning in Health Services—The Economic Doctrine
“In a health service provided free of charge efficient management is particularly difficult because neither the purpose nor the product of the organisation can be clearly defined, and because there are few automatic checks to managerial incompetence. …In any large organisation management requires quantitative information if it is to be able to analyse a situation, make a decision, and know whether its actions have achieved the desired result. In commerce this quantitative information is supplied primarily in monetary terms. By using the simple, convenient, and measurable criterion of profit as both objective and product, management has a yardstick for assessing the quality of the organisation and the effectiveness of its own decisions.” John Seale [25]
Standing out of the Crowd—Gaining (Economic) Advantage
“In some areas, particularly the more prosperous, competition for patients exists between local hospitals, since lack of regional planning has led to an excess of hospital facilities in some localities. In such circumstances hospital administrators are encouraged to use public relations officers and other means of self-advertisement. …This competition also leads to certain hospital ‘status symbols’, where features such as the possession of a computer; the possession of a ‘cobalt bomb’ unit; the ability to perform open-heart surgery albeit infrequently; and the listing of a neurosurgeon on the staff are all current symbols of status in the eyes of certain groups of the public. Even small hospitals of 150–200 beds may consider such features as necessities.” John Fry [27]

Addendum 3

Examples of Between and Within Country Health Inequities

Social and economic conditions and their effects on people’s lives determine their risk of illness and the actions taken to prevent them becoming ill or treat illness when it occurs.
Examples of health inequities between countries:
• the infant mortality rate (the risk of a baby dying between birth and 1 year of age) is 2 per 1000 live births in Iceland and over 120 per 1000 live births in Mozambique
• the lifetime risk of maternal death during or shortly after pregnancy is only 1 in 17,400 in Sweden but it is 1 in 8 in Afghanistan
Examples of health inequities within countries:
• in Bolivia, babies born to women with no education have infant mortality greater than 100 per 1000 live births, while the infant mortality rate of babies born to mothers with at least secondary education is under 40 per 1000
• life expectancy at birth among indigenous Australians is substantially lower (59.4 for males and 64.8 for females) than that of non-indigenous Australians (76.6 and 82.0, respectively)
• life expectancy at birth for men in the Carlton neighbourhood of Glasgow is 54 years, 28 years less than that of men in Lenzie, a few kilometres away
• the prevalence of long-term disabilities among European men aged 80+ years is 58.8% among the lower educated versus 40.2% among the higher educated

Addendum 4

A Sustainable Health System—US Approaches

What Does A Sustainable Health System Mean?
When we talk about a “sustainable health system”, it reflects a commitment to “improving the lives of the people and communities we serve, for generations to come.” Here are some ways we think about the elements of that system:
It’s a system …
• that improves the health of our population overall—not just the health of the patients who walk through the doors of our facilities, but people throughout our communities
• that uses new models of care delivery to make care more accessible, less costly, and more effective
• that delivers care in the place and at the point of time or illness progression to have the most impact on the continued health of the patient
• with a workforce working in new ways, often to the top of their license or profession, using the fullest potential of our talented and committed people
• that is financially responsible, investing prudently in people, infrastructure, innovation, education, and research that will truly serve patients and population health
• that works within our communities, as part of the fabric that holds us together
• that values integration and a network of care, and partners locally, regionally, and nationally to improve health and health care
• that measures its results, far beyond the current clinical outcomes and process measures that are in place nationally, so that we know how we are doing, how our patients are doing, and that what we are doing in terms of treatments, therapies, and procedures is effective, necessary, and of value
• that treats patients and families as partners in care, knowing that patients who are fully informed about the risks and benefits of treatments and procedures often make different choices and choices they are happier with than if they had left the decision up to their physician
• that drives change and improvement, rather than just letting change happen to it
• that is transparent, internally and externally, sharing our processes and our results with each other, with our patients and their families, and with other providers, to hold ourselves accountable and ultimately to make us all better
Dartmouth-Hitchcock is a nonprofit academic health system
serving communities in northern New England

Addendum 5

A Sustainable Health System—UK Approaches

What is Sustainable Health?
It is easy to imagine a sustainable health and care system—it goes on forever within the limits of financial, social, and environmental resources. The challenge is the current approach to delivering health and care cannot continue in the same way and stay within these limits.
A sustainable health and care system is achieved by delivering high quality care and improved public health without exhausting natural resources or causing severe ecological damage.
It may also be useful to think about the relationship between sustainability and health in three distinct ways moving from a narrow focus to a broad focus. The resources and guidance on this website focus on points 1 and 2.
A sustainable health and care system:
1—Sustainable Health and Care Sector This involves “greening” the sector with particular attention to energy, travel, waste, procurement, water, infrastructure adaptation, and buildings. This ensures resources (physical, financial, and human) used in the sector are:
• Used efficiently (e.g. buildings and homes are well insulated and use less fuel to heat)
• Used responsibly (e.g. clinical waste is disposed of safely to protect local people)
2—Sustainable Health Care
This is slightly broader (but more health care specific) than point 1 and involves working across the health system and partners to deliver health care that deliver on the triple bottom line, i.e. simultaneous financial, social, and environmental return on investment. It includes adapting how we deliver services, health promotion, more prevention, corporate social responsibility and developing more sustainable models of care.
A sustainable way of living:
3—Sustainable Health and Well-being
This is the broadest level and involves considering the sustainability of everything that impacts on health and well-being (e.g. education, farming, banking etc.).
Sustainable Development Unit
The SDU is funded by, and accountable to, NHS England and Public Health England
to work across the NHS, public health and social care system.

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Sturmberg, J.P. (2018). …how things ought to be . In: Health System Redesign. Springer, Cham.

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