Integrative Health Systems

Integrative Health Systems

The context and nature of challenges presented to our health systems are changing fundamentally and rapidly, unfortunately, it can be said that the systems themselves are far from keeping pace. The most significant factor that is changing in the health equation today is that humans are creating their own ill health. As discussed chronic diseases are now responsible for 7 out of every 10 deaths globally – most of which are behavioral and environmental. As a consequence, our focus in health systems has to shift from how we prevent natural diseases to how we create environments that lead to good health. This is a whole new set of factors and dynamics.

Today we find that health systems are trying to deal with a new set of issues with old approaches. The health issues we face have changed to behavioral ones but we are still treating them as if they are a given by nature. In this context prophylaxis and preventing future illnesses is much more cheaper and effective way of keeping good health and prolonging life, than treatment of disease. However, we still spend trillions of dollars yearly focused on sickness prevention despite this fact. We spend trillions of dollars a year treating the complications of disease versus using technology to better engage patients in proactively managing and preventing those through good health.

In any health system, there are two sides to the healthcare equation, health creation, and sickness prevention. The centralized model that evolved over the Industrial Age worked to place a strong emphasis on the centralized institutions of health provisioning. This was a relatively simplified model that took responsibility from the individual and concentrated it in the formal health system. As with all of the Industrial Age institutions a “push model” evolved where formal centralized institutions pushed out health services to relatively passive end users of the system. This model has been successful in dealing with many illnesses and emergencies but it is becoming clear that it is certainly not designed to create health.

Today there needs to be a shift to looking at the behavioral and environmental end of the equation. The industrial model where healthcare was largely just about the prevention of disease needs to evolve into a much more complex system that is able to incorporate all aspects that enable good health and its maintenance. The idea that health can be confined to one dimension – confined to the formal institutions of the health system – is coming to an end. Health is no longer just a political, administrative or clinical matter, it needs to be an integrated part of the design and management of all aspects of our designed environments and economic organization, thus requiring a much more holistic approach.

It is often identified that today we need a health system that is preventive, preemptive, personalized and participatory but to actually achieve a system that innately creates that – without it being forced on to it or patched on to the side – would quite literally require a restructuring of the basic organizational principles of our health systems, because at present they are designed in such a way to do quite the opposite. The challenge of making that transition from a system that is based upon the principles of simple systems to one that is fundamentally complex is huge; it requires a reconceptualization of the foundations of what health systems are and how they work. Likewise, this move from a relatively simple but fractured centralized model of the past, to a more complex distributed model of the future is required to meet the needs of global health – to move from the centralized national systems of the past to a more globally integrated system of the future.

Integrated Approach

The most important change in this transition is a shift in our basic assumptions and ways of reasoning; a shift from the reductionist approaches of the past to a more integrated holistic approach required to build effective health systems for the future. The reductionist approach that we have employed to date works by breaking a system down into parts and focusing on the optimization of those parts assuming the whole is some linear combination of its elements; if we optimize for all the parts then the whole must be working efficiently.

We break all aspects of health and medicine down into specific domains and then focus our efforts on those component units. Physicians and nurses train, educate, and practice in silos without valuable interactions. We divide hospitals out into departments. Disease-specific global health initiatives have separate reporting requirements. These vertical approaches with the focus on specific issues have the advantages that they are easily measurable while being results oriented strengthening health systems with a sense of priority and tangible metrics for measuring success. This reductionist approach has advantages when dealing with relatively isolated discrete components, for example, it excels when dealing with issues like fractured bones or specific surgical operations.

When a health system or the human body, is seen as a collection of component parts, the innate tendency is to isolate the single factor that is the “cause” for the observed behavior. Like a watchmaker who repairs a broken watch by locating the broken component, physicians typically treat disease by trying to identify and solve for that isolatable issue. Implicit within this paradigm is the idea that each health issue has a potential singular target for medical treatment. For cases of malaria, it is the mosquito bite, for infection, the target is the pathogen; with the case of cancer, it is the tumor.

While the success of this approach is manifest, it fails to take in to account the context within which the specific phenomenon exists and often time this context can be as important as the phenomenon itself. We start to focus just on the disease, and not the person affected by it. This analytical paradigm is simply not designed to address more complex questions, and, thus, a myriad of relevant contextual questions deriving from the environmental context are not factored into the equation.1 Reductionist approaches always define the system as closed; a reductionist approach to health systems defines them as the sum total of the set of relatively close formal institutions for health provisioning. What it is not good at accounting for is the system in relation to its environment. For this reason, it becomes focused on the internal efficiencies of healthcare service provisioning – by the formal institutions – but fails to look at the overall results, the overall environment.

Today’s health dilemmas are increasingly complex, rendering analytical approaches that look for single direct linear cause and effect explanations inadequate. One can take obesity as an example. It is caused by multiple interacting factors including lifestyle, diet, family history, culture, one’s social and economic position and exercise habits. Given the complexity of this, it is unlikely that we will find one “cause” a much more productive starting point would be to look at the system as a whole rather than trying to quickly move towards finding one cause and solution.2

Health systems are a classic example of the limitations in reductionist thinking leading to unintended consequences on the macro-level. Today we have a medical industry which is incredibly specialized; incredibly technical there are lots of people doing things for us but the outcome of that is fragmentation; the number of people you have to talk to in a complicated medical situation is overwhelming. An ever greater focus on the parts has along many dimensions not been balanced with a more comprehensive assessment of the whole; the result is an imbalance and ineffective overall outcomes for the end-user.

Silos

Lack of a holistic approach leads to the formation of disconnected components – what we call silos – over time resulting in the duplication of services, unintended consequences, and negative synergies. It is no secret that modern health systems have become massively complicated and fractured resulting in the formation of inert silos during their development. The end result of this is both inertia, lack of interconnectivity between parts and incapacity to deal with the patient’s needs as a whole.

As an illustration of this, we can think about the current challenges of an aging population. Around the world people are living longer but often with multiple health issues, needing care over many years. Our hope is that people of all ages get the health and social support they need but health systems around the world are not yet ready for this influx of an older population. Elderly people often experience more than one health condition at the same time and these issues tend to be ongoing, yet health systems are typically organized to detect and treat individual diseases

and conditions, as consequence they tend to manage older people’s health issues in fragmented ways that lead to far from optimal overall outcomes for people. This fragmentation means that we miss opportunities to manage chronic conditions and prevent people becoming care dependent, likewise, it makes healthcare overly complicated and difficult for those that are least well equipped to deal with the system.

Holistic Approach

Rather than dividing a complex problem into its component parts, the systems perspective appreciates the holistic and composite characteristics of a problem and evaluates the problem in the context of its environment. The systems perspective is grounded in the assertion that the forest cannot be explained by studying the trees individually.

All relevant factors need to be considered when dealing with people’s health. Health is not a thing for the health system but an ongoing process within society that pervades all activities. In the past, we have made progress by focusing on individual diseases and programs to combat them, in the future, we need to be looking at the whole context that creates health. Moving from looking at the outputs of a formal health system to the inputs required to maintain a healthy population. Less medicine more health and care, meaning that the health equation must consider economic, political, and social components; factors that might seem unrelated to health but ultimately work to create the overall outcomes.

Real solutions have to embrace the complexities inherent in the human condition and this means looking at health systems as open systems, not limited to the formal institutions but instead embedded within the everyday lives of people; looking at both the formal health system and the informal networks that constitute people’s everyday life.

Subjective and Objective

A holistic approach breaks down the divides between the subjective and objective dimensions of health. The reductionist approach to understanding the human body, since the beginning of the modern era, has resulted in a dichotomy between mind and body. A separate domain is created for dealing with the human psyche while medicine has focused on physical conditions; ailments as caused by physical phenomena, largely uninterested in the human psychological and behavioral aspects that create the context for any health condition and how people experience their health or illness.

Reductionism is an objectivist paradigm, it is based upon objective discrete elements of matter as the building blocks that cause higher-level phenomena. Such a paradigm looks for objective physical component parts as the cause of any event, placing limited emphasis on the subjective experience of the individual. The reductionist approach has led to a focus on discrete tangible parts with limited account of subjective perception and behavioral factors. The result of this is that today there remains a huge cultural and psychological dimension to health systems that go largely under-explored and utilized. Opening up the subjective psychological dimension to health reveals an unexplored world of opportunities; simply looking at how people experience there health and how they think about their desire for their health has huge potential.

Culture is often the unexplored realm in healthcare and thus often the stumbling block upon which more objective approaches fail. Traditionally we think of humans as being rational and having an objective view of things and thus exclude behavior that deviates from this. In reality, people are often far from rational and failing to take account of that can cost you billions of dollars when it comes to trying to implement a new health policy or initiate a change process in a large health system. Culture within a large organization, like a national health system, is the product of years and years of established rules, agreed values, customer practice and so on, it is intangible and difficult to define or place your hand on it but it still has a huge effect on how the system operates, why it behaves as it does and creates the outcomes that it creates. When a large-scale change takes place or is proposed then the culture begins to look at it, there is long implicit and explicit debates that go on and finally the culture of the organization will adopt somethings that fit in with its paradigm and reject others that do not.

In this respect, we can see how any health system will reflect and respond to the desires and motives that society places upon it, which are a product of its culture. If people think of illness and overcoming it in a very simplified linear cause and effect fashion – where there should simply be a pill for everything – then it is no wonder that we will get a system that reflects that, and of course many of the unintended consequences that result from it. Cultures are largely stories about the way the world is and stories really matter within social organizations like health systems. Research across every culture shows that stories are how we connect, they are how we communicate. Research also shows that stories are how researchers make diagnosis, 80% of diagnosis can be made based just on the story alone, just on the basis of your illness, which is better than any test or any combination of tests – telling a story does not lead to radiation and infection or the other negative side effects of medical tests – but we rarely hear about millions of dollars being invested into people telling better stories.3

A shared vision is one that is owned by all who are affected by or invested in the current system. A shared vision provides a common set of goals, mutual understanding, and shared expectations for all participants. It is created through collaboration between diverse stakeholders who develop interactive models and consider future scenarios by challenging basic assumptions. Systems thinking holds that it is critical to open up, to reveal and surface this shared set of models so that we can examine them, development them and try to work towards a more robust, dynamic and constructive culture.

Whereas the reductionist approach results in a centralized and hierarchical rule-bound health system that spawns more specialized domains and departments as it scales, an integrative, systems thinking approach flips this around, positing the idea that large-scale complex systems can be the product of the interaction between simple rules that result in emergence.  This idea of simple rules is counterintuitive to the mechanistic approach, in which if one needs a complex outcome, one needs a complex machine. There have been several past attempts to set out a complex set of rules to govern healthcare when these have not yielded desired results, our instincts have been to create even more rules, the end result is the evolution of a convoluted system as a product of an overly complicated set of rules and regulations.

Complexity science asserts that these assumptions lead us in the wrong direction. The emphasis shifts from rules that specify formal health system procedures and processes to creating the context for the emergence of a healthy population. A shift from a rule-bound system where all situations are specified to a situation of defining simple rules and guidelines; the answer is to create the conditions for interaction, self-organization, and emergence..fusion-accordian #accordion-47947-4 .panel-title a .fa-fusion-box{ color: #ffffff;}.fusion-accordian #accordion-47947-4 .panel-title a .fa-fusion-box:before{ font-size: 13px; width: 13px;}.fusion-accordian #accordion-47947-4 .panel-title a{font-size:13px;}.fusion-accordian #accordion-47947-4 .fa-fusion-box { background-color: #333333;border-color: #333333;}.fusion-accordian #accordion-47947-4 .panel-title a:hover, #accordion-47947-4 .fusion-toggle-boxed-mode:hover .panel-title a { color: #1a80b6;}.fusion-accordian #accordion-47947-4 .panel-title .active .fa-fusion-box,.fusion-accordian #accordion-47947-4 .panel-title a:hover .fa-fusion-box { background-color: #1a80b6!important;border-color: #1a80b6!important;}

Reference






1. https://goo.gl/QhfNoN

2. https://goo.gl/poNp1v

3. https://goo.gl/vp95ut

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