Traditional healthcare systems are in trouble. In the OECD, costly hospitals and clinics dominate health services, and account for 97% of the United States’ healthcare spending. These systems are struggling in the face of cost constraints, public demand for higher quality and exaggerated expectations.
But there is a different system, widely practised in poorer countries that cannot afford Western-style hospitals, and centred on community-based healthcare. We need both approaches; and we need them to work together. Indeed, the growing gap between the promise and the reality of healthcare has created room – in developed and developing countries alike – for new players who are concerned more with social behaviour than with biology.
In his seminal 1996 article in the Harvard Business Review, W. Brian Arthur identified the important distinctions between a healthcare system defined by planning, hierarchy and control and one characterized by observation, positioning and flattened organizations. The first type of system, he argued, is concerned with materials, processing and optimization. It is principally focused on access to medical care, and typically faces diminishing returns.
By contrast, the second type of system is a networked world of psychology, cognition and adaption. It can increase returns through its agile structure and ability to meet varied, locally determined needs. It is not driven by the interests of any specific industry, and it complements, rather than competes with, high-cost healthcare systems. It prioritizes well-being, healthy behaviour and how health choices are made.
The latter approach is particularly relevant to conditions such as heart disease, hypertension and diabetes, which most closely reflect individual behaviour, physical context and socioeconomic factors.
Consider diabetes. A few major pharmaceutical companies compete for a finite group of diabetics by offering new formulations, marginal improvements in blood-sugar control, competitive pricing and strategic partnerships with insurers and health care providers. These incumbents are primarily concerned with defending their market position. Their activities do not extend to helping the hundreds of millions of obese people at risk of diabetes, or to those who respond poorly to existing treatment.
But the key to living well with diabetes is a nutritious diet, an active lifestyle, social support and coaching that is tailored to each individual’s circumstances. This basic formula also forms the foundation of efforts to prevent diabetes, as well as most chronic diseases. And it benefits healthy people, too.
Indeed, traditional medical care accounts for only a small share (perhaps 20%) of our quality of life and life expectancy, while the rest is determined by healthy behaviour, social and economic factors and the physical environment. Dealing with the global epidemic of chronic diseases requires us to address this 80%, and doing so cannot be left to traditional healthcare organizations alone.
Instead, many successful initiatives, built upon existing social infrastructure, solve known health problems and even uncover new issues. Examples of this new approach include technology companies such as Omada Health, which delivers customized online health coaching at home for people at risk of diabetes, social enterprises such as the Grameen Bank, which is building low-cost primary care systems on the back of its micro-lending networks and the One Million Community Health Worker Campaign, which teaches ordinary citizens how to provide care in their own communities, based on lessons learned from similar models in Ethiopia, Rwanda and elsewhere in Sub-Saharan Africa.
Such healthcare initiatives can be accelerated in practical ways. For starters, national healthcare spending across the OECD must shift from its almost exclusive focus on medical care and embrace new entrants that can deliver health improvements. Moreover, these new entrants should have access to the costly data and financial infrastructure of traditional healthcare systems. Physicians and nurses should be encouraged to work with new health practitioners to engage external stakeholders, such as schools, food companies, financial firms and social services. Finally, greater support is needed for community groups and family caregivers who help people striving for better health.
Western healthcare authorities are taking note. Britain’s National Health Service in Wales, for example, is experimenting with community practices similar to those used in Brazil. New York City, inspired by African health networks, is expanding its community health networks to connect the city’s disjointed services.
To be sure, the promise of traditional healthcare will always be compelling as long as technological progress continues to enhance health infrastructure and service delivery. Even so, there is much to learn from a new generation of health experts who understand how individuals make decisions, how collective action creates a healthier environment and how good health is a means to a better life.
The new world of healthcare has unlimited potential, because its frontier is where we live, work and play, making all of us healthcare experts and innovators. Ultimately, the battle against chronic disease will be won or lost at home.
Published in collaboration with Project Syndicate
Author: Prabhjot Singh, a professor of international and public affairs at Columbia University, is director of Systems Design at the Earth Institute and chair of the One Million Community Health Worker Campaign in Sub-Saharan Africa.
Image: An employee checks a Sci-B-Vac, a hepatitis B vaccine, at SciVac’s laboratory in the central Israeli city of Rehovot July 14, 2013. REUTERS/Baz Ratner