Towards sustainable transformation in contemporary health care: Learning from practices that extend reform ideals of efficiency, effectiveness and involvement to the clinical encounter

Health care systems are facing various pressures for change towards more cost-effective and sustainable health services to ensure care for current and future generations. The health system’s success in prolonging life expectancy and eliminating many deadly diseases, generated novel issues including the rise of non-communicable diseases in high-income countries, and increasingly also in low- and middle-income countries. Increases in demand for health care have raised concerns about the precarious balance between supply and demand. Furthermore, ever new medical technologies and innovations have lowered clinical thresholds for diagnosis and treatment, which continues to elevate both price and demand for care. Despite previous (and ongoing) successes, contemporary health care faces new problems that make it increasingly difficult to sustain the costs, quality and equity of health care. Various attempts to face the challenges of contemporary health care systems introduced different paradigms of the changes needed to protect the various public values under pressure. Three paradigms of transformation: the efficiency paradigm, the effectiveness paradigm and the involvement paradigm have largely been shaping health care policy practices throughout welfare societies. Since each transformation paradigm focuses on one key function of the health system, the three paradigms are commonly considered complementary functions of the same process of transformation. Nevertheless, the three dominant sets of transformation practices are far from complementary functions of a mutually supportive transformation of health care institutions and practices. Unlike paradigms that temporally shift from one dominant way of thinking to a new way of thinking, as the concept introduced by Thomas Kuhn would imply, these paradigms actually co-exist. Tiago Moreira, who analysed transformations in contemporary health care that have taken place over the past four decades, relates this to the concept of three dominant ‘modes of coordination’, which he coined: the Market (efficiency), the Laboratory (effectiveness) and the Forum (involvement). The three modes of coordination are a logical (and necessary) response to the diversity of challenges facing contemporary health care systems. Yet, their co-existence simultaneously convolutes attempts at sustainable health system transformation. After all, the modes of coordination propose changes with different underlying epistemic and political dimensions that may contradict or even exclude changes proposed by other modes of coordination. Whereas policy actors may have the luxury to cling dogmatically to a paradigmatic policy solution, this is hard to sustain in clinical practice. Actors operating at the micro-level, especially the professionals who form the central focus of all initiatives studied in this thesis, are confronted with a variety of practices that offer solutions to different problems in health care. As the modes of coordination extend beyond the policy silos from which they initially arose to the clinical encounter, they can no longer easily be kept apart, nor are they easily ‘aligned’ or ‘integrated’. This thesis pays specific attention to the clinical encounter: the place where the three dominant health care transformations are likely to meet. What happens to the modes of coordination, when they are extended to the clinical encounter thereby becomes an important unit of analysis since a variety of transformative practices and pathways have been introduced that extend the three modes of coordination regarding efficiency, effectiveness and involvement to the micro-level. This thesis examines what dominant transformations in health care become when they are extended to the clinical encounter; what challenges emerge in their encounter, and what new action repertoires emerge from such detailed empirical study.