What is ‘Health System Design’ and Why Does it Matter? Lessons Learned from a Scoping Exercise

by Michaela Nesson

Rwanda rebuilt its health sector after the 1994 genocide. In the U.S. today, healthcare payment reform continues to prove its complexity. And globally, efforts toward achieving Universal Health Coverage vary widely by country. Each of these presents a case of health system overhaul, in which some type of drastic change has been sought. What does this transformational work look like? Who is involved in it? Where is it taking place?

These questions sparked my project this summer at the Arnhold Institute for Global Health. There, I worked under the mentorship of two senior staff members to conduct a scoping exercise into the field of ‘Health System Design’ (HSD). We sought to better understand and define the field of HSD, globally and locally.

Why and how did I do this? Our motivation was to create a common framework for HSD, so that researchers, thought leaders, policymakers, and implementers alike would be able to rest on common definitions. This would benefit the Arnhold Institute internally, as well as improve efficiency and effectiveness of HSD efforts throughout the U.S. and globe. To achieve our goal of finding – and if not, producing – a definition of the field of HSD, I went to the literature. I read white papers, perspective pieces, peer-reviewed studies, strategic plans, descriptions of pilot programs and design initiatives, curriculum published at universities, and plenty of other material. I organized the content thematically and visually, analyzing common themes and inconsistencies. I solicited input from a host of other staff members of diverse disciplines, who all offered insightful advice. As the project progressed, we realized its challenges: we wrestled with the main question of what specific criteria defined HSD as a distinct field. The project culminated in a paper I wrote capturing its evolution.

This project opened my eyes to the expansiveness of HSD and the challenges of defining it. It was a valuable experience in seeing through a project from start to finish. I learned an immense amount, both in terms of content and process. I gained an understanding of just how vast the world of HSD is, with my findings falling under a wide array of categories, from complete system overhaul to targeted improvement initiatives. I discovered a lot of implementation of HSD efforts, without consensus on what HSD was.

There is a clear need for the development of a systematic definition, with criteria that specify what HSD is and is not (the challenge being how broadly or narrowly to define them). Participating in this creative research process taught me the importance of collaborating to determine these criteria. The evolution of the project wouldn’t have been possible without the feedback that advanced it at each stage. I was incredibly fortunate to receive guidance, support, and input from so many people within the Arnhold Institute, spanning many disciplines. This speaks more broadly to the immense value of multidisciplinary approaches; there is so much potential for collaboration across disciplines to result in cutting-edge solutions.

I hope that as the HSD definitional process continues, multidisciplinary collaboration really takes root. Many successful health system redesign initiatives exist for us to learn from, more are being rolled out today, and we hope that this definitional work will allow for tomorrow’s initiatives to advance even further. Health sectors across the globe and here in the U.S. are in need of vital changes; these will be made possible only through collaboration across sectors.

Michaela Nesson is a senior in Pforzheimer House studying Sociology, Global Health & Health Policy, and Spanish. This summer, she interned as an HGHI Summer 2018 Fellow at the Arnhold Institute for Global Health at the Icahn School of Medicine at Mount Sinai.