December 3, 2019

Choices in Health: A journey to the front lines of national health systems

By Ashish K. Jha

What’s the best way to organize a healthcare delivery system? We in the U.S. are once again having a major debate over how to ensure that all Americans get high-quality healthcare at a price that is affordable. For some, this means “Medicare For All,” while others are deeply skeptical that a single-payer model could work here. Experts across the political spectrum often point to the health systems of other high-income countries with tales either of great care at low costs or of awful wait times and suffering. But what’s the reality?

The Data.

Over the past few years, we have been examining performance data for health systems of high-income countries, and we find that the story is far more nuanced and complex. Of course, we know that most high-income countries cover everyone while spending far less. But how do they get there?

As it turns out, there is no one single approach. While nearly everyone has a system that is administratively simpler, that’s only part of the story. Countries spend less by making difficult choices: settling for lower physician and nurse salaries, for example, or reducing access to certain types of specialty services or expensive treatments. We can see some of these choices in the data – with large variations in utilization and outcomes across different conditions.

While data are helpful and provide an important perspective, we all know that they are not enough. National data fail to capture the experiences of people – patients, doctors, nurses in the healthcare systems.  What does it feel like to have heart failure in Berlin, and how does that compare to having heart failure in Boston? Are the same set of services available for the patient? Do doctors face the same types of challenges in caring for heart failure patients, or do their difficulties look very different? Does the financing and organization of the healthcare system really affect care at the front lines – and, if yes, how? These are the critical questions about health systems that national data just don’t tell us.

The Project

Over the next six months, working with a great team of folks at the Harvard Global Health Institute, my goal is to do a deep dive into health systems of eight high-income countries: Canada, Denmark, France, Germany, the Netherlands, Singapore, Switzerland, and the UK. Why these countries? Of course, there are lots of good options, and while these are not written into stone, they represent a mix of primarily government-run systems (the UK), systems with a large role for private insurance (the Netherlands), or systems with a large component of market-based approaches (Singapore).

Our project will use the lens of clinical personas – focusing on a few prototypic patients (such as an older person with heart failure and multiple co-morbidities or a younger person with a complex, high-cost condition such as cystic fibrosis). Our goal is to really understand how patients experience the choices their health systems make. For example, to what extent do people feel that their system treats them with dignity and respect? Are delays in care viewed as a real problem, and how do patients and providers deal with them? Is access to high-cost medicines and other therapies actually difficult? And how do healthcare systems interface with social care systems to meet the social needs of people, especially the poor? In trying to answer each of these questions, our primary lens will be the patients’ perceptions and experiences of these choices in each of these countries.

Is this new?

So what’s new here? Hasn’t this already been done? A little, but not really. Not recently, and not focusing on the complex, high-need patients for whom an accessible, high-quality healthcare system is particularly important. A few other innovations make our approach unique. First, as a physician, I can use my expertise to really understand the clinical approaches that health systems use, as well as the benefits and costs of such approaches. That clinical perspective will enable us to have a better understanding of the experience not just of patients, but also of physicians and nurses in these countries. Second, we have access to, and have analyzed, vast amounts of data on system performance across these eight countries. Therefore, we can illuminate the stories with the more generalizable data. One can always find some example that makes any health system look heroic – or disastrous. That’s not the point. We will make sure our stories are supplemented by the data in a way that paints a fair picture of how health systems are working. Finally, our team has deep knowledge of how health systems around the globe are tackling issues of care delivery, allowing us to put stories and data from our eight focus countries into a broader global context.


The journey begins January 2020. We have a website (, and I’ll be blogging regularly here. We’ll have a photo journal and produce podcasts that talk about how systems are making choices – and how patients are experiencing them. We are developing partnerships with medical journals and lay media to share these stories more broadly. Who knows, there might even be a book at the end of all of this.  The project really does need an entire team – and we have an awesome one (see here). And we need your help — we’d love your input about people to meet with, systems to see and key issues to understand. Contact us and let us know what is critical to understand about the experience of care in these countries.

Final thoughts

The bottom line that we already know is that there is no single correct way to structure a healthcare system. Everyone does it a bit differently, some very differently. Our hope is that a deep understanding of what health systems are doing, what choices they are making, and how they affect people on the front lines will help us in the U.S. make better, more informed decisions. And given how badly we need to reform our healthcare system, maybe this project can play a small role in helping us evolve towards a system that cares for all Americans, provides high-quality services, and doesn’t bankrupt the nation.