When organisms from various evolutionary lineages respond similarly to similar environmental stresses, convergent evolution takes place. The structure and function of the wings of insects, birds, and bats, for instance, are comparable, but they evolved independently.
Similar to this, convergent evolution can be applied to the alterations that are taking place within health systems all over the world. The environmental pressures shaping health system design span shifting pathologies and shifting political priorities. As measured by disability-adjusted life years, noncommunicable diseases like cancer and mental illness rose to become the leading cause of disease burden worldwide between 1990 and 2016. This trend is likely to continue due to aging populations. Growing evidence demonstrates that social determinants of health, such as housing and education, are at least as important as medical services in generating health outcomes. At the same time, health financing is shifting from paying for services to directing spending based on how well it improves outcomes. Finally, a commitment to universal health coverage (UHC) — individuals and communities receiving the health services they need without suffering financial hardship — has gained momentum, with all United Nations member states pursuing UHC by 2030 as part of the Sustainable Development Goals.
Principles of the World These common evolutionary pressures shape system design choices in the United States and around the world. Commonalities in problems encountered suggest that solutions — or at least principles underlying those solutions — may also be generalizable. I have contributed to the development of a population health strategy at NYC Health + Hospitals, the largest public healthcare system in the United States. Population health is defined as a more proactive approach to addressing human suffering that can be avoided. Four principles undergird the strategy: identifying and stratifying an attributed population (i.e., the population they’re responsible for); grounding in high-quality, community-based care; meeting patients where they are, both physically and in terms of their health trajectory; and using data to guide care delivery and drive improvement. One or more of these principles are already being implemented by local health systems in many instances, but rarely are all four of them. Information Center Innovating in Health Care
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The patient group that local health systems are responsible for must first be identified. Although this process of assigning patients to clinicians—for example, through “accountable care organizations” in the United States—may appear to be uncomplicated or uninteresting, it is essential for establishing care models that are not solely dependent on patient visits. For instance, what is the appropriate place of accountability for patients who only seek acute care, such as the emergency room, or who do not seek necessary care at all, whether due to discrimination, inability to pay, or lack of health literacy? Once an attributed population is identified, health systems should stratify patients into groups based on risk of adverse outcomes. In the same way we triage hospitalized patients into intensive care, step-down units, and general wards, health systems should risk-stratify attributed patients to ensure that resources are appropriately directed to patients according to need. For instance, as part of a general move toward regionally integrated care in the United Kingdom, a clinical alliance in Nottinghamshire uses predictive modeling to identify patients at elevated risk for hospitalization and provides them with preventative care, such as “virtual wards” providing multidisciplinary, intensive outpatient services.
Second, high-quality community-based care is becoming an increasingly important component of efficient health systems. Of the 218 essential, cost-effective interventions identified by the Disease Control Priorities Network, 140 are delivered through primary care centers or community- and population-based approaches, rather than through hospitals. In Xiamen, a city in southeastern China, the growing prevalence of chronic diseases led to a new model for primary care known as Joint Management by Three Professionals: specialists who determine care pathways, generalists who implement them, and community health workers responsible for health education, including through home visits. Community health worker programs are particularly emblematic of convergent evolution, having arisen in diverse contexts, including as primary care extenders in India and sub-Saharan Africa; community members of family health teams in Brazil and Costa Rica; promotores de salud (health promoters) at the Mexican border; and as a standardized intervention to reduce hospitalizations for low-income patients in the United States.
Third, and in part due to the evolution toward community-based care, health systems around the world are starting to “meet patients where they are,” both physically and in terms of their health trajectory. Technology — particularly telehealth such as text-messaging and phone or video consultations —enables the delivery of care remotely. For example, mobile technology supports thousands of community health workers delivering perinatal care across rural Liberia, facilitating escalation of childbirth care to the nearest health facility when indicated. Integrating social and behavioral health services with physical health services is also referred to as “meeting patients where they are.” Depressive disorders are frequently overlooked by health systems despite the fact that they cause more disability than any other type of cancer worldwide. In the meantime, health systems are collaborating with social service organizations to address the underlying causes of illness because it is becoming increasingly clear that social factors like educational attainment frequently dominate in determining health trajectories. In Quebec, Canada, such partnership is facilitated by a whole-of-government approach to health, enshrined in a Government Policy of Prevention in Health, with specific targets such as reducing by 10% the gap in premature mortality between the lowest and highest socioeconomic groups in the province.