Let's get more population health out of health systems
Authors: Margaret E Kruk
Journal: The Lancet Public Health (2017)

Are health systems a determinant of population health? The dominant epidemiological frameworks for the causation of population health—the multilevel, life course, and dynamic or complex systems approaches—invoke a broad range of drivers of population health, from genes to public policy to education to exercise, but neglect to mention medical care.1Keyes KM Galea S Population health science. Oxford University Press, Oxford; New York2016Crossref Google Scholar Why are health systems missing from the academic discourse about determinants of population health? Perhaps because epidemiologists consider medical care to reflect a failure of public health: after all, if we all consumed the right diet, wore helmets, and maintained a robust social network, we could theoretically avert much of what ails us. Or maybe clinicians and health systems researchers seem more concerned with patients and hospitals than populations. The separation between health systems and population health is a conceptual artifact that diminishes the benefits that society can reap from its investment in health care. For one, it is clear that evidence-based health care can avert mortality and extend life expectancy at the population level as well as improve people's quality of life. Take coronary heart disease mortality for example, which declined by 34% in the USA in the 1980's—although healthier lifestyles played an important role, more and better health care for patients with coronary disease was estimated to be responsible for 70% of the fall. This care ranged from primary care management of hypertension to highly specialised procedures, such as coronary artery stenting and intensive care.2Hunink MG Goldman L Tosteson AN et al.The recent decline in mortality from coronary heart disease, 1980–1990. The effect of secular trends in risk factors and treatment.JAMA. 1997; 277: 535-542Crossref PubMed Google Scholar Health systems are also social institutions that influence populations' confidence in their governments and societies.3Rockers PC Kruk ME Laugesen MJ Perceptions of the health system and public trust in government in low- and middle-income countries: evidence from the World Health Surveys.J Health Polit Policy Law. 2012; 37: 405-437Crossref PubMed Scopus (42) Google Scholar In most countries where government is the largest payer or provider of health care, access to and quality of health services are seen as top priorities for governments and a litmus test for government performance. Even in the USA, where private insurance finances the majority of health care, failures in government-funded Veterans' Administration health care routinely make national news. Trust in government and government institutions in turn leads to better acceptance of health advice from authorities for pro-health behaviors, such as immunisation or screening.4Whetten K Leserman J Whetten R et al.Exploring lack of trust in care providers and the government as a barrier to health service use.Am J Public Health. 2006; 96: 716-721Crossref PubMed Scopus (207) Google Scholar Generalised trust, or social capital, has been shown to directly influence health behaviors and health status in different settings.5Bender AM Kawachi I Jorgensen T Pisinger C Neighborhood social capital is associated with participation in health checks of a general population: a multilevel analysis of a population-based lifestyle intervention—the Inter99 study.BMC Public Health. 2015; 15: 694Crossref PubMed Scopus (18) Google Scholar But health systems can do much more for population health. First, despite the triumphs of medical care, a good deal of care is not linked to better health and some is simply harmful. These shortfalls, reasonably enough, generate skepticism in the public health community. Achievement of better outcomes means targeting more judicious use of our medical arsenal for people who need it and avoiding overcare for those who do not. Unfortunately, few robust strategies currently exist for reigning in the overuse of tests or low-value treatments.6Rosenberg A Agiro A Gottlieb M et al.Early Trends Among Seven Recommendations From the Choosing Wisely Campaign.JAMA Intern Med. 2015; 175: 1913-1920Crossref PubMed Scopus (7) Google Scholar Second, in low-income countries, the problem is the opposite: too little care or, as is becoming apparent, poor quality care. Although facilities are multiplying and more health professionals are being trained, health systems are seemingly underproducing health. For example, because most childbirth complications occur without warning and require expert medical treatment, women have long been urged to deliver in facilities. Yet, in India, the health benefits have been elusive for the millions of families who have made this decision: neither maternal nor newborn mortality have declined.7Powell-Jackson T Mazumdar S Mills A Financial incentives in health: new evidence from India's Janani Suraksha Yojana.J Health Econ. 2015; 43: 154-169Crossref PubMed Scopus (115) Google Scholar The intense focus on expansion of health service coverage in the past two decades has diverted attention from the quality of those services.8Kruk ME Larson E Twum-Danso NA Time for a quality revolution in global health.Lancet Glob Health. 2016; 4: e594-e596Summary Full Text Full Text PDF PubMed Scopus (70) Google Scholar Third, health systems need to be more responsive to people's expectations of good customer service when they use health care. Whereas every other service domain is becoming more attuned and responsive to user feedback, health systems too often fail to hear or value their users' preferences, which results in inconvenient hours, inflexible rules, unpleasant administrators or, in extreme cases, disrespectful or even abusive treatment.9Bohren MA Vogel JP Hunter EC et al.The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review.PLoS Med. 2015; 12: e1001847Crossref PubMed Scopus (660) Google Scholar This type of experience dissuades people from coming back or adhering to care, thereby diminishing the health system's ability to improve health. Finally, health systems need to speak the language of population health. Efficiency and cost control might be relevant to hospital managers, but they are not the ultimate aims of health care. Health system performance should be assessed based on results that matter to people and communities rather than just clinicians. A small change in 5 year survival might be less relevant to people with heart disease than is the ability to breathe freely or take a walk without chest pain. Maintaining healthy communities also means taking on greater accountability for defined populations rather than just the sick. Community-health system links are well developed in countries such as the UK and Brazil, but will require substantial system reorientation in others, including the USA.10D'Aunno T Broffman L Sparer M Kumar SR Factors that distinguish high-performing accountable care organizations in the Medicare Shared Savings Program.Health Serv Res. 2016; (published online Dec 26.)DOI:10.1111/1475-6773.12642Google Scholar It is past time for closer conceptual, research, and practice linkages between health systems and population health. The fields have much to offer each other in pursuit of a common goal: better health for all. I declare no competing interests. I thank Sandro Galea for discussions about current directions in population health science.