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Panteli D, Mauer N, Winkelmann Jet al., authors; Lessof S, Azzopardi Muscat N, Permanand G, et al., editors. Transforming health service delivery: What can policy-makers do to drive change? [Internet] Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2023. (Policy Brief, No. 58.)
Transforming health service delivery: What can policy-makers do to drive change? [Internet]
Show details1. Introduction
Why is health service delivery transformation essential?
Policy-makers are continuously faced with the need to ensure that health service delivery evolves to match population health needs in line with changing disease and demographic patterns; and to do so against the backdrop of health system challenges (such as workforce constraints and rising health care costs) as well as contextual factors (such as economic downturn, armed conflict or the ramifications of climate change). The health service delivery disruptions caused by the COVID-19 pandemic have caused considerable backlogs with which many countries continue to grapple (Arseneault et al., 2022; van Ginneken et al., 2022).
The population in the WHO European Region is ageing rapidly, with the proportion of people aged 65 and over projected to make up one quarter of the population by 2050 (WHO, 2022a), which corresponds to a much steeper increase in this age group compared to previous years (Figure 1). This trend is accompanied by changes in disease patterns and health care needs. Non-communicable diseases are on the rise and a larger share of the global disease burden is caused by disability rather than premature mortality (IHME, 2019). These shifts underscore the growing need for chronic disease management and long-term care, and rethinking the way care is delivered to better meet people’s expectations and contribute to wellbeing for all.
Figure 1
Share of older people and health expenditure across the WHO European Region. Sources: WHO, 2023a (% of people above 65); WHO Regional Office for Europe, 2023c (total health expenditure as % of GDP).
At the same time, health expenditure in the WHO European Region is increasing, largely due to rising costs linked to technological progress and an overall greater demand for health care (Figure 1). In 2020, countries in the WHO European Region spent an average of 8.5% of their gross domestic product (GDP) on health. For many countries, this represented the culmination of progressive increases in health spending in the past decade, while GDP as a whole fell as a result of the COVID-19 pandemic (Eurostat, 2023). Many countries are experiencing critical workforce shortages, a trend that is expected to lead to a global gap of 10 million health and care workers by 2030 (WHO, 2023b).
In an interconnected and globalized world, pandemic events, war, economic decline and climate change further intensify the pressures that are already placed on health systems and health care delivery (van Daalen et al., 2022). Combined with the increasing and evolving need for delivering services and the sustainability challenges described above, these problems drive home the need for transforming health service delivery so that it makes the best use of available resources while maximizing outcomes and remaining resilient. Care models adopted in the past are no longer fit to meet the health care needs and expectations of today. This calls for a transition from health systems that have long been reliant on reactive hospital and acute care to those that can anticipate and manage the needs of an older demographic and ensure continuity of care for patients affected by multiple and chronic conditions, starting at the community and primary care level (Carroll, Stokes & Darley, 2021). At the same time, new technologies are becoming increasingly available that may facilitate such a shift to more integrated and person-centred health systems able to provide both preventive and curative care, while also overcoming the issues of fragmented services and empowering patients to participate in clinical processes (van Ginneken et al., forthcoming).
What does service delivery transformation actually entail?
The changes described above are in line with calls for health system transformation that had begun long before the COVID-19 pandemic (Halfon et al., 2014). In 2015, the WHO Regional Office for Europe initiated a Health System Transformation project that has delivered important insights about the crucial factors that can contribute to large-scale change in health systems (Hunter & Bengoa, 2023), wherein transformation entails interventions that affect multiple stakeholders and aim at improving population health outcomes by positively impacting on the quality of patient care and the efficiency of health care delivery (Best et al., 2012). A prerequisite for such transformation is the wide adoption of effective solutions.
For the 2018 Tallinn Conference, the European Observatory on Health Systems and Policies published a policy brief looking at the key strategies for ensuring that innovation in service delivery is implemented, sustained and spread (Nolte, 2018). Already at that point, the realization was clear that promising examples of innovative changes in service delivery often fail to be adopted more widely and instead remain time-limited pilots or localized projects. Not much has changed since then in that respect, although the COVID-19 pandemic delivered a sobering reality check about both the need to change and the potential scope for rapidly implementing new ways of delivering care when there is a pressing need to do so. However, there is a real risk that learnings from the pandemic are not harnessed and practice returns to the status quo ante (Fahy et al., 2021). It is therefore timely to consider how innovative ideas can be leveraged to enable service delivery transformation in a manner that enables access to good quality health care for all.
Successfully changing health service delivery for the better requires understanding how and which problems emerge, identifying solutions that are effective, affordable and equitable, potentially testing and implementing these solutions, and monitoring their implementation to calibrate support and identify areas for further adaptation. To drive the widespread transformation of service delivery, policy-makers need to be able to recognize and seize windows of opportunity, and understand how to harness and sustain political will to support the implementation of intended changes, which takes place at the local level, and to provide grassroots support for these processes. They need to provide leadership, both in terms of the aims to be achieved and attaining shared commitment around those aims, as well as fostering a culture that is open to embracing change. They also need to ensure sufficient resources (financial, human, technological and evidentiary) for transformation and engage relevant stakeholders to (co)-develop and sustainably implement effective solutions. This includes enabling and harnessing innovative approaches that come from the context of service delivery itself, i.e. embracing the need for a combination of top-down and bottom-up initiatives.
Transforming complex systems: striking a balance between top-down and bottom-up approaches
Health systems are dynamic, complex systems: they encompass a multitude of actors with different and evolving interests and varying, interconnected networks. Because of their complexity, the way actors within the system will react to change is not always easy to predict, and the behaviour of the system as a whole is often non-linear and disorderly (Carroll, Stokes & Darley, 2021). Implementing even relatively simple changes in health service delivery can be challenging because of the complexity of context, for instance if the envisioned change challenges established norms and/or the financial or reputational interests of health professionals; what is more, the changes needed to transform service delivery are often complex in themselves.
For policy-makers aiming to drive forward the transformation of health service delivery, this is the first fundamental realization: complex systems are resistant to rigid, top-down changes. In what seems like a catch-22, the system must change from within, but large-scale implementation is vital for its overall transformation. The role of policy, therefore, is primarily that of creating the right conditions in which transformation will flourish; these can be shaped by, but are not limited to, regulatory changes. This means setting the right direction; clearing the way, by making system-level factors as supportive as possible and removing obstacles; and providing the resources and support to facilitate service-level change and manage adaptation.
Aim, target audience and structure of this brief
Other policy briefs in this series for the 2023 Tallinn Health Systems Conference focus on: how policy-makers can build trust by harnessing stakeholder involvement (McKee, Greenley & Permanand, 2024); how to diagnose the main areas in service delivery where change might be necessary (Karanikolos et al., 2024, Rajan et al., 2024); and how to secure and deploy financial resources for service delivery transformation (Forman, Permanand & Cylus, 2024). This brief brings these dimensions together and puts them in context with the other ingredients policy-makers must have in their arsenal to successfully catalyse health service delivery transformation.
The target audience for this brief are policy-makers who determine how service delivery is organized; depending on the health system, this may include decision-makers at the national, regional and/or local levels. This brief is not primarily addressed to decision-makers at the organizational or service levels (i.e. those responsible for the operational side of service delivery). However, evidence from major service delivery reconfigurations shows that a combination of system (top-down) and distributed (bottom-up) leadership is important in enabling change (Turner et al., 2016); this brief therefore also reflects on how system-level policy-makers can foster and support leadership at other levels (see Figure 2).
Figure 2
Leadership for health service delivery transformation and focus of this brief (red box). Source: Authors’ compilation based on West, Armit & Loewenthal, 2015; Figueroa et al., 2019; AdventHealth University, 2020; Sims et al, 2021).
The structure of the brief rests on the fundamental perspective that because health systems are complex systems, bringing about change depends on the beliefs, motivations and actions of a wide range of actors across all levels within the system. These actors form their own judgements and make their own decisions, which means that how change unfolds within the system is not directly within the control of policy-makers, whether at the local, national or international levels. Consequently, the aim of policy should not be to control change directly but rather to support implementation by improving the system’s capacity to change.
This policy brief therefore looks at the following ways in which policy-makers can act to drive the transformation of health service delivery:
- First, providing leadership at the system level: this entails offering clear direction around the intended change, engaging stakeholders to create a collective commitment to transformation and adapting the regulatory framework accordingly if needed (Section 2).
- Second, ensuring that sufficient resources are available to make transformation possible (Section 3); this encompasses financial, human, technological and evidentiary resources, and combines both:
- ◦
enablers at the system level; and
- ◦
support to organizations and people within the system (at the service delivery level) to take their own actions to implement changes in their daily work and practice, i.e. to drive transformation at the local level.
Actions in all these areas are necessary to successfully transform health service delivery. After examining each area separately, the brief highlights policy implications across the spectrum and revisits how different actions fit together (Section 4) to better illustrate options for policy-makers, specific examples presented in boxes throughout the brief map onto priority areas, such as digitalization, workforce strategies, care integration and the greening of health care to provide tangible insights of what it takes to implement service delivery transformations in practice. Blue boxes highlight important elements in the transformation process, while green boxes zoom in on case studies from specific settings.
It is important to note that the brief focuses on the transformation of service delivery rather than that of health systems as a whole. It does not attempt to prescribe which actions or policies are necessary for transformation, as it assumes different health systems will need to focus on different areas to address their specific transformation needs; the focus is rather on the transformation process.
2. Leadership and governance for transformation
Providing leadership for change at the system level entails setting out a clear vision and a compelling case of what change is needed, and generating the necessary understanding and motivation by the actors within the system to act to bring about that change. That motivation typically depends on acceptance that there is a problem with the current situation, acceptance of the vision for the desired future, and recognition of the proposed solutions to that problem (in particular, their relative advantage over the current situation and feasibility to put into practice). For transformation to succeed, substantial buy-in from stakeholders is required; stakeholder involvement along the phases of the process of change is key for achieving this, including at system level in the policy formulation stage, and at service level as part of implementation. Understanding the power dynamics among these stakeholders is, in turn, crucial for organizing this effectively and for generating and sustaining the necessary will to drive transformation forward (see Box 1). The following paragraphs discuss these issues in detail; because of the pivotal role of stakeholder engagement, it is discussed where appropriate; approaches to stakeholder engagement to forge collective commitment for transformation are subsequently presented in more detail.
Box 1
The political economy of health service delivery transformation.
Leadership: forging a clear vision for change
To develop a clear vision for transformation, policy-makers need to identify and prioritize the challenges to be addressed, and then set a strategic direction on how they will be addressed.
Identifying targets for transformation
While health systems pursue similar goals, they display different gaps and unmet needs on the way to achieving them, and transformation needs will therefore vary. There are different instruments that enable health policy-makers to monitor how well their health systems function, how population health trends evolve, and how these measures intersect and are impacted by the implementation of policies and interventions. These can include formalized national or regional HSPA programmes, regular or ad hoc national surveys, supranational initiatives for data collection (such as by the EU, WHO or Global Burden of Disease study) and stakeholder consultation processes (see Box 2). Unfavourable changes over time, a disadvantaged position compared to international peers or jointly set targets can provide impetus for action.
Box 2
Identifying targets for transformation – where can information come from?
Box 3
Case study – The ‘Needs Examination, Evaluation and Dissemination (NEED)’ project.
Identifying possible solutions
Beyond a comprehensive picture of a population’s health status and disease burden, health systems require reliable information on effective solutions that have the potential to be widely implemented to address existing gaps in service delivery. A number of different approaches can be leveraged to achieve this, including horizon scanning initiatives, dedicating funding streams to the development and piloting of innovations at the country level and as part of supranational collaborative efforts, as well as co-creation platforms that actively engage stakeholders (see Box 4).
Box 4
Identifying possible solutions towards building a strategy for change.
Building structures that enable stakeholders from within the system to propose and shape ideas for changing health service delivery is an important component in the process of health service delivery transformation. A ‘co-creation’ approach can help to improve the technical content of potential changes, as well as promote their acceptability (see also McKee, Greenley & Permanand, 2024). An example from Austria, where young physicians were invited to provide insights to shape how the new primary care delivery model would be set up together with policy-makers, showcases how such approaches can be put into practice. More formalized participatory approaches to leveraging and building stakeholder capacity for understanding and addressing health system challenges, such as group model building (GMB), may require support from methodological experts in the academic setting but can provide a solid basis for policy and its communication. An example from Singapore showcased the usefulness of such methods for understanding the complexity of chronic disease care and providing policy recommendations (Ansah et al., 2018). Policy-makers can also motivate organizations at the service delivery level to institutionalize programmes, such as innovation contests that actively incentivize clinicians to development and/or adapt ideas for change based on their daily practice (Jung et al., 2022, 2023), and to ensure that these ideas are fed back centrally to assist with strategy building. In particular for the development of digital health solutions, the participatory model of ‘living labs’ is increasingly leveraged to ensure meaningful patient involvement from the early stages of innovation (see Box 5).
Box 5
Case study – Living labs for the co-development of digital health solutions.
A key component of all these options is ensuring that identified solutions are beneficial for patients and the system as a whole (or come with a positive, evidence-based ‘value proposition’; see Nolte, 2018). This is not only fundamentally in line with health system goals but also a prerequisite for creating collective commitment to change. In many countries, HTA programmes aim to summarize all relevant, high-quality evidence on the comparative benefit of different interventions across a number of domains (including patient health outcomes, costs, ethical and organizational implications) (Kristensen, Nielsen & Panteli, 2019). Here too, involving stakeholders (and in particular, patients and citizens) is crucial to ensuring that the evidence and its analysis are aligned with the goal of improving health and wellbeing, and that potential solutions are adapted to the context of the setting in which they are to be introduced.
Governance: adapting and aligning mechanisms to facilitate change
To successfully drive transformation, policy-makers must engage and align other relevant stakeholders around a shared understanding of the underlying need, the desired outcome and what change is necessary to achieve it (see also next paragraph). By deciding what entities are involved in the change process, what their relationships are, what processes must be followed in making and implementing decisions, how accountability is ensured and the potential consequences of non-adoption, policy-makers provide the setting for all the activities of transformation within the health system as a whole (Greer et al., 2019).
Developing or adapting the necessary governance framework to support transformation requires a good understanding of the political economy of service delivery (see Box 1), as changes inevitably challenge established norms and interests within the system and create resistance and delays. Furthermore, relevant mechanisms, such as payment models, must be aligned and geared towards supporting transformation as much as possible. For example, if seeking to increase care integration, it is essential to align system-level mechanisms such as budgets, payment mechanisms and accountability in a similarly integrated way for the change to be successful (Struckmann et al., 2016).
Regulation is one of the key governance tools to achieve this, be it in the form of formal legislation or other types of mandatory requirement. Depending on the changes involved in the transformation process, different regulatory elements will need to be adapted. For instance, if the goal is to transform delivery towards more patient-centred care leveraging digital health solutions, mechanisms for data governance and the licensing and evaluation of digital health applications might need to be introduced or adapted (see Fahy et al., 2021; WHO Regional Office for Europe, 2023a); these changes might need to be accompanied by changes to the standards around which services can be delivered (and financed) in the outpatient versus the inpatient setting as well as changes to the scope of practice of the clinicians involved; new regulation might need to be introduced to facilitate new components that have not previously been part of service delivery, such as the introduction of e-prescriptions.
Professional standards are a powerful tool in shaping what happens during the provision of services along with clinical practice guidelines (see also Section 3). Enabling health professions to set or shape their own standards and expectations about how professionals should carry out their work is key for health service delivery transformation. Experiences from the United States in using a concept mapping approach for stakeholder engagement in this area have shown that it allows policy-makers to streamline improvements (Newlon et al., 2023). Indeed, active stakeholder engagement to ensure a consistent regulatory landscape is crucial, because these different sources of regulation open up the possibility of inconsistency and tension between the requirements of government policy-makers and the health professions themselves.
Building collective commitment for transformation: stakeholder engagement
Previous paragraphs have highlighted the key role of stakeholder involvement for the identification of health system needs and the possible solutions to address them. Indeed, generating and retaining motivation for transformation is closely linked to engagement; the more relevant stakeholders in the system are engaged in both understanding and defining the problems that exist, and in shaping the solutions to address them, the more likely they are to be committed to making the necessary changes (Horton, Illingworth & Warburton, 2018). Consequently, leaders must ensure that stakeholder engagement permeates the different stages of transformation, from participatory approaches to identify needs, to the co-design of system-level mechanisms and their implementation. A system-level strategy for engagement that incorporates all these components is advisable to increase the chances of success for transformative change; early engagement with relevant stakeholders can preempt future problems and challenges faced during implementation. Pathways to engage stakeholders can differ depending on the purpose, availability of resources, time and actors to be involved (see Box 6) and the extent and configuration must be chosen carefully (Stewart, 2013; Greer et al., 2021).
Box 6
Stakeholder engagement: purpose and key modalities.
Stakeholder analysis: understanding who to engage (and how)
A prerequisite for successful stakeholder engagement is an analysis of all relevant stakeholders, including both the identification of the groups involved and the benefits and costs of intended changes (the likely stakes) for each of them. Their estimated positions, along with their level of power, expected interest in the intended change and potential avenues for engagement are key to consider. Several tools have been developed to facilitate stakeholder mapping and analysis in the delivery of health services (see, for instance, Judice et al., 2013; Reich et al., 2023). Figure 3 shows an example on reproductive health from the WHO.
Figure 3
Stakeholder mapping for family planning services. Source: WHO, undated.
Approaches such as force field analysis can help with the visualization of these insights and, subsequently, with the formulation of strategies to engage with stakeholders towards serving the purpose of the intended change (see Figure 4). Strategies to achieve this typically aim to influence four strategic levers, often labelled in political analysis as the four ‘Ps’ (Reich, 2002; Roberts, 2003): 1) recruiting new players into or dissuading existing players from participating in the policy process; 2) increasing or decreasing the power and resources of players in the system (e.g. by allocating money, staff, facilities to supporters of a change); 3) exerting influence to change the position of players in the system (e.g. through deals, promises or threats); and 4) steering public perception of a problem and possible solutions, for example through policy advocates.
Figure 4
Example of force field analysis for a plan to improve shift change processes. Source: Barrow, Annamaraju & Toney-Butler, 2023.
Coalition building and the engagement of popular thought leaders who are sympathetic to the envisioned transformation agenda can be fundamental to generating political will, as politicians are motivated to influence public opinion in their favour (Cairney, 2019; Weintraub & McKee, 2019; Baum et al., 2020). This can entail working with civil society organizations, professionals’ associations, researchers and knowledge-brokers. McKee and colleagues offer a detailed analysis about how engaging with people within the health system can advance trust and transformation (McKee, et al., 2024).
Sustaining political will for transformation is essential and hinges on stakeholder support
The sustained existence of political will is a critical contributor to the success of transformation efforts, given their scope and duration. Indeed, transforming the delivery of health services is a process that does not happen overnight but requires sustained political commitment to negotiate, create, monitor and adapt the relevant policy measures that enable it. For service-level change, sustained effort is likely to be needed for a year or more to ‘hold’ the change before it starts to become business as usual (Brewster et al., 2015). Multiplied by different sites of service change across the system, this means that sustained leadership for several years is a key component, which further underlines the importance of continuously fostering commitment around the intended change: coalitions supporting the transformation agenda are likely to persist over time, while political leadership may change more quickly.
To anchor a transformation agenda onto the political agenda, sustained leadership at the policy level, combining technical evidence and a clear narrative of what change is needed, and why, is crucial (see an example from Austria in Box 7). Technical evidence of benefits, harms and costs, or the precise changes envisioned, as well as implementation considerations (such as acceptability, feasibility and equity) is essential in the technical field of health. However, a clear story about the need, value of and possibility for change that both professional and lay audiences can understand is equally important. An example of how system-level leadership can successfully engage stakeholders to ensure the success of a transformation process is the establishment of an interagency taskforce to propel sustainable change in primary health care in Uzbekistan (WHO Regional Office for Europe, 2023b). Box 8 summarizes lessons learned from this initiative supported by the WHO Regional Office for Europe.
Box 7
Case study – Political will and technical expertise for greening the health sector in Austria.
Box 8
Case study – Interagency taskforce to ensure strong leadership throughout health service transformation in Uzbekistan.
Building capacities for stakeholder engagement at the system and service levels is crucial for transformation to succeed
The simplified description of stakeholder analysis provided in this section might suggest that mapping stakeholders and developing strategies to engage and manage them is easy to implement; however, this requires technical skills in policy analysis that are frequently not available at health ministries or other health authorities, who might be more focused on recruiting staff that can provide technical solutions (Reich, 2002). Therefore, this is one of the necessary elements of capacity building towards service delivery transformation in which health policy-makers should invest.
Stakeholder engagement is crucial not only at the system level, but also for the implementation of transformative changes on the ground at the local level. Engagement processes at the service level follow similar principles to those described above but are by definition closer to service users and may therefore leverage different modalities, such as more face-to-face formats like neighbourhood committee meetings (see an example from the United Kingdom in Box 9). Both methodological guidance and financial support from the system level can help implementers at the service level introduce and manage these processes.
Box 9
Case study – Stakeholder engagement at the local level: the Public Partnership Forum of the Hillingdon Hospital in the United Kingdom.
3. Ensuring sufficient resources for transformation
The previous sections have illustrated how policy-makers can provide direction for transformation and shape governance mechanisms to introduce or enable the implementation of changes. To operationalize transformation efforts in line with their strategic vision, they also need to ensure that service delivery is sufficiently and appropriately resourced. This does not only entail providing the necessary funds, staffing mix and technologies at the system level for new care pathways to be delivered; an additional dimension for possible policy action – one that frequently gets less attention than it should – is the creation of space within the system for those implementing changes on the ground to successfully drive transformation at the local level. Service-level change must reconcile the general ambitions of the policy change with the context-specific character of local problems, stakeholders, options and processes. What is more, service-level actors are typically focused on exactly that, service delivery, and change processes are not part of their core skills – therefore, support is needed not only for the content of the desired changes (e.g. resources for a different care pathway), but also for those processes of change themselves (e.g. training and time for managing change). The following sections highlight key considerations around the necessary resources for transformation, taking possible policy-maker actions that enable implementers at the service level into account.
Money: securing and distributing funding for transformation
Because the transformation of service delivery is a process that takes time, it requires commitment to sustained financial resources. In the aftermath of the COVID-19 pandemic, some believe that an unsustainable amount of funds was spent on health in recent years. This may be true in absolute terms with regard to health expenditure, but this funding was not necessarily invested in ways that strengthen health service delivery as a whole (Sagan et al., 2021). Therefore, the current juncture may provide additional challenges for policy-makers in securing sufficient funding for health in general and the transformation of service delivery in particular.
Securing the funds for transformation: what resources do policy-makers have?
In a separate brief for this series, Forman, Permanand & Cylus (2024) identify five key cross-cutting lines of argumentation for additional funding for health, which satisfy public financial management objectives and are therefore more likely to be successful (see Figure 5). Depending on tradition and the health system set-up, different options might be more or less appropriate. Making the business case for the proposed changes requires information, which mechanisms described earlier in the brief can provide (such as HTA or testing in the context of dedicated innovation testing). The necessary financial support for ensuring health systems are resourced appropriately to enable change and improvement usually comes from within the health systems themselves. However, in the European context, the EU also provides different types of support that can help with service delivery transformation (see Fahy, Mauer & Panteli, 2021 and an example from Estonia in Box 10).
Box 10
Case study – Driving the implementation of personalized medicine in Estonia.
Figure 5
Making the case for investment in service delivery transformation. Source: Forman, Permanand & Cylus, 2024.
Unless substantial additional funding has been made available, allocating available funds to the changes required for transformation can be challenging, as it usually entails taking funds away from elsewhere in the system. Policy-makers can be supported in such efforts by collaborative governance and the collective commitment to transformation achieved through stakeholder involvement and the availability of robust evidence on benefit. Given that transformation efforts take time, this should also be reflected in the duration of financing contracts to enhance predictability and motivate change.
Payment mechanisms: how can resource allocation support transformation efforts?
Resource allocation can help to steer transformation, in particular by seeking to encourage certain actions through payment mechanisms. Traditional payment mechanisms for service delivery, such as fee for service, capitation or programme budgets, may not be conducive to change, especially towards more integrated models of care. Taking a shift towards integrated care for multimorbid patients as an example, van Ginneken et al. (forthcoming) argue that payment models that cover a large patient group (eventually all patients in a catchment area), encompass care delivery by multiple sectors (primary, secondary, social care) and include a long-term view are presumed to incentivize integration, as are models that feature pooled budgets, shared savings/loss agreements, and some way of tracking and rewarding quality. However, evidence on newer payment models, such as pay-for-performance schemes and bundled payments, is still evolving. Ideally, payment models would be tailored depending on the specifics of the transformation effort and the context of implementation.
Finally, factoring in the costs of service-level transformation processes when deciding on the financing of service providers is an important facilitator of transformation. Securing investment for transformation and leveraging payment mechanisms to drive change are important policy actions at the system level; however, it is important to recognize that: a) the necessary managerial processes within service delivery organizations and stakeholder engagement processes in the local context (both fundamental for transformation success across settings) entail substantial costs; b) insufficient resources for transformation may carry substantial opportunity costs (such as the erosion of an organization’s other functions while the focus is on change management); and c) fear or uncertainty about the costs of implementing change might discourage service-level actors from going ahead. Offsetting these costs when reimbursing providers is an important dimension of support.
People: planning for transformation and empowering health professionals
Obviously, money is not the only key resource for service delivery transformation. Having sufficient health professionals with the right skills and sufficient capacity is also a vital resource and one that cannot be changed as quickly, given the long time it takes to train skilled health professionals. Strategic, multiprofessional and intersectoral workforce planning that takes into account any necessary skill-mix changes included in the transformation plans is the foundation for securing the necessary workforce. This should also entail a link with the educational system and updating relevant curricula (Kreutzberg et al., 2019; Maier et al., 2022). Arguably, strengthening the health workforce as a whole is a foundational prerequisite for enabling health service delivery transformation; in 2022, the WHO Regional Office for Europe took stock of the situation of health professionals across the Region and came up with ten key actions for policy-makers that can support this goal (Box 11).
Box 11
Ten actions to strengthen the health workforce in the WHO European Region.
Leadership development for service delivery transformation: supporting organizational and clinical leaders to drive transformation
Beyond workforce planning at the macro level, ensuring that professionals at the organizational level can successfully adapt and implement the necessary changes towards achieving transformation goals within their local context is of crucial importance for the sustained implementation of transformative change. This entails both support for the development of organizational level leadership and empowering the workforce, inter alia by providing options for tailored skills development. It also means allowing for time within professionals’ working hours to consider, embrace and tailor the practice changes necessary for transformation. In addition to enabling the operational side of change, giving professionals the time and power to engage with implementation can foster their motivation to contribute to the transformation effort.
Leaders at the service delivery level are important for setting specific goals within the transformation process, identifying and promoting new priorities, directing multiple stakeholders towards these priorities, and aligning systems and stakeholders at the local level (Gilburt, 2016; Boguslavsky Gutierrez & Holschneider, 2019). This requires strong individuals who promote and implement change across the health sector and who possess certain leadership skills (such as systems thinking) to keep an eye on the larger picture and balance short-terms risks with long-term rewards (see also Figure 2 in Section 1). An effective tool for strengthening leadership at all levels is leadership programmes, which can be introduced or supported by system-level policy-makers. Such programmes often aim to build an understanding of how change can happen in complex systems and to develop skills around electing, aligning and orchestrating the various elements of change processes; they can target organizational leaders or clinical leaders, such as physicians and nurses (Frich et al., 2014; West, Armit & Loewenthal, 2015; Ferguson et al., 2016; Heinen et al., 2019; Lyons et al., 2020; Bard et al., 2022). They have been shown to improve organizational performance and, ultimately, patient outcomes (Geerts, Goodall & Agius, 2020; Debets et al., 2023).
Ensuring that the workforce is empowered and has the necessary skills and time to implement change
One of the key qualities of leaders at the organizational level, which must be nurtured for transformation to succeed, is their ability to empower frontline staff delivering services (Boguslavsky, Gutierrez & Holschneider, 2019; Debets et al., 2023). This necessitates targeting both structural and psychological empowerment, and ensuring that clinicians have the necessary agency and autonomy to interact with and implement change in their daily practice (Boamah, 2018; Andersson, Eriksson & Müllern, 2022; Bard et al., 2022; Fragkos, Makrykosta & Frangos, 2022; Gottlieb, Gottlieb & Bitzas, 2022). Transformational leadership principles can contribute to this goal (West, Armit & Loewenthal, 2015). Along with ensuring that leadership development programmes take these components into account, policy-makers can advocate for multidisciplinary options that bring different professions together (Frich & Spehar, 2018). What is more, they can ensure that skills development options for frontline staff are available and in line with contributing to implementing change.
Indeed, skills development programmes that entail on-the-job training are often implemented at the organizational level; however, policy-makers can support such initiatives by motivating and engaging system-level actors, such as professional councils and associations, to provide standards for content and format. This requires cross-sectoral collaboration between regulators from the education and health sectors; for instance, competency-based training of health professionals benefits from collaborations between regulatory bodies and health education and training institutions (Cometto, Buchan & Dussault, 2020). There are promising initiatives in continuing professional development (CPD), interprofessional education (IPE) and competency-based education to respond to the changing skill needs and competencies in service delivery (see Box 12) (Batenburg & Kroezen, 2022; Maier et al., 2022). The content of such programmes will differ in line with the transformation agenda, but based on current trends, is likely to include working in multidisciplinary teams, realizing patient-centred care and leveraging the potential of digital health solutions (van Ginneken et al., forthcoming). For instance, an ongoing project funded by the EU, BeWell, aims to promote the upskilling and reskilling of the European health workforce by developing a green and digital skills strategy for the health ecosystem that can be implemented at a local, regional, national and, ultimately, the European level.
Box 12
Continuing professional development, interprofessional education and competency-based education.
Time is perhaps the factor most neglected when it comes to supporting the workforce in implementing service delivery transformation on the ground. Both managers and frontline clinicians need time in their everyday work for adapting to changes, both in the practical sense (e.g. because of the need to adhere to new procedural protocols or learn how to navigate a new digital health system) and in terms of headspace to figure out how their practice needs to adapt. What is more, as transformation progresses, these adjustments will need to be re-evaluated – just like skills and leadership development, securing time within working hours to engage with transformation should be viewed as a continuous approach.
Technology: providing the right infrastructures
Technical resources, such as data infrastructures or the laboratories needed to enable the system-wide rollout of personalized medicine, may also take longer to put in place than securing the necessary financial resources. Depending on the aim and focus of transformation, the technical resources required will differ. However, in recent years, substantial investment has gone into the development of digital health infrastructures across the European Region, although scope and progress vary (see Box 13). It is important to note that new infrastructures will not contribute to transformation in a vacuum and require those who operate them to have the necessary skillset and time to do so (see also previous paragraphs and McKee, Greenley & Permanand, 2024).
Box 13
Progress and gaps in digital health uptake in the WHO European Region.
For EU Member States, targeted support to advance the digitalization of health care is provided through a number of instruments, notably the Recovery and Resilience Facility, the Cohesion Policy Funds (primarily the European Regional Development Fund), and Digital Europe, which offer funding and are complemented by loans and investment services offered through InvestEU and the European Investment Bank (Fahy, Mauer & Panteli, 2021; Mauer, Panteli & Eichwalder, 2022). In 2022, the WHO Regional Office for Europe signed an agreement with the Healthcare Information and Management Systems Society, a global non-profit advisor on advancing the reform of the health ecosystem through information and technology to further support Member States achieve digitalization goals.
Having the appropriate digital systems in place is not only key for the delivery of health services, but also for collecting and analysing data that can support transformation. Technical support to ensure the establishment, interoperability, maintenance and adaptation of IT systems goes beyond system-level mechanisms. System-level policy-makers can support local implementers both by providing overall standards and the possibility for technical support. Furthermore, they can provide assistance with data analytics, both directly and by incorporating relevant skills in their overall approach to fostering skills development (see previous paragraphs).
Information: ensuring that evidence is produced and communicated properly
Regulation and the allocation of resources are important tools to compel changes; however, information can be a powerful policy mechanism for bringing about motivated change, especially within a complex health system. One reason why information and evidence can be such powerful tools supporting implementation is that they are suited to bringing about change within a complex system. Whereas regulation and resource allocation provide external reasons to do something (an extrinsic motivation), information can change minds and create motivation that provides an internal reason for action by the people who need to make the relevant changes. Intrinsic motivation is more sustained over time and leaves space for people to act on that belief in ways that they see as best suited to their local circumstances.
Ensuring that those delivering health services have access to robust information is crucial for achieving transformation goals
Fostering the availability of robust information to support practices at the local level can include both mechanisms that can help organizations and individual professionals evaluate their practice in light of transformation goals (such as providing data about trends at the system level: for example, data about comparative cancer outcomes through the EUROCARE projects drove system-level change in cancer care; or publishing performance information and benchmarking, e.g. about prescribing patterns for antibiotics, or levels of MRSA infections in hospitals), and tools that can support implementers in shaping how they deliver care, such as establishing or strengthening programmes for the development of care guidelines (see Box 14). Clinical guidelines are not the only tool that aims to enable evidence-informed decisions in health and health care. HTA has been mentioned earlier in this brief as a key tool for weighing different options and can substantially influence the delivery of services, especially when informing coverage or procurement decisions; in fact, different mechanisms within the evidence ecosystem must be aligned for optimal effect (see Schünemann et al., 2022).
Box 14
Clinical guidelines as a tool for transformation.
At the service level, sustaining progress of change and building momentum must be supported by continuous measurement of the outcomes of service delivery and exchange on the issues that require attention. Monitoring the progress and effects of transformation efforts is vital for implementers (managers and frontline clinicians) to evaluate the achievement of milestones; several of the tools presented in Box 2 in Section 2 can support this process if they are sufficiently granular and readily available. Those implementing the changes necessary for service delivery transformation do not benefit just from exchange with stakeholders in their local context; exchanging experiences with others who are implementing similar changes elsewhere can be very useful for knowledge transfer and the identification of good practice. System-level policy-makers can help with establishing (and providing resources for) networks and platforms for exchange across settings within the health system. One step further, knowledge exchange with relevant counterparts from other countries can further provide impetus for transformation.
Strong, responsive communication is essential for successful transformation efforts and continuous improvement
An important component in providing evidence for health system actors is communication – the best evidence is likely to be ignored unless it is properly disseminated. Communication is not only important in making the need for transformation understood by health system actors, communities and individuals; communication strategies around health service delivery transformation must ensure that the audience is both aware of the need for change (problem recognition) and understands the options that can help address this need (best practices/successful implementation in the local context). A communication plan with a stepwise approach and integrated feedback loops is helpful for developing an effective communication strategy to convey these ideas to different target audiences (see Figure 6).
Figure 6
Key components of building successful communication strategies for transformation. Source: Health Foundation, 2015.
Communication strategies are important both at the system level (led by policy-makers to reach health system actors; see Section 2) and at the local level, where decision-makers can tailor the approaches presented to motivate their respective constituencies. On both levels, the aim of communication strategies is to achieve widespread support for the envisioned changes in the transformation process across different groups and to provide technical support to those ready to adopt the new. Communication strategies have to strike a balance between breadth and depth of engagement. In-depth engagement can help to maximize commitment to the change, but with large-scale change this is simply not feasible, so a combination of methods balancing forms of engagement, time and resources is required. For example, opinion leaders from patient organizations and professional associations can both influence priority audiences and help to sharpen the message. Prioritizing the audience with the greatest stakes in the change can be helpful.
Key messages need to be formulated clearly and concisely; information should include the expected benefits, harms, costs and implications of changes, and be tailored to specific target groups (Health Foundation, 2015; WHO, 2017). Using real-life stories and personal narratives can be very powerful in conveying the impact of the transformation. Moreover, showing the gap between current practice and an ideal scenario, or using messages from successful implementation examples, i.e. by showing how people have benefited from change, can propel the case for the transformation (Institute for Healthcare Improvement, 2018).
Health systems are also social systems, with different communications channels suited to different types of engagement. For example, utilizing mass media to introduce a new practice initially, followed by leveraging opinion leaders to disseminate these messages among their peers, can expedite the adoption rate significantly (Albright et al., 2022). Health systems are quite distinctive in their communication channels, with overlapping systems of professions, organizations, care networks and personal networks. Communication methods and channels should match the objective and target audience of the information to be communicated. For example, presentations at large meetings may help to build awareness of the change, while one-to-one conversations may be more effective in moving people closer to the decision to adopt. Once the communication strategy has been rolled out, it is important to sustain interest, enthusiasm and commitment by celebrating people’s contribution to the achievement of milestones and sharing this widely (Health Foundation, 2015).
For leaders in service delivery, communicating findings on the progress of transformation efforts in the community can help maintain the motivation to adhere to introduced changes or flag areas where (further) adaptation to the local context might be needed. A crucial element throughout the transformation process is maintaining a two-way channel of communication, i.e. listening to the target audience and being open to receiving feedback; this can be done in a variety of ways, both direct and indirect (Health Foundation, 2015; WHO, 2017). Stakeholder engagement processes described in Section 2, are one of the ways for actively receiving feedback and subsequently communicating how this has been considered in the evolution of changes on the ground.
Each of the mechanisms discussed in this section can contribute to enabling change for service delivery transformation. However, they need to be aligned under an overarching strategic framework to ensure that they can exercise their influence as intended. What is more, a particular challenge for health is that there are also levers that influence the implementation of change in service delivery that are under the control of actors other than policy-makers, such as guidelines and standards produced by professional bodies. This is another area where stakeholder engagement is vital to ensure a coherent approach, both in terms of individual instances of implementation, and ideally structurally, to ensure a coherent system-level approach to transformation for the system as a whole.
4. Policy implications
Transforming health service delivery to achieve health system goals requires the implementation of substantial changes in complex systems. Its success depends not only on the availability of effective solutions, but crucially on the system’s willingness and ability to change. The nature of a health system does not respond well to top-down, tightly defined change; a different paradigm is needed for effective transformation. Policy-makers must therefore embrace the realization that a strong policy vision and the introduction of relevant policy measures must come hand in hand with supporting the change process on the ground and facilitating the creation of an ecosystem wherein transformation can be successfully enacted.
Previous sections have showcased the different dimensions on which policy-makers can take action to drive the transformation of health service delivery by:
- providing clear direction on the intended changes and leadership at the system level and taking all relevant stakeholders on board;
- using the tools at their disposal to enable change and remove barriers (mainly through adapting governance mechanisms; introducing necessary regulatory changes; ensuring sufficient human, financial and technical resources; and providing or enabling the development and communication of high-quality information around the change process and effects of transformation); and
- ensuring that actors implementing change on the ground are supported to do so within their local context.
The range of the different possible actions described along these dimensions makes it clear that policy-maker support is needed throughout the change process which is inherent in the transformation of health service delivery. Figure 7 maps the actions described in this brief onto the change process to further highlight this and to provide a simplified way for policy-makers to consider where they may want or need to focus their attention first.
Figure 7
Process of change underpinning health service delivery transformation and key areas for policy-maker action. Source: author compilation.
However, it is crucial to realize that service delivery transformation does not simply necessitate different policy actions impacting different dimensions or stages of the change process; it requires an overall strategic plan that encompasses all of these elements. This, in turn, presupposes leadership with a long-term vision and commitment: change takes time. Implementation will likely not be linear and results may not be visible quickly; policy-makers need to factor this in so as not to be discouraged themselves and in order to be able to communicate effectively with politicians, health system actors and the public to sustain momentum. Importantly, active stakeholder engagement throughout the process also provides the necessary conditions for health system actors to feed back both the successes and challenges of implementing changes on the ground to policy-makers, and to contribute further to shaping transformation efforts at the system level.
Building leadership capacities for transformation at all levels within the system is vital, and the ability for leaders to understand and engage with the relevant actors to drive forward change is a necessary skill that is sometimes neglected. Beyond leadership capacities, ensuring that there are enough technical personnel with both analytical and engagement skills for policy development, that the skills development of health professionals includes elements that support a culture of transformation, and that patients and the public are engaged in the process to enhance their understanding of and contribution to the implementation of positive change should also be part of policy aspirations.
Beyond building the necessary capacities in terms of skillset, health systems need to be sufficiently resourced in terms of money, people, infrastructures and time for transformative ideas to emerge and flourish. Importantly, investing in the transformation of service delivery goes beyond paying for personnel, facilities and products. It entails accounting for and financing all the necessary mechanisms described in this brief, from dedicated funding streams to develop and test service delivery innovations, to the different components of stakeholder engagement and the possibility for frontline clinicians to develop or implement new approaches during their paid working time.
Strong health information systems that can support the transformation of service delivery both in terms of identifying areas for action and monitoring the progress of implementation are pivotal to ensuring that changes have the desired effects and serve to advance health system goals (see also Rajan et al. 2024 and Karanikolos et al. 2024 in this policy brief series). The WHO Regional Office for Europe´s recent report The ongoing journey to commitment and transformation: Digital health in the WHO European Region 2023 (WHO Regional Office for Europe, 2023a) provides important guidance for policy-makers on how to leverage digitalization for this purpose (see Box 13). Ideally, such systems should be integrated within a broader evidence ecosystem that can facilitate the generation of robust evidence and its dissemination in tailored formats.
Cross-country learning can support transformation. However, as every health system creates its own unique context, insight from elsewhere needs to be adapted in combination with knowledge of the distinctive local system:
- innovations from elsewhere can help to identify potential for change, as well as possible options for implementing such a change
- the barriers and facilitators of change in different systems can help to illuminate how policy tools can be used, even if they will inevitably require adaptation for that specific setting; and
- insight from transformation initiatives elsewhere can help to demonstrate the possibility of change and provide examples of how to achieve it in practice; policy-makers and service-level implementers can draw on this knowledge.
Finally, transformation efforts must balance on the one hand the degree of change the policy is seeking to achieve and on the other the capacity and capability of the system to absorb and act on this. Limitations of resources or staff, for instance imposed by the workforce constraints currently experienced by countries in the WHO European Region, will of course also limit the overall capacity of the system to make the desired changes. Policies for health service delivery transformation thus need to be carefully planned in collaboration with all relevant stakeholders to ensure that they do not unduly disadvantage the system and, in so doing, further jeopardize people’s trust in its ability to meet their needs.
5. Conclusions
To address changing population health needs against the backdrop of long-term and emerging challenges, health systems need to do better with less. The transformation of health service delivery towards person-centred models that aim to improve outcomes and minimize the burden for patients and the health system is vital to achieving this goal. Policy-makers have the ability to drive this type of transformation in a multitude of ways. Fundamental prerequisites for all of them are: the realization that their main role is to enable rather than impose change; and a good understanding of the political economy around health service delivery in their own setting. Cross-country collaboration can help to inspire and shape transformation efforts, but adaptation to the particularities of each system is necessary and can only be successful if it is based on meaningful stakeholder engagement.
- POLICY BRIEF - Transforming health service deliveryPOLICY BRIEF - Transforming health service delivery
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