Why is health service delivery transformation essential?

Policy-makers are continuously faced with the need to ensure that health service delivery evolves to match health needs; and to do so against the backdrop of health system challenges, such as workforce constraints and rising health care costs. They need to find innovative solutions to transform health service delivery from reactive hospital and acute care to a health system which can anticipate and ensure person-centred care, leveraging the opportunities afforded by new technologies.

What does service delivery transformation actually entail?

The transformation of health service delivery affects multiple stakeholders. It aims to improve population health outcomes by enhancing quality of care and efficiency. Successfully changing service delivery requires an understanding of the problems, identifying effective, affordable and equitable solutions, testing and implementing them, monitoring their implementation, and identifying areas for further adaptation. This includes enabling and harnessing innovative service delivery approaches and embracing the need for a combination of top-down and bottom-up initiatives. Policy-makers need to be able to recognize and seize windows of opportunity, and understand how to harness and sustain political will, while providing grassroots support to see implementation through to a successful conclusion.

Policy-makers need to:

• provide leadership on aims and shared commitment; in fostering a culture that is open to change; and in adapting and aligning governance mechanisms; and
• ensure sufficient resources for transformation, by combining enablers at the system level and support to organizations and people within the system.

What does this brief add?

Transformation processes are complex and time-consuming, and cannot be dictated from the top down. Health systems are complex systems with a multitude of actors and different and evolving interests. This policy brief aims to support system-level policy-makers in understanding how they can shape the conditions in which transformation will flourish by providing a practical overview of policy actions and the tools to support them.

Having a clear vision for change means identifying the challenges and potential solutions

There are different instruments that enable health policy-makers to identify targets for transformation by monitoring how well their health systems function and how population health trends evolve, including health system performance assessment (HSPA), international and national surveys, and stakeholder consultation processes.

Health systems also require reliable information on effective solutions that have the potential to be widely implemented. Horizon scanning, national and international dedicated funding streams for the development and piloting of new approaches, and participatory platforms can all help with this.

A key consideration must also be ensuring that solutions are beneficial for patients as well as the system as a whole (or come with a positive, evidence-based ‘value proposition’) and here mechanisms such as health technology assessment (HTA) can contribute.

Governance is about adapting and aligning mechanisms to facilitate change

Policy-makers provide the setting for all health systems transformation, deciding who is involved and on what basis, and shaping decision-making, implementation and accountability. Adapting the governance framework to support transformation requires a good understanding of the political economy of service delivery to overcome resistance to changing norms. Mechanisms such as payment models also need to be aligned and geared towards transformation. Regulation is one of the key governance tools to achieve this (whether formal legislation or requirements such as professional standards) and will need to be adapted appropriately.

Building collective commitment for transformation requires stakeholder engagement

Leaders must ensure that stakeholder engagement permeates all stages of transformation. Analysis of relevant stakeholders (the groups involved, the benefits and costs for each) is essential and there are useful tools available. Participatory approaches to needs identification, to the co-design of system-level mechanisms and to implementation are also key. A system-level strategy incorporating all these elements of engagement increases the chances of success.

Coalition building and the engagement of popular leaders sympathetic to the transformation can be fundamental to generating political will. This can entail working with civil society organizations, professionals’ associations, researchers and knowledge-brokers, and can also assist policy-makers with sustaining the (political) will for transformation over time.

Financing transformation efforts must consider organizational needs

Policy-makers may find it difficult to ringfence additional funds for transforming service delivery in the ‘backlash’ to spending in the pandemic. Different arguments can be used to make the case, and collaborative governance and a collective commitment to change can support the allocation of scarce resources.

Channelling these resources to the actors involved must reflect both transformation goals and the needs of the professionals and organizations implementing the change. Traditional payment mechanisms for service delivery may not be conducive to change, especially towards more integrated models of care, but the evidence on newer mechanisms is still developing. Ideally, payment models would be tailored to the specifics of the transformation and the context, and factor in the cost of the change process itself (managerial costs, local stakeholder engagement, opportunity costs).

Sufficient staff with the right skills, time and power to implement change is necessary

Having sufficient health professionals with the right skills and capacity is a vital resource for transformation that can be achieved by strategic, multiprofessional and intersectoral workforce planning. It should consider necessary skill-mix changes and link with the educational system.

Ensuring that professionals at the organizational level can successfully adapt and implement change is of crucial importance for the sustained implementation of transformation. This means developing organization-level leadership and providing options for tailored skills development for the workforce. Policy-makers can organize and/or foster leadership programmes, motivating system actors and promoting standards for skills development and workforce empowerment.

The available infrastructure must allow for introducing and monitoring changes

Technological resources, such as data infrastructures or laboratories (to enable personalized medicine, for example), may take longer to put in place than funding for transformation, and here policy-makers can provide standards and roll-out support (in addition to funding). Both the European Union (EU) and World Health Organization (WHO) are actively pursuing ways in which to assist their Member States with digitalizing health systems.

Appropriate digital systems are key for the delivery of health services, but also for collecting and analysing data to support transformation. Policy-makers would do well to ensure the establishment, interoperability, maintenance and adaptation of information technology (IT) systems by enacting system-level measures and by providing support to local implementers. They can also assist with data analytics, both directly and by incorporating relevant skills in their overall approach to training and development.

The right information communicated properly can be a powerful tool for transformation

Information can be a powerful policy mechanism for motivating change, especially within a complex health system. Providing data about trends, publishing performance information and benchmarking, and programmes for the development of evidence-based resources, such as care guidelines, all help. Sustaining progress and building momentum at the service level must be supported by continuous measurement of outcomes and exchange. Policy-makers can help with establishing platforms for the exchange of experiences and in identifying good practice.

Communication strategies are important both at the system level (led by policy-makers to reach health system actors) and at the local level, where decision-makers need to motivate their respective constituencies. Communication strategies must ensure that the audience is aware of the need for change (problem recognition) and understands the options. Communication plans must take different audiences and types of engagement into account as well as providing options for feedback. Combining approaches can significantly expedite the adoption of new approaches.