Health System Innovation Research Articles

A Review of Differentiated Service Delivery for HIV Treatment: Effectiveness, Mechanisms, Targeting, and Scale.

Differentiated service delivery (DSD) models were initially developed as a means to combat suboptimal long-term retention in HIV care, and to better titrate limited health systems resources to patient needs, primarily in low-income countries. The models themselves are designed to streamline care along the HIV care cascade and range from individual to group-based care and facility to community-based health delivery systems. However, much remains to be understood about how well and for whom DSD models work and whether these models can be scaled, are sustainable, and can reach vulnerable and high-risk populations. Implementation science is tasked with addressing some of these questions through systematic, scientific inquiry. We review the available published evidence on the implementation of DSD and suggest further health systems innovations needed to maximize the public health impact of DSD and future implementation science research directions in this expanding field. While early observational data supported the effectiveness of various DSD models, more recently published trials as well as evaluations of national scale-up provide more rigorous evidence for effectiveness and performance at scale. Deeper understanding of the mechanism of effect of various DSD models and generalizability of studies to other countries or contexts remains somewhat limited. Relative implementability of DSD models may differ based on patient preference, logistical complexity of model adoption and maintenance, human resource and pharmacy supply chain needs, and comparative cost-effectiveness. However, few studies to date have evaluated comparative implementation or cost-effectiveness from a health systems perspective. While DSD represents an exciting and promising "next step" in HIV health care delivery, this innovation comes with its own set of implementation challenges. Evidence on the effectiveness of DSD generally supports the use of most DSD models, although it is still unclear which models are most relevant in diverse settings and populations and which are the most cost-effective. Challenges during scale-up highlight the need for accurate differentiation of patients, sustainable inclusion of a new cadre of health care worker (the community health care worker), and substantial strengthening of existing pharmacy supply chains. To maximize the public health impact of DSD, systems need to be patient-centered and adaptive, as well as employ robust quality improvement processes.

Effect analysis on technical innovation of clinical medicine resources in Beijing

Objective Evaluate the status quo and spillover effects of clinical medical resources in Beijing, to find solutions for promoting clinical resources of the hospital and transformation of clinical research. Methods By analyzing the patents, clinical trials and clinical research transformation cases of hospitals in Beijing, and comparing with advanced area at home and abroad, identify the factors that restrict the spillover of clinical resources, analyzed the role of medical institutions in the health system. Results Compare with the advanced level of abroad, there is a lot of space for improvement in Clinical resource output and industry support in Beijing. Beijing’s hospital patent amounts has reached a certain scale, however, the number and growth rate of patents is lower than Shanghai. The patents in different hospitals varies greatly, which indicating that the hospital′s emphasis on technological innovation and the overall transformation of results management are varied a lot, and overall, Beijing is lack of a unified policy at the regional level. Beijing is the most concentrated area of clinical medicine resources in China. The number of clinical trials carried out surpasses Shanghai and Tokyo in the forefront in Asia, but there is still a large gap to the international advanced region. Conclusions Hospitals is important in the health innovation system, It is recommended to strengthen the clinical innovation policy guarantee and talent construction, promote the patent-based medical results spillover, and establish a virtuous cycle of clinical resource technology innovation Key words: Clinical medicine resources; Hospital innovation; Technology transfer; Technology spillover

Academic-Practice Partnerships: A Win-Win.

Partnerships between academia and practice can lead to improved patient care and health system innovations. Nurse educators in both academia and practice are positioned to facilitate opportunities for students and practicing nurses to be involved in evidence-based practice (EBP) care initiatives involving academic-health care partners in clinical and/or community-based systems. Best practices in collaborative partnerships have demonstrated the significance of their far-reaching impact on patients, students, direct care nurses, and health systems. Translation of EBP knowledge to practice transforms patient outcomes and empowers nurses to address the complexity of health care systems. This article describes the process and outcomes of an academic-practice partnership facilitated by nurse educators in both academic and practice settings. The impact of the adoption of EBP projects on clinical practice, students, and practicing nurses is described. National and international implications for academic- practice partnerships are discussed. [J Contin Educ Nurs. 2019;50(6):282-288.].

Solution Model for Enhancing the Experiences of Urban First Nations and Métis Patients Accessing and Navigating the Health System for Inflammatory Arthritis Care

Health system innovations that better support Indigenous patients, particularly in urban settings, exist in primary health services, but this has not been translated and integrated into specialty care. We sought to identify the experiences of urban First Nations and Métis patients with inflammatory arthritis in accessing and navigating the health system. We used a qualitative research method called Patient and Community Engagement Research Program (PaCER) led by patients using an iterative three phase process: Set, Collect, and Reflect. Initial access and continuity of specialty care can be facilitated with collaboration between primary and specialty care in an urban Indigenous health service model, where health system change was built on culturally responsive models of care.

Diversity, novelty and satisfactoriness in health innovation

How innovations emerge and what path they follow is a central topic in evolutionary economics. This paper contributes to this stream of literature by presenting empirical evidence on health innovation patterns in a small middle-income country. Moreover, it has theoretical implications in terms of understanding the selection process of health-related innovations. A qualitative processual analysis of five case studies in the Uruguayan health innovation system was conducted between 2007 and 2017. The paper analyzes how the diversity degree of the specific domain where innovation emerges determines two basic evaluation criteria of innovation fitness: novelty and satisfactoriness. Moreover, the research shows how market and non-market institutional mechanisms define these criteria. Based on this theoretical framework, results show how different types of innovations have been developed with different degrees of novelty, according to their satisfactoriness for the specific requirements of the Uruguayan health innovation system.

Differentiated Care Preferences of Stable Patients on Antiretroviral Therapy in Zambia: A Discrete Choice Experiment.

Although differentiated service delivery (DSD) models for stable patients on antiretroviral therapy (ART) offer a range of health systems innovations, their comparative desirability to patients remains unknown. We conducted a discrete choice experiment to quantify service attributes most desired by patients to inform model prioritization. Between July and December 2016, a sample of HIV-positive adults on ART at 12 clinics in Zambia were asked to choose between 2 hypothetical facilities that differed across 6 DSD attributes. We used mixed logit models to explore preferences, heterogeneity, and trade-offs. Of 486 respondents, 59% were female and 85% resided in urban locations. Patients strongly preferred infrequent clinic visits [3- vs. 1-month visits: β (ie, relative utility) = 2.84; P < 0.001]. Milder preferences were observed for waiting time for ART pick-up (1 vs. 6 hours.; β = -0.67; P < 0.001) or provider (1 vs. 3 hours.; β = -0.41; P = 0.002); "buddy" ART collection (β = 0.84; P < 0.001); and ART pick-up location (clinic vs. community: β = 0.35; P = 0.028). Urban patients demonstrated a preference for collecting ART at a clinic (β = 1.32, P < 0.001), and although most rural patients preferred community ART pick-up (β = -0.74, P = 0.049), 40% of rural patients still preferred facility ART collection. Stable patients on ART primarily want to attend clinic infrequently, supporting a focus in Zambia on optimizing multimonth prescribing over other DSD features-particularly in urban areas. Substantial preference heterogeneity highlights the need for DSD models to be flexible, and accommodate both setting features and patient choice in their design.

Mismatch between antenatal care attendance and institutional delivery in south Ethiopia: A multilevel analysis

ObjectivesUptake of maternal health services remains suboptimal in Ethiopia. Significant proportions of antenatal care attendees give birth at home. This study was conducted to identify the predictors of non-institutional delivery...

Putting knowledge flows front and centre in health systems strengthening

ABSTRACTThis paper is a conceptual paper outlining a framework to analyse the main barriers linking knowledge production and application in the area of health in developing countries. It does so through a broad mapping and rethinking of the role of social and technological innovation in health systems strengthening. An analytical framework called the 4F framework – where the four Fs stand for Form, Field, Flows and Functions – is presented. By conducting a very high-level analysis of the barriers and enablers in knowledge production and application in the health sector in Kenya we give an indicative overview of the 4F Framework’s potential. The empirical analysis suggests knowledge is often siloed into particular areas. At the macro level, there is insufficient focus on knowledge exchange between policy sectors i.e. health, industry, education. The analysis suggests that the framework provides a means to move from building ‘health and wellbeing systems’ to focusing on ‘competence building systems in the area of health and wellbeing’ which will provide a longer term holistic approach to health systems strengthening. The paper ends by presenting a number of recommendations for policy makers to ensure enhanced up-take of both technological and social innovation in health systems.

Directions for improving the economic mechanism of public administration of innovations in the national health system (subsystem of extreme medical care)

Directions for improving the economic mechanism of public administration of innovations in the national health system (subsystem of extreme medical care)

Analysis of Iran's National Medical Education Evolution and Innovation Plan using the Michelle and Scott's model of policymaking

Introduction: Lack of a clear policy for the development of health human resources has created inconsistencies. These imbalances are threats to the health system to achieve its goals. Therefore, the development of human resources through proper performance of higher education health system is an important part of the policy development process of the health sector. The present paper aims to introduce the methods applied for the compilation of evolution and innovation program of medical sciences training as well as the most important directions for evolution and innovation. Methods:In this study, we evaluated the methodology for designing packages of Iran’s higher education health system evolution and innovation. For this purpose, the evaluation of the policy process was conducted based on Michelle and Scott's policy process models. This policy evaluation model starts by problem identification and definition and continue by agenda setting, policy formation, legitimation, implementation, evaluation, and policy modification, using the proper feedback. Qualitative content analysis method was used as a research method for subjective interpretation of the content of the text data. Results: Twelve policies, 68 strategies and their translation in the health system were adopted in a comprehensive plan for higher health education. Eleven practical packages were also developed in order to implement these policies as packages for reform and innovation in medical education. These packages were organized based on the IPOCC pattern. Conclusions: The lack of a comprehensive look at each project or program could bring about irreparableness consequences. However, the MoHME of Iran, relying on the integration of health higher education with health care system and comprehensive method used for transformation and innovation plan in the field of health higher education could take an important step towards improving the nation's health.

Expenditure Reductions Associated with a Social Service Referral Program.

Recent health system innovations provide encouraging evidence that greater coordination of medical and social services can improve health outcomes and reduce health care expenditures. This study evaluated the savings associated with a managed care organization's call center-based social service referral program that aimed to assist participants address their social needs, such as homelessness, transportation barriers, and food insecurity. The program evaluation linked social service referral data with health care claims to analyze expenditures in 2 annual periods, before and after the first social service referral. Secondary data analysis estimated the change in mean expenditures over 2 annual periods using generalized estimating equations regression analysis with the identity link. The study compared the change in mean health care expenditures for the second year for those reporting social needs met versus the group whose needs remained unmet. By comparing the difference between the first and second year mean expenditures for both groups, the study estimated the associated savings of social services, after controlling for group differences. These results showed that the decrease in second year mean expenditures for the group of participants who reported all of their social needs met was $2443 (10%) greater than the decrease in second year mean expenditures for the group who reported none of their social needs met, after controlling for group differences. Organizations that integrate medical and social services may thrive under policy initiatives that require financial accountability for the total well-being of patients.

Moving from formative research to co-creation of interventions: insights from a community health system project in Mozambique, Nepal and Peru

Different methodological approaches for implementation research in global health focusing on how interventions are developed, implemented and evaluated are needed. In this paper, we detail the approach developed and implemented...

Scaling-up strategies of integrated care initiatives: a systematic literature review

Introduction: To make effective use of integrated initiatives and rapidly increase their wide-scale impact to benefit more people on a lasting basis, large-scale implementation is desirable. However, an understanding of what elements are related with successful implementation of integrated care initiatives on a larger scale remains largely unknown. WHO/ExpandNet argue that ‘’strategic planning for the expansion and institutionalization of successfully tested health systems innovations is essential’’[1]. Flexible, but intentional, scale-up strategies can help guide system changes [2]. This literature review aims to explore what scaling-up strategies for integrated care initiatives are described in literature, to describe to what extent these are theory-based, and how they match the framework for scaling-up, as defined by WHO [3]. Methods: PubMed Medline and Web of Science were consulted to collect data. A combination of three concepts are used as search strategy: 1 search terms describing “integrated care”; 2 search terms related to “scaling-up”; and 3 search terms related to “strategy”. Papers focusing on scaling-up and/or expansion of integrated care initiatives and reporting a strategy for expansion between January 2007 and December 2017 are identified. After the articles are retrieved, the framework for scaling-up, as defined by WHO, is used as a guide to extract the data. The guide includes the types of scaling-up i.e. vertical; horizontal; diversification; spontaneous, the steps for developing a scaling-up strategy for integrated care i.e. scalability; capacity of user organization; environment and planning actions; capacity of resource team; choices for vertical scaling-up; choices for horizontal scaling-up; role of diversification; actions for spontaneous scaling-up; and identification of next steps including the strategic choices made i.e. dissemination and advocacy; organizational process; costs/ resource mobilization; monitoring and evaluation. Results: A number of 6,222 articles were identified in the two databases, after removing duplicates, a total of 5,568 potentially relevant articles have been reviewed based on title. After papers are included based on the title selection, the abstracts will be reviewed. Next, the included papers will be up for full text review. The reference lists of the full papers will also be checked to include additional relevant papers for final review. The data-analysis is ongoing at this moment Dec 2017. Discussion: The framework for scaling-up does not specifically focus on scaling-up integrated care initiatives, however, since it is widely used and one of the few available comprehensive frameworks in scaling-up health interventions it has huge promise for the field of integrated care. We hypothesize to find a blend of types, strategic choices and steps for the scaling-up of integrated care. Conclusion: This literature review will yield information around scaling-up strategies aimed at the transfer and scaling-up of successful integrated care initiatives. The insights on the usage of and potential gaps in scaling-up strategies will be useful to guide the further development, implementation and evaluation of scaling-up strategies. The literature search is currently being undertaken, therefore, it is too early to report on lessons learned, these will be presented at the conference. Limitations: This review will select English articles which may result in language bias.

Alberta's Data Mobilization Strategy: Leveraging Linked Data for Innovation

IntroductionThe Province of Alberta maintains a mature data ecosystem with linkable data dating back over 30 years. The population-based nature of the data makes this a valuable asset for driving analytics to support health system innovation, with a focus on improving health outcomes and quality of life.&#x0D; Objectives and ApproachAlberta Health has created the Secondary Use Data Access (SUDA) initiative to leverage its administrative health data. SUDA envisions strengthening partnerships between the public and private sectors with two main access approaches. The first is direct access to de-identified data held within the Alberta Health data warehouse by key health system stakeholders (e.g. academic instituions, Health Quality Council of Alberta, regulatory colleges). The second is indirect access to private and not-for-profit stakeholders, using a safe haven approach. Indirect access is achieved through private sector investments to a trusted third party that hires analysts to be placed within Alberta Health.&#x0D; ResultsStaffing agreements and privacy impact assessments have been drafted to support the work. The indirect access route includes a multiple stakeholder steering committee to vette and prioritize projects. Private and not-for-profit stakeholders do not have access to the data, but rather receive access to aggregate data and statitstical models. All disclosures are done by Alberta Health staff to ensure compliance with Alberta's Health Information Act. Direct access has been established for the Alberta Medical Association as part of a long standing data sharing agreement, with access restricted to de-identified data only. To date, seven industry proposals for analytics have been received and are currently being actioned.&#x0D; Conclusion/ImplicationsThe Secondary Use Data Access initiative uses a safe haven approach to leveraging data. It reduces the need to provision data outside of the data warehouse and allows for better monitoring of access and use of data. The approach provides assurances that people's health information is secure.

National health innovation systems: Clustering the OECD countries by innovative output in healthcare using a multi indicator approach

The importance of innovation in healthcare has increased within the last decades as challenges, like rising costs and an aging demographic, have to be solved. The degree of innovativeness in healthcare is strongly influenced by the National Health Innovation System, which as a sectoral innovation system encompasses a wide variety of actors and related knowledge. Despite the highly practical relevance of the topic, there are only a few studies that analyze innovation in healthcare on a national level. Thus, this study is a starting point and, building on the theoretical framework of national innovation systems, answers the following questions: “Can countries be grouped by their innovation output in healthcare and do those groups differ in factors describing the healthcare system? Do countries with strong national innovation systems also have strong national health innovation systems and vice versa?” We compare the healthcare innovation output of 30 OECD countries using a multi-indicator approach and categorize them into four distinct groups using cluster analysis. The cluster consisting of the Scandinavian countries, the Netherlands and Switzerland shows the highest innovation output measured in knowledge production and knowledge commercialization. Surprisingly, these countries, with the exception of Switzerland, only rank in the medium group when considering the entire national innovation system. Policymakers and researchers might be particularly interested in studying the healthcare systems of these countries.

\u2018We have the internet in our hands\u2019: Bangladeshi college students\u2019 use of ICTs for health information

BackgroundInformation and Communications Technologies (ICTs) which enable people to access, use and promote health information through digital technology, promise important health systems innovations which can challenge gatekeepers’ control of information, through processes of disintermediation. College students, in pursuit of sexual and reproductive health (SRH) information, are particularly affected by gatekeeping as strong social and cultural norms restrict their access to information and services. This paper examines mobile phone usage for obtaining health information in Mirzapur, Bangladesh. It contrasts college students’ usage with that of the general population, asks whether students are using digital technologies for health information in innovative ways, and examines how gender affects this.MethodsThis study relies on two surveys: a 2013–2014 General Survey that randomly sampled 854 households drawn from the general population and a 2015 Student Survey that randomly sampled 436 students from two Mirzapur colleges. Select focus group discussions and in-depth interviews were undertaken with students. Icddr,b’s Ethical Review Board granted ethical clearance.ResultsThe data show that Mirzapur’s college students are economically relatively well positioned, more likely to own mobile and smart phones, and more aware of the internet than the general population. They are interested in health information and use phones and computers to access information. Moreover, they use digital technology to share previously-discreet information, adding value to that information and bypassing former gatekeepers. But access to health information is not entirely unfettered, affecting male and female students differently, and powerful gatekeepers, both old and new, can still control sources of information.ConclusionPersonal searches for SRH and the resultant online information shared through discrete, personal face-to-face discussions has some potential to challenge social norms. This is particularly so for women students, as sharing information may enable them to bypass gatekeepers and make decisions about reproduction. This suggests that digital health information seeking may be exercising a disruptive effect within the health sector. However, the extent of this disruption may depend, not on students’ mobile phone usage, but on the degree to which powerful new gatekeepers are able to retain control over and market SRH information through students’ peer-to-peer sharing.

Riding the winner across the finishing line: lessons from integration stayers

Background: Better integrated clinical models of care with close cooperation between hospital-based specialists and community practitioners are fundamental to effective chronic disease management. Yet despite integrated care being an international priority for over 20 years, sustained at-scale integration outcomes are still uncommon. Aims and Objectives: To allow clinician researchers with over a decade of service implementation at scale in Europe and Australia, to identify key integration success factors and barriers across diverse settings and business models. To involve the symposium audience in understanding and applying them in their own settings To summarise learning and service integration development relevant to workshop participant Speakers: Prof. Claire Jackson (Chair), ‘Building quality and cost effectiveness of diabetes care via the ‘beacon’ community model’ Dr Albert Alonso, ‘Safely transferring hospital COPD care into the community' Associate Professor Di O’Halloran, ‘What is the secret sauce in hospital / community integration?' Carline Nicholson,‘How can we align diverse business models, funding and culture? The Symposium will highlight the challenges faced in implementing models of integrated care and how they may be overcome. Practice, organisational and external factors including clinician leadership and resourcing are critical for translation of evidence into ongoing practice. It will also highlight the importance of the external environment in creating the framework to allow effective adoption of health system innovation. Participants will apply frameworks to their own settings using facilitated small-group work. Target audience: clinicians, researchers, consumers, policy makers, and health care organisations working at the community/ hospital interface Learnings/take away messages: To understand the key enablers and barriers in large scale integration intervention; and to apply these in diverse settings internationally

Using Theories of Change to inform implementation of health systems research and innovation: experiences of Future Health Systems consortium partners in Bangladesh, India and Uganda

BackgroundThe Theory of Change (ToC) is a management and evaluation tool supporting critical thinking in the design, implementation and evaluation of development programmes. We document the experience of Future Health Systems (FHS) Consortium research teams in Bangladesh, India and Uganda with using ToC. We seek to understand how and why ToCs were applied and to clarify how they facilitate the implementation of iterative intervention designs and stakeholder engagement in health systems research and strengthening.MethodsThis paper combines literature on ToC, with a summary of reflections by FHS research members on the motivation, development, revision and use of the ToC, as well as on the benefits and challenges of the process. We describe three FHS teams’ experiences along four potential uses of ToCs, namely planning, communication, learning and accountability.ResultsThe three teams developed ToCs for planning and evaluation purposes as required for their initial plans for FHS in 2011 and revised them half-way through the project, based on assumptions informed by and adjusted through the teams’ experiences during the previous 2 years of implementation. All teams found that the revised ToCs and their accompanying narratives recognised greater feedback among intervention components and among key stakeholders. The ToC development and revision fostered channels for both internal and external communication, among research team members and with key stakeholders, respectively. The process of revising the ToCs challenged the teams’ initial assumptions based on new evidence and experience. In contrast, the ToCs were only minimally used for accountability purposes.ConclusionsThe ToC development and revision process helped FHS research teams, and occasionally key local stakeholders, to reflect on and make their assumptions and mental models about their respective interventions explicit. Other projects using the ToC should allow time for revising and reflecting upon the ToCs, to recognise and document the adaptive nature of health systems, and to foster the time, space and flexibility that health systems strengthening programmes must have to learn from implementation and stakeholder engagement.

A cross-sectional study of malaria endemicity and health system readiness to deliver services in Kenya, Namibia and Senegal.

Despite good progress towards elimination, malaria continues to contribute substantially to the sub-Saharan African disease burden. Sustaining previous gains requires continued readiness to deliver malaria services in response to actual disease burden, which in turn contributes to health systems strengthening. This study investigates a health system innovation. We examined whether malaria prevalence, or endemicity, is a driver of health facility readiness to deliver malaria services. To estimate this association, we geo-linked cross-sectional facility survey data to endemicity data for Kenya, Namibia and Senegal. We tested the validity and reliability of the primary study outcome, the malaria service readiness index and mapped service readiness components in a geographic information system. We conducted a weighted multivariable linear regression analysis of the relationship between endemicity and malaria service readiness, stratified for urban or rural facility location. As endemicity increased in rural areas, there was a concurrent, modest increase in service readiness at the facility level [β: 0.028; (95% CI 0.008, 0.047)], whereas no relationship existed in urban settings. Private-for-profit facilities were generally less prepared than public [β: -0.102; (95% CI - 0.154, -0.050)]. Most facilities had the necessary supplies to diagnose malaria, yet availability of malaria guidelines and adequately trained staff as well as medicines and commodities varied. Findings require cautious interpretation outside the study sample, which was a more limited subset of the original surveys' sampling schemes. Our approach and findings may be used by national malaria programs to identify low performing facilities in malarious areas for targeted service delivery interventions. This study demonstrates use of existing data sources to evaluate health system performance and to identify within- and cross-country variations for targeted interventions.

The DIY Digital Medical Centre.

SummaryHealthcare systems worldwide are confronted with major economic, organizational and logistical challenges. Historic evolution of health care has led to significant healthcare sector fragmentation, resulting in systemic inefficiencies and suboptimal resource exploitation. To attain a sustainable healthcare model, fundamental, system‐wide improvements that effectively network, and ensure fulfilment of potential synergies between sectors, and include and facilitate coherent strategic planning and organisation of healthcare infrastructure are needed. Critically, they must be specifically designed to sustainably achieve peak performance within the current policy environment for cost‐control, and efficiency and quality improvement for service delivery. We propose creation of a new healthcare cluster, to be embedded in existing healthcare systems. It consists of (i) local 24/7 walk‐in virtually autonomous do‐it‐yourself Digital Medical Centres performing routine diagnosis, monitoring, prevention, treatment and standardized documentation and health outcome assessment/reporting, which are online interfaced with (ii) regional 24/7 eClinician Centres providing on‐demand clinical supervision/assistance to Digital Medical Centre patients. Both of these are, in turn, online interfaced with (iii) the National Clinical Informatics Centre, which houses the national patient data centre (cloud) and data analysis units that conduct patient‐ and population‐level, personalized and predictive(‐medicine) intervention optimization analyses. The National Clinical Informatics Centre also interfaces with biomedical research and prioritizes and accelerates the translation of new discoveries into clinical practice. The associated Health Policy Innovation and Evaluation Centre rapidly integrates new findings with health policy/regulatory discussions. This new cluster would synergistically link all health system components in a circular format, enable not only access by all arms of the health service to latest patient data, but also automatic algorithm analysis and prediction of clinical development of individual patients, reduce bureaucratic burden on medical professionals by enabling a greater level of focus of their expertise on non‐routine medical tasks, lead to automatic translation of aggregate patient data/new knowledge into medical practice, and orient future evolution of health systems towards greater cohesion/integration and hence efficiency. A central plank of the proposed concept is increased emphasis on reduction of disease incidence and severity, to diminish both patient suffering and treatment costs. This will be achieved at the individual and population levels, through (i) significantly improved access to medical services, (ii) stronger focus on primary and secondary prevention and early treatment measures, and disease susceptibility prediction via personalized medicine, involving inter alia genome analysis at birth and periodic analysis of microbiomes and biomarkers, and integration with other patient health and epidemiology parameters, (iii) improved surveillance and (iv) intervention outcome benchmarking. The dMCs will become drivers of innovation and integrative evolution in health systems, of disease reduction and efficiency gains, and thus major contributors to development of sustainability of health care.