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Health Care and Government Policy

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Laurinda Abreu

Health systems at the stage of complexity

The need for collaborative intelligence

Constantino Sakellarides, Ana Escoval, Patrícia Barbosa, Ana Isabel Santos, Ana Rita Pedro et Débora Miranda

Résumé

Health systems are becoming increasingly complex and hard for their stakeholders to understand. It is now both necessary and possible to address health systems change management from a complexity perspective. To do so, a set of complementary conceptual frameworks that can provide an integrated and comprehensive understanding of relevant change processes in health systems have been identified, described and adopted: (a) a personal and interpersonal problem-solving and development aspirations framework; (b) organisational and managerial strategies; (c) a public policy matrix; and (d) a cultural values map. These conceptual constructs, based on different theoretical contributions, are necessarily subject to continuous updating, review and change.

It is suggested that the notion of collaborative intelligence may be particularly relevant in this context. Collaborative intelligence can be defined as the active search for and analysis of critical information – in line with the trends expected to occur in the change management frameworks adopted – and the timely sharing of this information with all relevant stakeholders in a way conducive to convergent action.

The Portuguese national health service (Serviço Nacional de Saúde – SNS) requires major change in terms of person-centredness, healthcare integration and financial support. A recent development, the ‘Person-centred SNS’ initiative (SNS+ Proximidade) responds to some of these objectives. A Collaborative Intelligence initiative could be useful in promoting, supporting and sustaining such changes.

At this stage of complexity, collaborative and adaptive policy making and implementation are necessary, and collaborative intelligence will become one of its key requirements.

Texte intégral

1. Introduction: Health systems are facing challenging times

1Health systems are evolving rapidly and becoming more complex and less easy for most people to understand (Greer et al., 2016b; Kluge et al., 2018). These changes are due to a large number of internal and external influences, including: public health challenges arising from the rapid transmission of life-threatening communicable diseases from distant locations and lifestyle risks; dominant, often-untraceable, external supranational influences and persistent financial threats; demographic shifts; new, sometimes disruptive and often costly new technologies; complex market mechanisms; weak public policy design and implementation; more informed and active stakeholders, health service users who are more inclined to express their concerns and expectations; global job markets and professionals’ dissatisfaction with the health systems where they practise.

2Western European health systems are still, to a large extent, expressions of the industrial revolution and post-World War II ‘social contract’. For each new level of economic growth achieved, better well-being objectives were offered to ensure the kind of social stability necessary to attain more economic growth, which in turn would lead to improved well-being. As post-war economic growth subsided, this initial formula evolved towards a more general expectation: an explicit and transparent political process for harmonising financial, economic and social policies.

3The design and implementation of a social contract entails two basic components: an institutional component (welfare-state institutions) on one hand, and the way social interactions actually occur ‘around’ these institutions (governance) on the other. It is the combination of these two elements that shapes the real expression of a social contract. On-going changes in European societies tend to weaken the institutional aspect of social contracts and reinforce the governance one, adding to the increasing complexity of current health systems.

4Under these circumstances, it is here suggested that the notion of collaborative intelligence might be helpful in reinforcing the institutional component of social contracts and, in very particular cases, the governance component as well. In simple terms, collaborative intelligence is here defined as the active search for and analysis of critical information, in line with the trends expected to occur in the management of the change frameworks adopted, and the timely sharing of this information with all relevant stakeholders in a way conducive to convergent action. The theoretical foundations of this notion are summarised in this contribution. Our working hypothesis is that it is now both possible and necessary to look at health systems from a complexity perspective and that the notion of collaborative intelligence is especially useful in managing change in complex health systems.

5Complexity is generally perceived to be a prevailing feature of current social systems in economically advanced societies. This concept is increasingly used in health systems literature, notwithstanding the fact there is still a need to work towards commonly accepted definitions in this domain. In reviewing this issue, Thompson et al. (2016) indicate that the most common attributes of complexity theory used in health services research include ‘relationships’, ‘self-organisation’ and ‘diversity’, and particular importance is attached to the way diverse relationships and communications between individuals in a system can influence change. For Braithwaite et al. (2017), key features of complexity science applied to health systems are multidimensionality (many components) and interrelatedness (many interactions).

6Our understanding of health systems can benefit if they are analysed as ‘complex adaptive systems’, as described by the University of Minnesota report Applying Complexity Science to Health and Health Care (Center for the Study of Health and Health Care Management, 2003). In this approach, traditional systems are seen as machine-like, controlling and predictable, rigid and self-preserving, finding comfort in control, repeating the past, being autonomous with somebody in charge, resisting change, burying contradictions, and being stable and disengaged. Contrastingly, complex adaptive systems are like living organisms: unpredictable, adaptable, flexible and creative, open and continuously evolving, responsive and catalytic, offering alternatives, acknowledging paradoxes, collaborative and connected.

7A set of conceptual frameworks necessary for understanding and influencing health systems change under current circumstances is outlined here. Health systems need to be understood, influenced and governed simultaneously at ‘macro’, intermediate (‘meso’) and ‘micro’ action levels:

  • At the systems periphery, at a micro level, there are personal and interpersonal decision-making processes taking place, involving professional practices and personal choices by individuals and their relatives. The quality of these decisions can be improved.

  • At an intermediate level there are complex organisational and managerial settings, and known change strategies need to be taken into account.

  • Finally, at a more macro level, public policies need to be agreed, designed and implemented in the areas of public health, health service financing, organisation and management, human resources and professional development, and the adoption of new technologies.

8All these decision-making settings are imbedded in cultural values. These may facilitate or hinder what may seem to be appropriate technical and political solutions. In this context, a comprehensive view of the requirements for managing change at all these different action levels is necessary.

9Current changes in the Portuguese health systems and national health service (Serviço Nacional de Saúde – SNS) can be selectively called upon to illustrate the need to adopt such a complexity perspective in health systems developments. An initiative aimed at progressively transforming the SNS has been taking place since early 2017: the ‘Person-centred SNS’ initiative (SNS+ Proximidade – Ministério da Saúde, 2017). This initiative focuses strongly on two relevant dimensions: enhancing individual and community capabilities for making informed decisions on health and health care; and integrating health care by managing personal trajectories through necessary healthcare services. These concerns relate to personal and interpersonal decision making on health promotion and health care, to organisational and managerial strategies, and to appropriate public policies, in line with prevailing cultural values.

10Meanwhile, the SNS has been subject to major financial constraints at least since 2010. Addressing this issue requires an understanding of current obstacles to re-harmonising financial, economic and social policies and the evolving nature of the underlying social contact for health. A Collaborative Intelligence initiative can here play an important role by providing broad support for both institutional development and good governance.

2. Understanding health systems from a complexity perspective

11A number of conceptual frameworks at distinct decision-making intervention levels need to be identified and used jointly to address the complex nature of health systems and to deal effectively with their change processes. Our working hypothesis is that the following conceptual constructs may fulfil such purposes:

  • Personal and interpersonal problem-solving and development aspirations (at the micro level),

  • Organisational and managerial strategies (at the intermediate, ‘meso’, level),

  • Public policy matrix (at the macro level),

  • Cultural values map (at all levels).

12These frameworks are based on various theoretical contributions to the literature in relevant scientific disciplines. They are necessarily subject to continuous upgrading as knowledge progresses. Therefore, they need to be seen as continuously evolving constructs, rather than definitive ones.

2.1 Personal and interpersonal problem-solving and development aspirations

13A shift from a disease-centred perspective focusing particularly on non-communicable diseases to a person-centred perspective focusing on multimorbidity is taking place in healthcare thinking. Multimorbidity has been defined in many different ways (Academy of Medical Sciences, 2018). The definition adopted by the UK National Institute for Clinical Excellence (NICE) clinical guidelines (National Guideline Centre (UK), 2016) offers a useful comprehensive insight into this complex notion. NICE describes multimorbidity as ‘the presence of two or more chronic health conditions, which can include: defined physical and mental health conditions such as diabetes or schizophrenia; ongoing conditions such as learning disability; symptom complexes such as frailty or chronic pain; sensory impairment such as sight or hearing loss; alcohol and substance misuse.’

14A broad-based epidemiological study of multimorbidity in Scotland (Barnett et al., 2012) estimated the prevalence of this condition at approximately 23%, observed that the onset of multimorbidity occurs 10-15 years earlier in people living in the most deprived areas than in those in the most affluent ones, and noted that this condition is often associated with mental health disorders. These authors concluded that their findings challenge the single-disease framework of most current approaches to health care, research and education, and that a more personalised, comprehensive and continuous care strategy is now necessary.

15This is, in fact, what the personal and interpersonal decision-making framework (Figure 1) is about: evolving from a ‘one problem – one solution’ paradigm (1) towards identifying specific population groups (clusters) with multimorbidity and developmental aspiration patterns that can benefit from a set of actions agreed between those that need care and those that provide it (2 and 3). Finally, adjustments can be made, as yet based predominantly on judgment, to respond to individual specificities (4).

Figure 1 - Personal and interpersonal problem-solving and developmental aspiration decision-making framework: a transition towards a person-centred, community-sensitive, integrated paradigm of health promotion and care

Figure 1 - Personal and interpersonal problem-solving and developmental aspiration decision-making framework: a transition towards a person-centred, community-sensitive, integrated paradigm of health promotion and care

16The way one might aspire to a more physically, intellectually and emotionally active and rewarding life needs to be considered a part of these decision-making processes. Such aspirations include: developing quality interpersonal relations; preventing social isolation, abuse and violence; reinforcing community membership; and matching narratives about past experiences with a positive outlook for the future of upcoming generations. The kind of transition from current healthcare models towards a combined paradigm of ‘precision’ (Hunter, 2016) and ‘narrative medicine’ (Zaharias, 2018; Simões, 2016) will depend strongly on the quality, volume and diversity of the data, as well as on the computational power available to analyse it. This dependence also applies to all the decision-making frameworks outlined in this paper.

17In summary, the personal and interpersonal problem-solving and developmental aspirations framework calls for a transition from a single-problem mind-set, associated with a fragmented, discontinuous healthcare response, to a person-centred, community-sensitive, integrated paradigm of health promotion and care. In a person-centred health system, healthcare integration is achieved mainly by managing value-adding personal healthcare trajectories.

18The opportunities and obstacles, as well as the progress observed in this transition, in conjunction with the changes that might be occurring at the ‘meso’ and ‘macro’ health systems levels, should be monitored and effectively shared among all health systems stakeholders in order to elicit convergent action supporting a more rapid and successful pace of change.

2.2 Organisational and managerial strategies

19Simplified, centralised, top-down, command-and-control, non-participatory organisational and managerial environments are still frequently found in health services. Since professional practices and responsiveness to the public’s perceptions and needs in health systems are hardly compatible with such a normative paradigm, its actual implementation is always very partial. This leads to a number of ambiguities and dysfunctional situations, including the inability to take full advantage of the benefits of top-down decision making in those well-defined and limited circumstances where it is necessary and valuable.

20The organisational and managerial strategies in the framework in Figure 2 (adapted from Mintzberg and Lampel, 2000; Mintzberg et al., 2003) can be summarised as follows. An underlying ‘boundary’ assumption distinguishes internal organisational processes – ranging from top-down simplified rationalisations (such as planning and programmes) to bottom-up innovative initiatives – from the external environment that an organisation is expected to influence. The outcomes of this external influence can be either reasonably predictable and controllable or, at the other extreme, quite unpredictable.

21Depending on where a given situation is placed in this matrix, an organisation can adopt different approaches (Figure 2, numerical labels): top-down rational simplifications such as traditional planning (1); bottom-up innovative initiatives (2); uncertainties associated with contingency planning, through alternative future scenarios (3); learning organisations, as a response to quasi-chaos situations (4); and a partial mix of all of the above situations, representing a highly complex mode (5). The last is often the case with organisational and managerial decisions in health systems. In fact, health systems are complex realities. All these approaches are necessary, often simultaneously, some having a predominant role over others depending on the circumstances.

22On the basis of this matrix, prevailing organisational and managerial modes can be identified and desirable change patterns agreed upon, allowing stakeholders to engage in concerted action towards a positive developmental agenda.

Figure 2 - Organisational and managerial strategies in health systems: from a simplified centralised, top-down, command-and-control, non-participatory paradigm towards complex adaptive health systems thinking

Figure 2 - Organisational and managerial strategies in health systems: from a simplified centralised, top-down, command-and-control, non-participatory paradigm towards complex adaptive health systems thinking

Adapted from Mintzberg and Lampel, 2000; Mintzberg et al., 2003

2.3 Public policy matrix

23At the more macro level, public policies need to be agreed, designed and implemented on a large number of relevant issues. A public policy matrix, adapted from Ralph Stacey’s work (Stacey, 2002), is suggested as a useful summary of key public policy decision-making issues (Figure 3). Two dimensions define the contents of this matrix. The first represents the degree of agreement (or cohesion) observed in both the various public sectors involved in health policies and the various political agendas. In fact a minimally stable socio-political environment requires two levels of political interactions: a convergent one, based on common values, and a divergent one resulting from different ways of ranking some of these values. A balance between these two modes of political interaction is essential for improving health systems in the ways outlined in the ‘micro’ and ‘meso’ frameworks described above.

24The second dimension represented in this public policy matrix concerns the available knowledge base used for policy decision-making purposes. It refers to the precision of this knowledge base and the quality of the available information used by stakeholders as they involve themselves in the policy-making process.

25Consequently, three different content domains are defined by this matrix: concerted rational decision making, a desirable circumstance that does not occur frequently in health policy making and implementation (1); contrastingly, a situation leading to confrontational and intangible policy-making processes, resulting in problematic health systems evolution (3); and typical complexity domains, where the principles of good governance – inclusion, transparency, accountability, contestability – play an important role (2).

26It is suggested that this framework makes it possible to track health policy developments and motivate stakeholders to contribute to more concerted, knowledge-based and participatory policy-making processes.

Figure 3 - Public policy decision-making matrix: Inter-sectoral and political concordance and the nature and quality of the information and knowledge required to decide health policy

Figure 3 - Public policy decision-making matrix: Inter-sectoral and political concordance and the nature and quality of the information and knowledge required to decide health policy

Adapted from Stacey, 2002

2.4 Cultural values map

27The Inglehart-Weizel cultural values maps (World Values Survey Association, 2002) can be used identify the cultural values environments where specific health systems evolve. These are bound to influence all three decision-making frameworks represented above. Four quadrants can be found in these values maps (Figure 4): a traditional/survival values domain (1); a traditional/self-expression quadrant (2); a secular-rational/survival domain (3); and finally a secular-rational/self-expression quadrant (4).

28Values evolve slowly. Becoming aware of their relevance is important, especially in a complexity perspective. This is a matter where it is possibly less appropriate to expect convergent preferences, particularly on the traditional/secular-rational axis. However, it might be easier for people to agree on the advantages of evolving from survival to self-expression values.

Figure 4 - Cultural values map

Figure 4 - Cultural values map

Adapted from World Values Survey Association, 2002

29It is important to note that, in a context of collaborative intelligence and complexity, the micro, meso and macro levels of decision making, as well as cultural values mapping, must be viewed jointly by all stakeholders concerned (Figure 5).

Figure 5 - Visual representation of an integrated health systems complexity framework

Figure 5 - Visual representation of an integrated health systems complexity framework

3. The notion of collaborative intelligence and its theoretical foundations

30Collaborative intelligence for health, broken down into its constituent elements, is here defined as (a) the purposeful search for, collection and analysis of critical information, (b) in line with desirable trends expected to occur in the context of the adopted management of change frameworks, (c) displayed and shared with all stakeholders, (d) in a way conducive to convergent action, (e) in order to achieve commonly accepted goals for protecting and promoting personal and community health.

3.1 The notion of collaborative intelligence includes two significant domains:

  1. Understanding complexity in order to elicit decision-making capacity in relation to commonly accepted goals.
    In this context, intelligence can be defined as the ability to purposefully and actively search for, acquire, organise and apply the knowledge and skills needed to fulfil intended objectives.

  2. Promoting concerted action, through effective information sharing and collaboration.
    Collaboration is generally perceived as ‘the action of working with someone to produce something’. It requires proximity, good communication and trust, and, in the context of health governance, can result from different sorts of motivations: mandatory cooperation, selfish cooperation, win-win cooperation and cooperation as a social value (Ruger, 2011).
    Sharing knowledge in a way conducive to convergent action requires considerable investment in good communication practices, in which a number of often complementary approaches need to be taken into account, including the following:

  • Visual thinking. This has been defined as the ‘the ability to find meaning in imagery’. For Dave Gray (2014) visual thinking is ‘a way to organize your thoughts and improve your ability to think and communicate.’

  • Metaphorical language. In a metaphor a thing can be regarded as representative or symbolic of something else. Significantly, the word metaphor is rooted in a Greek world that means ‘transfer’. Ottati and Renstrom (2010) state that ‘Metaphor serves multiple functions in persuasive communication, and the effect of metaphor on persuasion is potentially mediated by multiple psychological process mechanisms.’

  • Storytelling. This is the skill and practice of delivering good stories. Stories give otherwise isolated facts and experiences some sort of meaning: ‘The universe is made of stories, not of atoms’ (Muriel Rukeyser: Rukeyser, n.d.).

31The current underlying logic and dynamics of social media provide a special challenge for both intelligence and collaborative environments.

3.2 Theoretical foundations of collaborative intelligence

32The theoretical foundations of the concept of collaborative intelligence are rooted in a number of knowledge domains and disciplines. The most significant of these foundations are summarised here:

33(a) Collective intelligence
Francis Heylighen (2014), from the Global Brain Institute in Belgium, refers to this notion as an internet-based ‘global brain’, shared by all those pursuing a common goal. He refers to emergent mind as a network of agents that will act as a single coherent system on the basis of a collective perception of challenges, distributed knowledge and intelligence, shared values and distributed action.
Jerome Glenn, from the Millennium Project (Glenn, 2013), defines collective intelligence as: ‘An emergent property from synergies among three elements – (i) data/info/
knowledge, (ii) software/hardware, and (iii) experts and others with insight – that continually learns from feedback to produce just-in-time knowledge for better decisions than any of these elements acting alone.’
For Thomas Malone (Gimpel, 2015), at the MIT Centre for Collective Intelligence, the key question that collective intelligence addresses is ‘how can people and computers be connected so that—collectively—they act more intelligently than any singular person, group, or computer has ever done before.’ Collaborative intelligence can also be seen as a more purposeful, structured and targeted version or component of collective intelligence.

34(b) Knowledge brokering
Knowledge brokering has been defined as follows (Lavis et al., 2014): ‘The use of information-packaging mechanisms and/or interactive knowledge-sharing mechanisms to bridge the disjuncture between information and action in the policy-making process’. Although knowledge brokering is usually thought to be part of a collaborative process, it may also take place in highly confrontational and tactically planned procedures (Sakellarides et al., 2014b) or in situations where the availability of relevant information may be highly constrained or undesirable (Sakellarides et al., 2014a).

35(c) Health literacy, critical literacy, multiliteracies
Health literacy is generally defined as the ability to make informed decisions about one’s health in day-to-day living (Kickbusch, 2005). The notion of ‘critical’ literacy goes beyond decisions on personal health to include the set of skills that allow people to actively participate in decision making on community health and health services development (Sykes et al., 2013). The term multiliteracies was first used by a group of researchers and educators in New London, USA (the New London Group, 1996), concerned with the use of new communication technologies in a global world. In essence, multiliteracy implies targeting different population groups through multiple communication channels. As expected, its ‘communication’ component is being progressively expanded. In this context, multiliteracy has also been defined as the ability to ‘identify, interpret, create, and communicate meaning across a variety of visual, oral, corporal, musical and alphabetical forms of communication. Beyond a linguistic notion of literacy, multiliteracy involves an awareness of the social, economic and wider cultural factors that frame communication’ (Müller et al., 2009). Some examples of multiliteracy developed within the Portuguese ‘Patient-Centred SNS’ initiative are described in section 4.2.
In some ways, collaborative intelligence can be seen as an advanced, more structured and targeted form of multiliteracy.

36(d) Governance and good governance
The concepts of governance and good governance are of significant importance in this context. Governance refers to the process whereby elements in society interact to influence the attainment of objectives in domains of common interest (World Bank, 1992, 2017). Good governance pertains to the normative framework of the governance process, including the notions of transparency, accountability, participation, integrity and policy capacity (Greer et al., 2016c).

4. Managing health systems change in Portugal, from a complexity perspective

37Recent developments related to the SNS illustrate the relevance of considering a health system’s complexity and collaborative intelligence to change management. Two domains seem particularly suitable for this purpose. The first encompasses the issues of multimorbidity, health care integration and health literacy, which were addressed when discussing the personal and interpersonal decision-making framework. The second set of issues focuses on health systems financing and its underlying ‘social contract’.

4.1 Multimorbidity, integrated care and a life-course perspective of health literacy

38A noticeable feature of the current Portuguese health profile is the low healthy life expectancy at age 65 (Figure 6).

Figure 6 - Healthy life years expected at age 65 in selected European countries, 2015 (or nearest year)

Figure 6 - Healthy life years expected at age 65 in selected European countries, 2015 (or nearest year)

Adapted from OECD, Health at a Glance, 2017

39Under these circumstances, preventing the early onset of multimorbidity by investing in life-course health literacy promotion and adopting more person-centred, integrated forms of health care becomes a clear priority. During 2017, the Portuguese Ministry of Health decided to adopt an initiative known as ‘SNS+ Proximidade’ (which can be translated as ‘Person-centred SNS’) aimed at implementing the first steps towards a person-centred, better integrated national health service. This initiative was designed to include the following components (Figure 7):

Figure 7 - Main components of the Portuguese ‘Person-centred SNS’ initiative

I. Health care – Integration

Person-centred multimorbidity management

Acute condition management

Home-care investment and coordination

II. Person centredness – Life course approaches

Life course and health – local health plans

Health literacy and participation strategies

Promoting a person-centred SNS

III. Change management

40There is broad consensus that such integrated person-centred health care is a highly relevant and challenging proposition (World Health Organization, 2016). It requires new collaborative tools. Therefore, in the first phase of the ‘Person-centred SNS’ initiative, considerable technical investment was made in two directions. The first of these was towards developing a mostly web-based ‘personal healthcare plan’ to help in managing the healthcare trajectory through the SNS for patients with multimorbidity. The key issues in this management are summarised in Figure 8.

Figure 8 - Healthcare trajectory through the SNS for persons with multimorbidity

Figure 8 - Healthcare trajectory through the SNS for persons with multimorbidity

Translated from Ministério da Saúde, 2017

41Secondly, a set of instruments of a new kind was developed, aimed at promoting life-course health literacy, which is indispensable both for person-centred care and for community health promotion purposes. The personal health diary – ‘My Health Diary’ – plays an important role in this context, but other such tools, including a digital health literacy library and a collection of thematic microsites in the form of digital books, are also relevant here (Figures 9 and 10).

Figure 9 - Life-course literacy for improving health and health care – new collaborative tools for the SNS

Figure 9 - Life-course literacy for improving health and health care – new collaborative tools for the SNS

Translated from Ministério da Saúde, 2017

Figure 10 - Key elements of the initial steps towards a Portuguese health literacy strategy

Figure 10 - Key elements of the initial steps towards a Portuguese health literacy strategy

Translated from Ministério da Saúde, 2017

42These tools were designed to support person/patient activation activities in health centres, pharmacies, schools, public libraries and other community settings, where local mediators – intermediaries between the new digital tools and the community at large – can assist in these activation exercises (Elwyn et al., 2016; Hibbard and Gilburt, 2014).

43However, the ‘Person-centred SNS’ initiative also calls for a refined strategy of change, since healthcare integration solutions are known to enjoy limited social, political and professional support, at least at the outset. Implementing such an initiative requires substantial managerial and organisational changes. In view of the organisational and managerial strategy framework described so far, it seems reasonable to assume that it is necessary to move from the command-and-control organisational setting that still prevails in the Portuguese SNS to a more decentralised and innovative one, empowering local leadership as public entrepreneurs. Promoting collaborative intelligence – what stakeholders need to know to ensure convergent action towards a person-centred SNS – is relevant for improved personal and interpersonal decision making and for better organisational and managerial strategies. Managing such transitions so as to improve the quality of policy decision making is also necessary. It is also helpful to be aware of the pace and direction of the cultural transitions taking place in Portugal, in Europe and globally.

4.2 Health financing – the changing nature of the social contract for healthcare funding

44The Portuguese health system has been under severe financial strain in recent years. This is, to a considerable extent, a consequence of the economic recession after the 2007 financial crisis, the limited economic growth experienced particularly after 2000 (when the country became part of the euro economy), and the severe and abrupt form of fiscal austerity imposed during the current decade.

45The effects of these circumstances on real growth in GDP and, particularly, on healthcare spending trends from 2000 to 2015 have been dramatic in both absolute and relative terms, as recently shown by Charlesworth and Bloor (2018) and clearly illustrated in Figure 11.

Figure 11 - Growth in real health spending per capita (%) compared to real GDP growth per capita (%) between 2000 and 2015, in selected European countries

Figure 11 - Growth in real health spending per capita (%) compared to real GDP growth per capita (%) between 2000 and 2015, in selected European countries

Adapted from Charlesworth and Bloor, 2018

46In fact, Portugal experienced very limited economic growth during this 15-year period – only Greece and Italy did worse in this regard – but there was also practically no health spending growth during this same period, in sharp contrast to all other European countries analysed.

47The social and health consequences of this phenomenon, in Portugal and elsewhere, have been described by the Portuguese Health Systems Observatory (Observatório Português dos Sistemas de Saúde, 2012; Sakellarides et al., 2014a; Sakellarides, 2014; Santana et al., 2015; Greer et al., 2016a; Helderman, 2015; Karanikolos et al., 2016).

48Although these negative trends became more evident over a relatively prolonged time period, they did not seem to elicit the kind of social and political response they deserved either in Portugal or in Europe. In Portugal, especially since 2017, there has been mounting pressure to increase health budgets. However this does not seem to be part of a broad-based, coherent social and political movement towards harmonised fiscal, economic, social and health policies. This policy environment adds further obstacles to the implementation of reforms such as the ‘Person-centred SNS’ initiative, and calls for a more in-depth analysis of the nature of the social contract for health underlying current public policies.

4.3 The social contract for health in the twenty-first century

49After the Second World War, a surge in social solidarity and gregarious urban living resulted in the revival and reinforcement of the social contract inherited from the industrial welfare state. However, these kinds of ties have been weakened in recent decades by a rise in individualistic behaviour, mobility within and between countries, a greater distance between generations, the aging population, slow economic growth, rising inequalities and the increasing dominance of the financial sector of the economy. At the same time, country-specific social contracts have weakened as the boundaries of public sectors and nation-states have become more permeable to external influences (Sakellarides, 2009).

50People find it difficult to understand what in fact is occurring in their health system and they feel unable to influence it in any way. It seems currently even more evident that ‘they fear that their governments lack the culture, imagination and will to take advantage for everyone’s benefit of the enormous potential of intelligence, knowledge and creativity available in today’s society’ (Coulter and Magee, 2003).

51As mentioned above, the loss of the institutional memory rooted in the philosophical and political thinking that grew out of the welfare revolution and post-war social environment comes associated with an increasing weight of common social interactions in shaping how a health system works. What people experience, feel, find out, believe, know and share about their health and health system in their day-to-day living does make a difference. In fact it is now necessary to move on from a traditional, institutional, social contract way of thinking (Rawls, 1971) to one that fully recognises the essential role of social interactions in health governance and the importance of ‘agreements based on public reasoning’ fuelled by the values of integrity and fairness (Sen, 2009). This includes the need to work across social and economic sectors, harmonising financial, economic and social policies (Stuckler and Basu, 2013) beyond international boundaries (Figure 12).

52Collaborative intelligence has the potential for supporting people in understanding and engaging in the on-going transition from the traditional social contract, inherited from the industrial age, to a twenty-first-century social contract for health.

Figure 12 - Main features of a ‘new’ social contract for health, adding to or improving on the ‘traditional’ social contract

Figure 12 - Main features of a ‘new’ social contract for health, adding to or improving on the ‘traditional’ social contract

5. Future developments: a Collaborative Intelligence initiative

53In this work the theoretical foundations of the role of collaborative intelligence in health systems change have been systematically surveyed. A theoretical framework is now in place to stimulate a Collaborative Intelligence Initiative to support complex health systems development. For each of the development frameworks described above, desirable future trends are hypothesised for the Portuguese health system (Figure 13) under current conditions, on the basis of the available scientific evidence on health systems change dynamics, as briefly reviewed above.

54The issue, then, is how to identify, analyse, display and share useful and stimulating comparisons between the change expected in line with the preferred evolutionary trends set out here and the progress actually observed in these same domains. Getting such comparisons to play a significant role in stakeholders’ understanding of desirable directions of health system change, leading them to take convergent action, is the key role of collaborative intelligence for health. These comparisons are based on selected qualitative and quantitative ‘tracer descriptors’, based on the four frameworks represented in Figure 13 and also on the way they interact with each other.

55For the personal and interpersonal decision-making framework as it pertains to the Portuguese health system in its current state (Figure 13-A), content domains to monitor in progressing from stage 1 (S1) to stage 3 (S3) include the following:

  1. Person-centred management of health trajectories through healthcare services, focusing on multimorbidity: identifying multimorbidity population clusters and the sets of actions most likely to influence them positively that can be included in their personal healthcare plans. Progress can be monitored by analysing the extent to which these plans achieve their stated objectives, including those resulting from managing acute care and satisfactory, integrated, home care.

  2. Investing in a health literacy promotion strategy based around appropriate usage patterns of a health literacy library, ‘My Health Diary’ and the evaluation of person/patient activation protocols applied in a variety of community settings, with the support of the health literacy mediators who normally operate in these settings.

Figure 13 - Hypothetical desirable trends in health systems development: conceptual basis for developing a Collaborative Intelligence initiative

Figure 13 - Hypothetical desirable trends in health systems development: conceptual basis for developing a Collaborative Intelligence initiative

56Similarly, the monitoring of the expected change resulting from current organisational and managerial strategies in the Portuguese health system (Figure 13-B) needs to include the following aspects:

  1. Evolving from predominantly centralised, top-down organisational and managerial approaches to primary health care, long-term care and hospitals to more decentralised, bottom-up, self-managed approaches. This transition implies considerable improvements in performance contracting and performance-related financing and pay, and more open and participatory SNS organisations that can attract and retain qualified health professionals.

  2. Identifying, supporting and empowering public entrepreneurs to take up leadership roles in local SNS units and to adapt SNS change strategies to local realities through innovation in management, information, communication and health care. This will result in flexible adaptive responses to local, national and international contingencies and an organisational environment that welcomes users.

57Expectations for improving public policies (Figure 13-C) can be summarised as follows:

  1. Promoting better understanding and transparency regarding the balance between the convergent component of political interaction (based on common values) and the divergent component (prioritising different values), as expressed in relation to various health policy issues discussed in the public and political arenas; monitoring political and public perceptions concerning the idea of a social contract for health, and the way it may be evolving.

  2. Making explicit the knowledge base used or referred to in relation to policy issues on the political agenda; closely monitoring changes in key tracer descriptors of health policy outcomes, such as those represented in Figure 6 (healthy life years expected at age 65) and Figure 11 (growth of health spending in Portugal, in terms of GDP growth, as compared with other European countries).

58Anticipating desirable patterns of change in the country’s position on the cultural value map (Figure 13-D) is inherently more difficult and disputable. It is, however, possibly acceptable to state that the transition from ‘survival’ to ‘self-expression’ values is of significance in evolving towards person-centred care and participatory organisational and managerial modes. On the other hand, more ‘secular-rational’ values could be seen as less constraining if a more positive balance between convergent and divergent postures in political interactions is particularly valued.

59More desirable trends can be monitored, in general terms, as follows:

  1. Surveying progress in public participation and engagement in debates on health policy and the development of health services, with special attention to social capital improvement in Portugal (self-organisation capabilities and public trust).

  2. Tracking developments indirectly associated with political and cultural values and health policies, such as child poverty, social mobility or social inequalities.

60As stated above, dealing with complexity encompasses many distinct health systems dimensions as well as the interactions among them. The interplay between different sorts of transitions in each of the four frameworks adopted (A, B, C and D in Figure 13) can generally be exemplified as follows: Evolving from A-1 to A-3 is unlikely to occur, unless there is some progress from B-1 to B-3 and C-1 to C-3. The same can be said in relation to B, in terms of C and D. Conversely, success in A and B may induce progress in C and D. The way cultural transitions (from D-1 to D-3) may or may not occur is bound to constrain or facilitate health systems changes.

61A more technical description of how to deal with the tracer descriptors needed to implement a Collaborative Intelligence initiative in Portugal step by step will be presented elsewhere as a follow-up to this paper. Nevertheless, the main features of the initial phase of such a development are worth mentioning here briefly:

  1. Qualitative and quantitative tracer descriptors for personal and interpersonal decision making are identified for a specific time period. Given that the ‘Person-centred SNS’ initiative and personal health care plans are at a very early stage of development, some basic assumptions are needed about how these descriptors may evolve in the future under different organisational, policy and cultural scenarios.

  2. Dealing with the sort of interactions expected to occur in complex social systems requires selecting suitable analytical tools, from multivariate statistical methods to possible Artificial Intelligence algorithms.

  3. Selected tracer descriptor displays designed to reach different target populations should be tested through person/patient activation exercises.

  4. The effectiveness of different communication channels for distributing collaborative intelligence constructs needs to be predicted and later appropriately assessed.

62This initial phase of a Collaborative Intelligence initiative will be developed within an academic environment, in preparation for later engagement with public health, healthcare organisation and health policy-making bodies.

63With health systems at the stage of complexity, collaborative and adaptive policy making and implementation are required (Swanson and Bhadwal, 2009; Ansell et al., 2017). Under these circumstances, collaborative intelligence is a necessary component of health policy making.

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Table des illustrations

Titre Figure 1 - Personal and interpersonal problem-solving and developmental aspiration decision-making framework: a transition towards a person-centred, community-sensitive, integrated paradigm of health promotion and care
URL http://books.openedition.org/cidehus/docannexe/image/8291/img-1.png
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Titre Figure 2 - Organisational and managerial strategies in health systems: from a simplified centralised, top-down, command-and-control, non-participatory paradigm towards complex adaptive health systems thinking
Crédits Adapted from Mintzberg and Lampel, 2000; Mintzberg et al., 2003
URL http://books.openedition.org/cidehus/docannexe/image/8291/img-2.png
Fichier image/, 61k
Titre Figure 3 - Public policy decision-making matrix: Inter-sectoral and political concordance and the nature and quality of the information and knowledge required to decide health policy
Crédits Adapted from Stacey, 2002
URL http://books.openedition.org/cidehus/docannexe/image/8291/img-3.png
Fichier image/, 84k
Titre Figure 4 - Cultural values map
Crédits Adapted from World Values Survey Association, 2002
URL http://books.openedition.org/cidehus/docannexe/image/8291/img-4.png
Fichier image/, 96k
Titre Figure 5 - Visual representation of an integrated health systems complexity framework
URL http://books.openedition.org/cidehus/docannexe/image/8291/img-5.png
Fichier image/, 132k
Titre Figure 6 - Healthy life years expected at age 65 in selected European countries, 2015 (or nearest year)
Crédits Adapted from OECD, Health at a Glance, 2017
URL http://books.openedition.org/cidehus/docannexe/image/8291/img-6.png
Fichier image/, 19k
Titre Figure 8 - Healthcare trajectory through the SNS for persons with multimorbidity
Crédits Translated from Ministério da Saúde, 2017
URL http://books.openedition.org/cidehus/docannexe/image/8291/img-7.png
Fichier image/, 369k
Titre Figure 9 - Life-course literacy for improving health and health care – new collaborative tools for the SNS
Crédits Translated from Ministério da Saúde, 2017
URL http://books.openedition.org/cidehus/docannexe/image/8291/img-8.png
Fichier image/, 109k
Titre Figure 10 - Key elements of the initial steps towards a Portuguese health literacy strategy
Crédits Translated from Ministério da Saúde, 2017
URL http://books.openedition.org/cidehus/docannexe/image/8291/img-9.png
Fichier image/, 85k
Titre Figure 11 - Growth in real health spending per capita (%) compared to real GDP growth per capita (%) between 2000 and 2015, in selected European countries
Crédits Adapted from Charlesworth and Bloor, 2018
URL http://books.openedition.org/cidehus/docannexe/image/8291/img-10.png
Fichier image/, 57k
Titre Figure 12 - Main features of a ‘new’ social contract for health, adding to or improving on the ‘traditional’ social contract
URL http://books.openedition.org/cidehus/docannexe/image/8291/img-11.png
Fichier image/, 71k
Titre Figure 13 - Hypothetical desirable trends in health systems development: conceptual basis for developing a Collaborative Intelligence initiative
URL http://books.openedition.org/cidehus/docannexe/image/8291/img-12.png
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Auteurs

National School of Public Health, Universidade Nova de Lisboa

sak@ensp.unl.pt

National School of Public Health, Universidade Nova de Lisboa

anaescoval@ensp.unl.pt

National School of Public Health, Universidade Nova de Lisboa

patbarbosa@ensp.unl.pt

National School of Public Health, Universidade Nova de Lisboa

ai.santos@ensp.unl.pt

National School of Public Health, Universidade Nova de Lisboa

rita.pedro@ensp.unl.pt

National School of Public Health, Universidade Nova de Lisboa debora.miranda@ensp.unl.pt

© Publicações do Cidehus, 2019

Conditions d’utilisation : http://www.openedition.org/6540