(Version française disponible ici)
This article is the second of two on health reform. The first part is here: The health-care system needs rebuilding.
Health systems worldwide are struggling to meet population needs. Despite successive reforms and repeated political promises, results remain disappointing: lack of evidenced-based quality of care, unequal access, exhausted teams, rising costs. Why do so many efforts produce so few tangible improvements?
Part of the answer lies in magical thinking. Too often, policymakers believe that a plan filled with appealing initiatives will be enough to transform the system. Ambitions are announced without examining the root causes of underperformance or verifying whether the proposed solutions will deliver expected results. This approach, found across many jurisdictions, inevitably fails.
Thinking in the long term
To build a resilient health system, we must break with magical thinking and adopt a more scientific method. That means identifying the real causes of problems, setting clear and realistic targets, establishing a cause-and-effect model between the current situation and the desired outcomes, testing solutions, and adjusting based on results. Ambition matters, but discipline matters even more.
Transforming a health system cannot be done in two or three years. International experience shows that a ten-year horizon seems required. Such a timeframe makes it possible to go beyond electoral cycles and give teams the stability they need to consolidate change.
It is unrealistic to believe that digital transformation, clinical reorganization, or a major shift to community-based care can be achieved within a single political mandate. A long horizon is a condition for success: it allows not only the transformation itself but also the consolidation of gains, so they become sustainable.
Execution first
“Culture eats strategy for breakfast,” said Peter Drucker. We could add: execution eats strategy for dinner. Even the best vision will fail if it is not backed by disciplined execution and a supportive organizational culture.
Execution means translating a strategy into concrete actions, tracking them rigorously, learning from the gaps between expected and actual results, and adjusting along the way. In health care, execution also requires understanding implementation science, which aims to accelerate the adoption of clinical practices and innovations. Too often, a model of care proven effective in one setting takes 15 to 20 years to spread system-wide.
The heart of transformation is not just the vision—it is the ability to make that vision real in the daily lives of teams and patients.
A five-step approach
How can such a transformation be structured? I propose an approach inspired by the principle of execution that aligns strategy and operations, as developed by researchers Robert Kaplan and David Norton, and adapted to the realities of health care systems. This approach is based on five steps:
- Confirm the reason for transformation. A system is not transformed to adopt fashionable technologies or to satisfy particular stakeholders. It is transformed to address a few major issues that directly threaten population health, such as the surge in chronic disease or the lack of timely access to urgent care.
- Define a clear vision. This vision explains how the system will create value for the population, care teams, and stakeholders. It specifies the targeted issues, the ultimate goal (inspired by the Quintuple Aim), guiding principles, desired governance, and the future scenario for service delivery. This scenario is the cornerstone of the vision; which services and treatments to be offered in the future, and how, must must be presented to the public and to care teams.
- Define the strategy. Strategy describes how the system will move from its current state to the envisioned future through coherent, sequenced initiatives based on cause-and-effect logic. It must be understood and validated by stakeholders.
- Establish a roadmap. Initiatives are translated into milestones and aligned with ongoing operations. The roadmap is realistic, progressive, and backed by a resource plan.
- Implement and adjust continuously. Execution relies on a robust management system that monitors results, adjusts actions, and ensures alignment between strategy and operations.
This process is not strictly linear. At times, it is necessary to revisit earlier steps to refine the vision or strategy. But the framework provides clarity and discipline, preventing dispersion.
Principles to guide transformation
The approach rests on guiding principles that must remain stable throughout the process. Among them:
- Population health and value creation must remain the primary intention, not the deployment of tools or institutional restructuring.
- Act simultaneously on supply and demand, optimizing resources while reducing avoidable consumption, notably through prevention and health literacy.
- Integrate digital tools fully into clinical practice, patient engagement, and system management.
- Redirect a substantial share of hospital resources toward local care and community living settings.
- Adopt a ten-year horizon to rise above electoral cycles and allow stabilization.
- Actively involve clinical leaders, administrators, and the population, so transformation is anchored in real-world needs and realities.
These principles are not technical details but foundational choices that give coherence to the entire process.
Transforming a health system is first and foremost a collective endeavour. At every step, communication plays a central role: explaining the reason for change, sharing the vision, mobilizing around the strategy, clarifying the roadmap, celebrating results.
Without the support of citizens, patients, teams, and partners, even the best strategy will remain on paper. Communication must be constant, transparent, and inclusive.
The management system as backbone
Finally, no transformation can succeed without a strong management system. It enables results to be tracked, teams to be aligned, operations to continue while strategy is executed, and continuous improvement to take place.
This is the backbone of transformation. Without it, initiatives pile up but impact is diluted. With it, strategy comes alive in daily actions and becomes sustainable.
Transforming a health system is a daunting challenge, but not an insurmountable one. Success requires rejecting magical thinking, adopting a scientific and disciplined approach, embracing the long term, putting execution at the centre, and anchoring transformation in a solid management system.
Only at this price can a health system truly evolve—not through cosmetic changes, but through a transformation that sustainably improves population health and well-being.
A more detailed version of this approach to transforming the healthcare system is available in this position statement (in French.)
