Health system review vs. health services review

On 19 October 2016, Newfoundland and Labrador Medical Association (NLMA) held a forum to discuss the need for a review of health facilities and services in the province. Stakeholders were invited to a day of presentations and roundtable discussions to decide whether there was a need for a review, and if yes, how should the review be undertaken. I was also invited to the forum. The organizers promised to provide a detailed report of the discussions to all participant, but I would like to share a thought about the event.


I found that the forum had a specific objective, which was to recognize the need for a review of health facilities and services. The participants, however as I observed, were more concerned with the challenges the overall health system was facing.

Health system has six building blocks namely (1) services, (2) financing, (3) human resources, (4) information and research, (5) medical products and drugs, and (6) governance and leadership. These blocks are linked and work in relation to one another. As they say, the system is more than the sum of its parts. You cannot review and propose a change in health services without recognizing the fact that it is linked and will influence, and be influenced by, other parts.

The presentations and discussions raised the issues of the overall structure of the health system being set up for acute care services. It seemed as if all agreed that a system established around physicians and hospitals to manage acute diseases requires transformation to responding to emerging chronic diseases and elderly populations.

Participants discussed financing mechanisms and how fee-for-service and on-and-off budgeting problems influenced the volume and quality of services for populations.

Dr. Wendy Graham, a physician panelists, explained how she undertook tasks of dietitians, mental health counselor, social worker, and other health workers required in the community she served. Recruitment of different types of health workers, scopes of practice, and skill mixes that were required in different communities are all linked to human resources for health.

Dr. David Naylor and Dr. David Peachey showed a similar image of four silos explaining how the health system functioned in silos and was not integrated.


To connect the silos, digitalization of the health system and integration of electronic communication in day-to-day services were discussed in most of the tables. The comment by Federal Minister of Health Jane Philpot that it was shocking that most Canadians still could not go online for their health record resonated with many participants.

In short, I saw a mismatch between the goal of the forum and what most participants were saying. Although 87% agreed that there was a need for a review of health services and facilities, I think what the group meant was a review of the entire system.

Reviewing services and the location of health facilities without reviewing the types of governance around them, the financing system, human resources aspects of the system, and the information and communication system will be as fragmented as the system itself.

I agree with the idea of the review to come up with an actionable proposal for reform, but I think health services could be at the heart of a review in which other components of the health systems are also subject to investigation, reform, and change.


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