The Stew BLOG

Why Strive for Inclusive Health Value?

Bobby Milstein, Director, System Strategy | 02/27/2017

Many years ago, I was fortunate to hear Dr. Bill Foege speak about the formation of the Bill & Melinda Gates Foundation. A giant in the health field, credited with eradicating smallpox among other remarkable achievements, Foege was a principal strategist in the Foundation’s early design. He explained that when the Foundation was first established in 2000, the entire endeavor could be summed up in just three words: global health equity. Each word had meaning, and taken together as the guiding purpose for investing more than $22 billion, it was both practical and audacious.

The concept of inclusive health value has a similar orienting role at the center of Rethink Health Ventures. Although we launched the Ventures project publicly in the fall, its underpinnings have deep roots in research as well as drawing upon lessons from veteran changemakers. In Ventures, we recognize that those who seek to transform complex and contested systems must have a practice (i.e., a routine set of mindsets and actions) that matches the scale of the job to be done.

We can no longer rely on framing health problems narrowly in an effort to improve particular parts of our troubled health system. That kind of focused problem solving works best when challenges are small and disparate. It has led to enormous fragmentation across the health ecosystem, and had very little success in redirecting some of the worst—and still worsening—health trends, such as entrenched inequity, rising costs, and declining quality of life. To shift such deep-seated habits, the Ventures project equips leaders with a novel practice designed to generate inclusive health value. For serious champions of system change, this phrase serves both as a practical guide and a moral compass; and like the Gates Foundation goal, each word is packed with meaning.

For starters, we were deliberate in naming health value as the anchor, instead of population health, or health equity, or healthcare cost, or any of the other ways that one might ordinarily define health objectives. When we combine health with value, it is an instant reminder that we are not simply concerned with people’s health as individuals. There are always plural values in play that eventually translate into the singular value we collectively place on health itself. That value has both moral and economic dimensions, which are apparent in the character of our health ecosystem as well as in the priorities that run throughout the health economy.

Decisions reflect the values of those in power, and they define how resources flow. Population health, in turn, largely reflects the ways we negotiate differences among our plural values, build power to do things that we cannot do alone, and allocate resources across a balanced portfolio of vital investments. Any effort to counter the growing threats to our health and well-being, must therefore build enough power to make different choices and then assure that resources shift accordingly. When health value is at the center of our practice, leaders become more mindful of the many ways we shape our health when making inevitable tradeoffs among competing values.

Adding the idea of inclusion incorporates one other set of critical considerations. Questioning what counts as inclusive health value forces us to consider not just health value as an abstract end, but whose health is valued, and through what means. When challenged to be more inclusive, leaders naturally become system thinkers. They ask more poignant questions about how well-being is defined, produced, and distributed. They also recognize that certain people and particular priorities tend to be systematically excluded. When prompted to care about inclusion, almost immediately we become more conscious of these exclusions and the pernicious ways that they confer unfair benefits and burdens to particular groups.

Leaders in the Ventures project are developing an explicit practice to foster greater inclusion across a variety of practical situations. As a result, they are forming new partnerships to do business differently across sectors, and engaging residents themselves in new ways to reimagine and transform the conditions that produce health, equity, and prosperity in their regions.

With inclusion as the first criterion, leaders tend to act more like system stewards, seeing not just separate pieces of a larger puzzle, but caring about the entire pattern. When there are systematic exclusions, or if some people are routinely disempowered, then we all feel that loss at some point. This is not merely an argument based on a moral a priori, asserting that everybody ought to be included. It is a pragmatic imperative, borne from the fact that none of us can be healthy alone. Our well-being is fragile and interdependent on a vast array of vital conditions and services that defy sector boundaries. When particular people or particular priorities are systematically excluded, it weakens the power we need to act effectively when our lives and livelihoods our threatened in a rapidly changing world.

A disciplined practice designed to generate inclusive health value intentionally provokes us out of our normal routines; it offers a productive way to deal with a dynamic and democratic health ecosystem. For those who are dissatisfied with the status quo and dedicated to work differently, each word in this peculiar purpose has great gravity, and together they characterize both the means and ends that so many of us strive to achieve: inclusive, health, value.


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Photo credit: Glen Forde