If we want to analyse health improvements first of all we need to clarify our values,[1] core priorities,[2] and our principles [3] on which we take action. As Stephen R. Covey put it, “Most of us spend too much time on what is urgent and not enough time on what is important.” [4] We need to be clear about what we consider valuable and what quality care means to us. Without clarifying our values we cannot know whether an outcome of an action is an improvement or a setback.

According to Michael E. Porter defining value in health care can be problematic and the concept of value is often misunderstood. [5] Healthcare organizations often have conflicting goals and priorities. However, he argues, in a well-functioning organization value is always defined based on customer needs. In other words, the ultimate goal of a healthcare organization should be increasing value for patients. [6]

Scholars argue healthcare improvements can be classified into three major clusters, quality, accessibility, and cost. [7] First, we can define health care quality based on two main dimensions: quality of care for individual patients and effectiveness. We can also distinguish between the effectiveness of clinical care and the effectiveness of individual care. [8] Other factors that indicate improvement in healthcare delivery can be: decreased medication errors, [9][10][11] hospital admission for preventable conditions, [12][13]and diagnostic errors. [14][15][16]

Regarding cost, more and more people started to realize, with the accelerating wealth gap [17] high-quality healthcare has become less and less affordable for more and more people. Clayton Christensen in his insightful book reached a similar conclusion. [18] He argues, today more and more people find themselves unable to access even basic healthcare services.

When it comes to security and peace of mind the situation isn’t any better. Today an increasing number of people have become unable to afford even the most basic care insurances. [19][20]

In terms of accessibility, there is also room for improvement [21]. At a famous 2005 Supreme Court decision Chief Justice Beverley McLachlin drew a memorable and widely quoted conclusion: “Access to a waiting list is not access to health care.” [22]

The question is how can we approach these problems to achieve the most significant improvements? [23][24]What are the most effective ways of executing improvement initiatives in healthcare? [25] John Maxwell leadership expert argues, to change an organization’s most basic processes and values, we have to start from the top. [26] Improving an organization’s leadership can have the greatest positive impact on its state. [27] Improving organizational culture can also be a catalyst of organizational performance improvement. [28][29] Especially in healthcare, where the majority of services are delivered in a person-to-person manner, the role of organizational culture is significant. As the popular saying goes, “Culture eats strategy for breakfast.”. [30] Establishing an open organizational culture based on open communication, strong community [31] and psychological safety [32] can greatly improve person-centred care. Customer satisfaction starts with employee satisfaction [33]. According to former MIT professor Edgar Schein, every culture has three levels: Artefacts (the most visible part), Espoused Values (commonly held values), and the less visible part, Tacit Assumptions (taken for granted assumptions that really drive behaviour). [34] By opening up channels of communication between organizational levels [35] we can make sure “bad news is circulating faster than good news”. [36]

Lean thinkers developed a process-based approach to deliver greater customer value. They call it Continuous Improvement (CT) Process [37] [38] (also called Kaizen). [39] Simply put, it is based on three major steps: [40] identifying value from the perspective of the customer, identifying all non-value-adding activities—also called waste—(using tools like Value Stream Mapping) [41] eliminating all of these non-value-adding activities in a continuous manner. [42] Evidence shows, applying the Continuous Improvement Process to healthcare can lead to outstanding results in terms of organizational efficiency, [43][44][45]even in times of crisis and disruption, like the COVID-19 pandemic. [46]

Another great way to improve the quality of healthcare delivery is to focus on the experience of end-users. [47] Relationship scientist Harry T. Reis developed a universal model of human relationships that can be also applied to customer experiences with great success. [48] He argues, the most important factor of extraordinary interpersonal experiences is responsiveness. It rests on three pillars: understanding (the other person knows how I see myself and what is important to me), validation (my partner respects my needs and who I am as a person), and caring (the other person takes active and supportive steps in helping me meet my needs). By making responsiveness to customers a part of the organizational culture we can greatly enhance the quality of person-centred care. [49]

According to the popular saying, attributed to the great management guru, Peter Drucker, “What gets measured gets managed”. If we want real improvement, measurement is key. As Michael E. Porter put it: “Rigorous, disciplined measurement and improvement of value is the best way to drive system progress [in healthcare].” [50]

The first step for effectively measuring improvements in health and social care would be to set realistic and measurable goals and clear targets. [51] A good way to achieve that is to follow Edwin Locke’s goal-setting approach by setting SMART goals. [52][53] If we want a more comprehensive approach we can use the OKRs (Objectives and Key Results) goal-setting system [54][55](initially developed by former Intel CEO and chairman, Andy Grove). [56]

Secondly, we can create a clear and accurate measurement system by developing actionable metrics and indicators. [57] We need both qualitative and quantitative data, gathered from every important stakeholder of the organization. By taking a systematic approach and measuring improvements through ratios rather than absolute numbers we can make all measurements standardized, comparable, and therefore more actionable. [58]

It is also important to get the terms right if we want to achieve real improvement. We have to make a clear distinction between inputs, outputs, and outcomes. [59] We also have to clarify the real meaning of the numbers by measuring productivity, effectiveness, and efficiency. This way we can understand complex problems and gain an in-depth understanding of the correlation between different causes and effects. As an example let’s say we organize an educational program for the staff of a healthcare organization. The program aims to increase the quality of care delivered to patients. It costs £15 000 (this is an input), provides 100 hours of training (this is an output), and results in a 30% decrease in medication errors (this is an outcome). If we want to get a full picture of our investment we also have to examine the number of decreased medication errors per pound spent on training (productivity), the number of decreased medication errors per training hour (effectiveness), and the number of training hours per pound (efficiency). [60] This way we can create a standardized baseline across multiple initiatives. We can use this baseline to evaluate different improvement initiatives and select the one that has the greatest overall effectiveness in the long run. This way we can develop meaningful indicators of our improvements and not just a short-term one that shows just a partial, incomplete picture. Using this system of metrics we can better evaluate the overall administrative efficiency of the organization. [61] We can also combine these overall baselines across multiple organizations, measured in multiple timeframes and even across multiple industries.

Thirdly, it is crucial to take real action based on our improvement indicators. Dealing with too much data can be as harmful as not having any data at all. [62] Management experts Alistair Croll and Benjamin Yoskovitz suggest using a metrics prioritization system to determine the most important metric that drives business success. [63] They call it OMTM (One Metric That Matters). [64] By using this system we can take action based on our most important priorities without being distracted by too many details.

If we think in terms of general healthcare improvements throughout society, it is important to enhance the quality of communication and collaboration between different parties of the healthcare sector. All three parties (governmental, private, and the third sector). [65] Involving the “third sector” [66] (including non-governmental, faith-based, community-based, and patient-based organizations as well as professional associations, the World Health Organization) can also be a catalyst for change. [67] Donella Meadows in her insightful book [68] suggests the greatest way to improve the effectiveness of complex systems is to improve the quality of the communication between its parts. This way we can better respond to urgent health and humanitarian needs, [69] such as the COVID-19 epidemic, [70] HIV/AIDS crisis [71], and other urgent healthcare emergencies. By improving the quality of the communication between different organizations we can make the healthcare environment more homogeneous by developing standardized protocols, practices, measurement, and quality standards. [72]

Demand and supply for healthcare as well as recent trends in healthcare expenditures are in strong correlation with one another. We can develop a better understanding of the current market demand by following two different approaches. By looking at the big picture, by examining the forces that shape supply and demand for healthcare and by looking at the details, and by examining particular factors of consumer behaviour.

Based on the substitution- and income effect [73] economists assume that people are satisfaction maximisers. [74] If the price of services goes up, customers will automatically consume less. However, understanding demand for healthcare based on traditional microeconomic models can be problematic for several reasons. [75] Healthcare expenditures cannot always be planned in advance [76] and therefore are not always following the logic of the “invisible hand”. [77] For example, during an emergency people are not going to base their decision on price.

If we want to understand what drives demand for healthcare we have to take a closer look at customer behaviour. A common explanation of people’s behaviour from an economics perspective is the “Rational Actor” model. [78] Traditional economics assumes every actor behaves rationally and tries to maximize his or her gains. However, decades of research in cognitive sciences [79] and the emergence of Behavioural Economics [80] showed us that people behave much less rationally than we previously thought. Quite often people behave opposite to their self-interest, depending on circumstances. [81] This can also have implications related to healthcare consumption. Let me mention one well-researched example. People have a tendency for “overconsuming” healthcare services if it is covered by an insurance policy. (It is the finding of one of the greatest health insurance experiments conducted in the mid-1970s). [82][83]

Another noteworthy trend that greatly influences demand for healthcare is changes in the age structure of the population [84][85] and the emergence of aging societies. [86] Particularly in western countries societies, people are living longer, [87] which increases the demand for healthcare services. [88] The emergence and improvement of medical technologies can also increase demand. [89] As an example, with the development of X-ray technology a whole new industry has emerged based on the technology. [90] Developing new medications can also greatly influence healthcare demand. [91] Societal, environmental, and political factors also correlate with fluctuating demand for healthcare. [92] For example, with the improved quality of education people also focus more on their health. [93] Global warming and weather disasters also contribute to certain spikes in demand for healthcare in certain areas. [94] The legalization of different substances can also increase the demand for certain medications. [95] Increased economic wealth can also cause increased demand for healthcare. [96] Studies also show, in the past 40 years many industrial countries showed a great increase in demand for healthcare due to increased life expectancy, increased quality of life. [97]

Different economies have different healthcare systems based on entirely different structures. [98] For example, there is a Single-Payer System (where hospitals and healthcare facilities are public property and staff is public employees). This system is based on taxation and the government pays for most of the prescriptions and medical expenditures. It is in direct correlation with healthcare demand and supply because every citizen is required to get health insurance. [99]

The UK for example has a different kind of healthcare system. It is called the Socialized Healthcare System, founded and controlled by the government. In this system healthcare workers are directly paid by the government. This system allows people to access healthcare even in situations in which other systems would not [100]. For example low-income families or patients with special medical conditions. The US healthcare system is still different [101]. Most healthcare providers are private firms, the majority of households are covered by private insurance that people have to individually pay for. But the US system also has a single-payer system for individuals over 65 and for those below the poverty line.

Based on these different structures of health care sectors, the supply of healthcare can vary greatly. For example, as every huge bureaucratic organization, Socialized Healthcare Systems (for example in the UK) sometimes can operate quite inefficiently. [102] Therefore the level of supply in some cases is not capable of following in real-time the fluctuations in demand. For example, when we think about the long waiting lists of hospitals and GP practices. [103] In this regard, the mostly privatized US healthcare system is answering more quickly to fluctuations in demand. However, more and more scholars and healthcare professionals realize, access to healthcare in the US has become a luxury for many people and this trend is continuing. [104] The structure of the UK healthcare system, therefore, is better in terms of accessibility, [105] which can make a life and death difference in many people’s lives, especially from low-income households. [106]

In conclusion, we can say, healthcare improvements sometimes can be hard to define and measure. Healthcare is a very complex and highly interconnected environment. If we try to improve an individual part of the system we might cause unforeseen consequences at some other sub-part of the system. Therefore it is important to take a systemic approach for understanding and improving the system as a whole. Looking at customer needs can always be a good starting point. However, we have to consider many other areas of healthcare delivery as well, if we want to achieve real improvements. For example, examining and understanding the benefits and trade-offs of different healthcare structures and systems; looking at short- and long-term consumption trends; examining consumer behaviour can all be part of the big picture. This way we can assure we will not mistake short-term gains and quick fixes with long-term results and real improvements.

Endnotes

1. Allport, G. W., Vernon, P. E., & Lindzey, G. (1960). Study of values. Houghton Mifflin.
2. Boivin, A., Lehoux, P., Lacombe, R. et al. Involving patients in setting priorities for healthcare improvement: a cluster randomized trial. Implementation Sci 9, 24 (2014). Link here
3. Ray Dalio, Principles, Simon & Schuster, 2017
4. Stephen R. Covey, The Seven Habits of Highly Effective People: Powerful Lessons in Personal Change, Simon & Schuster, 19 November 2013, Originally published: 15 August 1989
5. Porter, Michael E. “What is value in health care.” N Engl J Med 363.26 (2010): 2477-2481. Link here
6. Porter, Michael E. PhD Value-Based Health Care Delivery, Annals of Surgery: October 2008 – Volume 248 – Issue 4 – p 503-509 doi: 10.1097/SLA.0b013e31818a43af
7. Mitton, C., Dionne, F., Peacock, S. et al. Quality and Cost in Healthcare. Appl Health Econ Health Policy 5, 201–208 (2006). Link here
8. Mitton, C., Dionne, F., Peacock, S. et al. Quality and Cost in Healthcare. Appl Health Econ Health Policy 5, 201–208 (2006). Link here
9. Richard A Hansen, Sandra B Greene, Charlotte E. Williams, Susan J. Blalock, Kathleen D Crook, Roger Akers, Timothy S. Carey, Types of medication errors in north carolina nursing homes: A target for quality improvement, The American Journal of Geriatric Pharmacotherapy, Volume 4, Issue 1, 2006, Pages 52-61, ISSN 1543-5946, Link here.
10. Barry R. Goldspiel, Pharm.D., FASHP, Robert DeChristoforo, M.S., Charles E. Daniels, Ph.D., FASHP, A continuous-improvement approach for reducing the number of chemotherapy-related medication errors, American Journal of Health-System Pharmacy, Volume 57, Issue suppl_4, 1 December 2000, Pages S4–S9, Link here
11. Chua, SS., Wong, I.C., Edmondson, H. et al. A Feasibility Study for Recording of Dispensing Errors and ‘Near Misses’ in Four UK Primary Care Pharmacies. Drug-Safety 26, 803–813 (2003). Link here
12. Friedman B, Basu J. The Rate and Cost of Hospital Readmissions for Preventable Conditions. Medical Care Research and Review. 2004;61(2):225-240. doi:10.1177/1077558704263799
13. Stamp, K., Duckett, S. and Fisher, D. (1998), Hospital use for potentially preventable conditions in Aboriginal and Torres Strait Islander and other Australian populations. Australian and New Zealand Journal of Public Health, 22: 673-678. Link here
14. Kuhn, G.J. (2002), Diagnostic Errors. Academic Emergency Medicine, 9: 740-750. Link here
15. Michael F. Perry, Jennifer E. Melvin, Rena T. Kasick, Kelly E. Kersey, Daniel J. Scherzer, Manmohan K. Kamboj, Robert J. Gajarski, Garey H. Noritz, Ryan S. Bode, Kimberly J. Novak, Berkeley L. Bennett, Ivor D. Hill, Jeffrey M. Hoffman, Richard E. McClead, The Diagnostic Error Index: A Quality Improvement Initiative to Identify and Measure Diagnostic Errors, The Journal of Pediatrics, Volume 232, 2021, Pages 257-263, ISSN 0022-3476, Link here
16. Newman-Toker DE, Pronovost PJ. Diagnostic Errors—The Next Frontier for Patient Safety. JAMA. 2009;301(10):1060–1062. doi:10.1001/jama.2009.249
17. Thomas Piketty, Capital in the Twenty-First Century, Harvard University Press, 14 August 2017, Originally published: 30 August 2013
18. Clayton M. Christensen, Jerome H. Grossman, Jason Hwang, The Innovator’s Prescription: A Disruptive Solution for Health Care, McGraw-Hill Education, 31 October 2008
19. Benjamin D. Sommers, M.D., Ph.D., Atul A. Gawande, M.D., M.P.H.,
20. Carmen DeNavas-Walt, Income, Poverty, and Health Insurance Coverage in the United States, DIANE Publishing Company, February 2010, Originally published: 2006
21. nhs.uk
22. theglobeandmail.com
23. health.org.uk
24. Prathibha Varkey, M. Katherine Reller, Roger K. Resar, Basics of Quality Improvement in Health Care, Mayo Clinic Proceedings, Volume 82, Issue 6, 2007, Pages 735-739, ISSN 0025-6196, Link here.
25. Bo Bergman, Andreas Hellström, Svante Lifvergren & Susanne M. Gustavsson (2015) An Emerging Science of Improvement in Health Care, Quality Engineering, 27:1, 17-34, DOI: 10.1080/08982112.2015.968042
26. John C. Maxwell, The 360 Degree Leader with Workbook, Developing Your Influence from Anywhere in the Organization, Thomas Nelson, 18 October 2011, Originally published: 2005
27. John C. Maxwell, The 5 Levels of Leadership: Proven Steps to Maximize Your Potential, Center Street, 4 October 2011
28. Roy K. Smollan & Janet G. Sayers (2009) Organizational Culture, Change and Emotions: A Qualitative Study, Journal of Change Management, 9:4, 435-457, DOI: 10.1080/14697010903360632
29. Abdul Rashid, Z., Sambasivan, M. and Abdul Rahman, A. (2004), “The influence of organizational culture on attitudes toward organizational change”, Leadership & Organization Development Journal, Vol. 25 No. 2, pp. 161-179. Link here
30. Julia Sloan, Learning to Think Strategically, Taylor & Francis, 4 September 2019Originally published: 15 June 2006
31. Daniel Coyle, The Culture Code: The Secrets of Highly Successful Groups, Random House, February 2018, Originally published: 5 September 2017
32. Amy C. Edmondson, The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth, Wiley, November 2018
33. Tony Hsieh, Delivering Happiness: A Path to Profits, Passion, and Purpose, Grand Central Publishing, 7 June 2010
34. Edgar H. Schein, Organizational Culture and Leadership, Wiley, 16 July 2010, Originally published: 1985
35. Edgar H. Schein, Peter A. Schein, The Corporate Culture Survival Guide, Wiley, 30 July 2019, Originally published: 2000
36. Jez Humble, Joanne Molesky, Barry O’Reilly, Lean Enterprise: How High Performance Organizations Innovate at Scale, O’Reilly Media, Incorporated, August 2020, Originally published: 2014
37. Aristide van Aartsengel, Selahattin Kurtoglu, A Guide to Continuous Improvement Transformation: Concepts, Processes, Implementation, Springer Berlin Heidelberg, March 2013
38. Jeffrey K. Liker, James K. Franz, The Toyota Way to Continuous Improvement: Linking Strategy and Operational Excellence to Achieve Superior Performance, McGraw-Hill Education, 15 April 2011
39. Isao Kato, Art Smalley, Toyota Kaizen Methods: Six Steps to Improvement, Taylor & Francis, 26 July 2017, Originally published: 19 October 2010
40. Bhuiyan, N. and Baghel, A. (2005), “An overview of continuous improvement: from the past to the present”, Management Decision, Vol. 43 No. 5, pp. 761-771. Link here
41. Cindy Jimmerson, Value Stream Mapping for Healthcare Made Easy, CRC Press, 26 July 2017, Originally published: 25 August 2009
42. James P. Womack, Daniel T. Jones, Lean Thinking: Banish Waste And Create Wealth In Your Corporation, Simon & Schuster UK, 26 September 2013, Originally published: 1996
43. Stelson, P., Hille, J., Eseonu, C. and Doolen, T. (2017), “What drives continuous improvement project success in healthcare?”, International Journal of Health Care Quality Assurance, Vol. 30 No. 1, pp. 43-57. Link here
44. Marco Lam & Dan Robertson (2012) Organizational Culture, Tenure, and Willingness to Participate in Continuous Improvement Projects in Healthcare, Quality Management Journal, 19:3, 7-15, DOI: 10.1080/10686967.2012.11918070
45. Daniel Barberato Henrique, Moacir Godinho Filho, Giuliano Marodin, Ana Beatriz Lopes de Sousa Jabbour & Charbel Jose Chiappetta Jabbour (2021) A framework to assess sustaining continuous improvement in lean healthcare, International Journal of Production Research, 59:10, 2885-2904, DOI: 10.1080/00207543.2020.1743892
46. R.N.J. Graham, T. Woodhead, Leadership for continuous improvement in healthcare during the time of COVID-19, Clinical Radiology, Volume 76, Issue 1, 2021, Pages 67-72, ISSN 0009-9260, Link here
47. Paul Bate, Glenn Robert, Bringing User Experience to Healthcare Improvement: The Concepts, Methods and Practices of Experience-based Design, Radcliffe Pub, 2007
48. REIS, H.T. (2007), Steps toward the ripening of relationship science. Personal Relationships, 14: 1-23. Link here
49. Conclusion drawn by Harvard psychologists Chip Heath and Dan Heath in their insightful book:
50. Porter, Michael E. “What is value in health care.” N Engl J Med 363.26 (2010): 2477-2481.
51. Bovend’Eerdt, Thamar JH, Rachel E. Botell, and Derick T. Wade. “Writing SMART rehabilitation goals and achieving goal attainment scaling: a practical guide.” Clinical rehabilitation 23.4 (2009): 352-361.
52. Latham, Gary P., and Edwin A. Locke. “Goal setting theory: Controversies and resolutions.” (2018).
53. Austin, James T., and Philip Bobko. “Goal‐setting theory: Unexplored areas and future research needs.” Journal of Occupational Psychology 58.4 (1985): 289-308.
54. Niven, Paul R., and Ben Lamorte. Objectives and key results: Driving focus, alignment, and engagement with OKRs. John Wiley & Sons, 2016.
55. Doerr, John. Measure what matters: OKRs: The simple idea that drives 10x growth. Penguin UK, 2018.
56. Grove, Andrew S. High output management. Vintage, 2015.
57. Reis, Eric. “The lean startup.” New York: Crown Business 27 (2011). Eric Ries distinguishes between “actionable metrics” (the ones we can act on) and “vanity metrics” (the ones that doesn’t show any areas for potential improvement).
58. Stroh, David Peter. Systems thinking for social change: A practical guide to solving complex problems, avoiding unintended consequences, and achieving lasting results. Chelsea Green Publishing, 2015.
59. Measurement systems developed by American Productivity and Quality Center, White Collar Productivity Improvement (APQC, 1986).
60. This example was taken from David Peter Stroh’s insightful book (slightly modified, applied to healthcare setting).
61. Woolhandler, Steffie, and David U. Himmelstein. “The deteriorating administrative efficiency of the US health care system.” New England Journal of Medicine 324.18 (1991): 1253-1258.
62. Provost, Lloyd P., and Sandra Murray. The health care data guide: learning from data for improvement. John Wiley & Sons, 2011.
63. Croll, Alistair, and Benjamin Yoskovitz. Lean analytics: Use data to build a better startup faster. ” O’Reilly Media, Inc.”, 2013.
64. Alm, Jesper, and John Lindblad. “The Multi-Business Startup. A study of challenges and considerations concerning strategy, organization, and prioritization.” (2021).
65. Ruger, Jennifer Prah, and Derek Yach. “The global role of the World Health Organization.” Global health governance: the scholarly journal for the new health security paradigm 2.2 (2009): 1.
66. Defourny, Jacques. “Third sector.” Handbook on the economics of reciprocity and social enterprise. Edward Elgar Publishing, 2013.
67. Getahun, Haileyesus, and Mario Raviglion. “Transforming the global tuberculosis response through effective engagement of civil society organizations: the role of the World Health Organization.” Bulletin of the World Health Organization 89 (2011): 616-618. Link here
68. Meadows, Donella H. Thinking in systems: A primer. chelsea green publishing, 2008.
69. Banatvala, Nicholas, and Anthony B. Zwi. “Public health and humanitarian interventions: developing the evidence base.” Bmj 321.7253 (2000): 101-105.
70. R.N.J. Graham, T. Woodhead, Leadership for continuous improvement in healthcare during the time of COVID-19, Clinical Radiology, Volume 76, Issue 1, 2021, Pages 67-72, ISSN 0009-9260, Link here
71. Needle, Richard H., et al. “Rapid assessment of the HIV/AIDS crisis in racial and ethnic minority communities: an approach for timely community interventions.” American Journal of Public Health 93.6 (2003): 970-979.
72. Vardaman, James M., et al. “Beyond communication: The role of standardized protocols in a changing health care environment.” Health care management review 37.1 (2012): 88-97.
73. LEMIEUX, THOMAS, AMY FINKELSTEIN, and OLIVIER DESCHENES. “Distinguishing Income from Substitution Effects in Disability Insurance.”
74. Hawe, Emma, and Lesley Cockcroft. OHE guide to UK health and health care statistics. London: Office of Health Economics, 2011.
75. Bromiley, Philip, and Chris Papenhausen. “Assumptions of rationality and equilibrium in strategy research: the limits of traditional economic analysis.” Strategic Organization 1.4 (2003): 413-437.
76. Farley, Joel F., Carolyn R. Harley, and Joshua W. Devine. “A comparison of comorbidity measurements to predict healthcare expenditures.” American Journal of Managed Care 12.2 (2006): 110-118.
77. Smith, Adam. The wealth of nations [1776]. Vol. 11937. na, 1937.
78. Brighton, Henry, and Gerd Gigerenzer. “Are rational actor models “rational” outside small worlds.” Evolution and Rationality: Decisions, Co-operation, and Strategic Behavior (2012): 84-109.
79. Daniel Kahneman, Thinking, Fast and Slow, Penguin Books, 2011
80. Earl, Peter. Behavioural economics. Edward Elgar Publishing, 1990.
81. Kevin Simler and Robin Hanson concluded, in most cases people are prone to act according to their identity, rather than their self-interest.
82. Gruber, Jonathan. The role of consumer copayments for health care: lessons from the RAND health insurance experiment and beyond. Vol. 7566. Menlo Park, CA: Henry J. Kaiser Family Foundation, 2006.
83. Joseph P. Newhouse, et al. Free for all?: lessons from the RAND health insurance experiment. Harvard University Press, 1993.
84. Bosworth, Barry P., and Gary Burtless, eds. Aging societies: The global dimension. Brookings Institution Press, 1998.
85. Layte, Richard. Projecting the impact of demographic change on the demand for and delivery of healthcare in Ireland. ESRI, 2009.
86. Harper, Sarah. “Economic and social implications of aging societies.” Science 346.6209 (2014): 587-591.
87. Greengross, Sally, et al. “Aging: a subject that must be at the top of world agendas: the aging of populations demands major changes across society and health care.” (1997): 1029-1030.
88. Reinhardt, Uwe E. “Does the aging of the population really drive the demand for health care?.” Health Affairs 22.6 (2003): 27-39.
89. Tan, L. T. H., and K. L. Ong. “The impact of medical technology on healthcare today.” Hong Kong Journal of Emergency Medicine 9.4 (2002): 231-236.
90. de Lacey, Gerald. “Medical and Legal Aspects of the Increasing Demand for Diagnostic Radiology: Clinical and Economic Aspects of the Use of X-rays in the Accident and Emergency Department.” (1976): 758-759.
91. Moreno, Carmen, et al. “How mental health care should change as a consequence of the COVID-19 pandemic.” The Lancet Psychiatry (2020).
92. Jones, Robert. Key topics in healthcare management: understanding the big picture. Radcliffe Publishing, 2007.
93. Haldre, Kai, Kai Part, and Evert Ketting. “Youth sexual health improvement in Estonia, 1990–2009: the role of sexuality education and youth-friendly services.” The European Journal of Contraception & Reproductive Health Care 17.5 (2012): 351-362.
94. McMichael, Anthony J. “Extreme weather events and infectious disease outbreaks.” Virulence 6.6 (2015): 543-547.
95. Bridgeman MB, Abazia DT. Medicinal Cannabis: History, Pharmacology, And Implications for the Acute Care Setting. P T. 2017;42(3):180-188
96. Rey, Béatrice, and Jean-Charles Rochet. “Health and wealth: How do they affect individual preferences?.” The Geneva Papers on Risk and Insurance Theory 29.1 (2004): 43-54.
97. Van Elk, Roel, Esther Mot, and Philip Hans Franses. “Modeling healthcare expenditures: overview of the literature and evidence from a panel time-series model.” Expert Review of Pharmacoeconomics & Outcomes Research 10.1 (2010): 25-35.
98. Johnson, James A., Carleen Stoskopf, and Leiyu Shi. Comparative health systems: a global perspective. Jones & Bartlett Learning, 2017.
99. Hsiao, William C., et al. “What other states can learn from Vermont’s bold experiment: embracing a single-payer health care financing system.” Health Affairs 30.7 (2011): 1232-1241.
100. Wendt, Claus, Lorraine Frisina, and Heinz Rothgang. “Healthcare system types: a conceptual framework for comparison.” Social Policy & Administration 43.1 (2009): 70-90.
101. Wendt, Claus, Lorraine Frisina, and Heinz Rothgang. “Healthcare system types: a conceptual framework for comparison.” Social Policy & Administration 43.1 (2009): 70-90.
102. Curry, Leslie. “The Future of the Public’s Health in the 21st Century.” Generations 29.2 (2005): 82.
103. Foote, Jeffrey L., N. H. North, and D. J. Houston. “Towards a systemic understanding of a hospital waiting list.” Journal of Health Organization and Management (2004).
104. youtube.com
105. Paterson, Iain, and Ken Judge. “Equality of access to healthcare.” Reducing inequalities in health. Routledge, 2003. 191-209.
106. Randhawa, Kirat. Illness and healthcare experiences of recent low-income international migrants in a UK city. Diss. University of Sussex, 2014.