The 20th century witnessed a monumental transformation in hospitals: once primarily places for poor people to die, hospitals became institutions that cured illness and promoted health. A range of facilities and professionals dedicated to treating the sick grew in tandem with the proliferation of hospitals, creating the health care systems we have today. 
Health care systems are now pervasive enough that even developing countries have structures for delivering care. Advances in treating HIV, heart disease, and other chronic conditions mean that a significant part of the population now lives for years in less-than-perfect health. As we grow increasingly reliant on this care, the question before us is how to strengthen health systems in order to deliver quality care to all who need it.
This was the pivotal theme at the talk “The coming transformation in global health,” held at Harvard Medical School on Feb. 28. Moderated by Paul Farmer, MD, PhD, chief of the Division of Global Health Equity, the discussion was framed by Lord Nigel Crisp KCB, former head of the National Health Service in the United Kingdom, and Dean Julio Frenk, MD, MPH, PhD, former minister of health of Mexico and current dean of the Harvard School of Public Health.
Frenk discussed the challenges and opportunities he encountered while reworking the health care system in Mexico. We can create a platform for enlightened social change by carefully and conscientiously restructuring our health care systems, but Frenk felt it was vital that these reforms be evidence-based and involve explicit ethical deliberation. When these systems change for the better, they can have a tremendous impact: 30 percent of children with leukemia in Mexico had to stop treatment because their families ran out of money, but this number dropped to two percent after the implementation of health care reforms.
Having worked extensively in both the UK and developing nations, Crisp was particularly struck by the lack of health workers in many resource-poor settings. One way around the exodus of trained medical professionals from their countries of origin is to break down the demarcations between health professions. Crisp cites settings in Africa where nurses have been trained to do Cesarean sections—patient outcomes are comparable to doctors performing the operation, with the added bonus that nurses are less likely to move abroad.
Another potential solution for limited availability of medical professionals is to engage patients in their own care, as well as with helping and supporting fellow patients. Even in settings with abundant staff and resources, such as a self-dialysis clinic in Sweden, this approach can energize and engage patients, lower infection rates, and increase patient satisfaction. Crisp emphasized that health is a co-production function: it is not something doctors give patients, but something that patients create with intermittent assistance from clinicians.
Throughout the program, the speakers underscored that health is not separable from other human endeavors. Just as the duty of hospitals shifted from comforting the dying to curing, the challenge going forward is to reform health care systems to deliver care not just to the privileged, but to all in need.
