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Neither private nor state run health care systems are perfect. Although there is increasing evidence that Health Maintenance Organizations (HMOs) provide comparable care at lower cost, HMOs tend to select healthy patients. The dual health care system in Hong Kong spends about 3.9 per cent of GDP, with health indices among the best in the world. Hong Kong still faces the problem of escalating health care expenditure. One should take advantage of the dual health care system to evolve a new paradigm for a primary‐led seamless health care service. The Diabetes Centre of a university teaching hospital together with the University of Community and Family Medicine has started a structured shared care programme in diabetes mellitus, involving general practitioners in both the private and public sectors integrating the primary and secondary care, and the private and public sectors. This programme starts to develop an infrastructure for providing quality care at an affordable cost for a large pool of patients with chronic disease. Unlike other “managed care schemes”, this one is not run by profit‐oriented companies, but by health professionals with an interest in providing best possible care at an affordable cost. The “disease management” approach needs a care delivery system without traditional boundaries; and a continuous improvement process which develops and refines the knowledge base, guidelines and delivery system.

The theme of this volume is reorganizing health care delivery systems: problems of managed care and other models of health care delivery. The volume contains 11 papers, organized into four sections. The sections cover, in order, managed care issues and organizational features, special groups of patients and health issues, lessons from other countries, and broader policy concerns and health insurance reform. Issues of how to best organize a health care delivery system are not new, but the amount of interest in this topic in the U.S. (as well as in other countries) has grown in recent decades. Reorganizing health care delivery systems is a concern of many of the systems of the world, and this volume contains some papers from countries other than the U.S., although the majority of the papers do relate issues to the U.S. health care delivery system. While the majority of the papers in this volume relate to structural and organizational factors, the impact of individual patients is not neglected. One section focuses very much on more specialized groups of patients, and several other papers use surveys of patients or other individual level data as part of their discussion of these issues. Before discussing the specific papers briefly, it is useful to review some material about the organization of the health care delivery system, especially within the U.S. This includes some discussion of how issues of organization of care and special forms of delivering care such as managed care have become major issues in the U.S. health care system at this point in time.

As all countries in the world, Polish health care system has to challenge four fundamental transformations: demographic, technological, epidemiological and cultural. Each of them generates serious threats for the sustainability of the system. The Polish society is ageing even faster than other in the European Union. For the sustainability of the system, the ageing of the population is a double challenge: on the expenditure side and on the financing side.

The Polish health care system is characterised by three negative features: under-financing of health care, misguided organisation of the health sector and health care entities and a dramatic shortage of health care professionals. The share of GDP devoted to health has remained constant over the last years at the level of 6.3%–6.7%. Poland has one of the lowest rates of practicing doctors and nurses in the EU countries. Lack of attractiveness of the medical professions caused by consistently low wages has created a huge generation gap.

Looking from the perspective of cost-effectiveness, we must to state, that the system, with its small financial outlays, provides a relatively high level of health for the population. However, it does not mean that better results could not be achieved. The majority of the public hospitals run in the form of independent public health care units that are highly inefficient and indebted. All attempts to restructure the sector and to solve the problem of arrears of the public hospitals failed so far.

To face the challenges, Poland must change its health policy. An increase in the sector's financing is needed, bearing in mind that increasing outlays alone is certainly not enough to solve all problems and secure sustainability. Deep structural and organisational changes are necessary. Unfortunately, politicians avoid making difficult but necessary decisions, e.g., drastic restructuring of the hospital sector, preferring above all to increase public spending on health.

The Models of Child Health Appraised (MOCHA) project identified the different models of primary care that exist for children, examined the particular attributes that might be different from those directed at adults and considered how these models might be appraised. The project took the multiple and interrelated dimensions of primary care and simplified them into a conceptual framework for appraisal. A general description of the models in existence in all 30 countries of the EU and EEA countries, focusing on lead practitioner, financial and regulatory and service provision classifications, was created. We then used the WHO ‘building blocks’ for high-performing health systems as a starting point for identifying a good system for children. The building blocks encompass safe and good quality services from an educated and empowered workforce, providing good data systems, access to all necessary medical products, prevention and treatments, and a service that is adequately financed and well led. An extensive search of the literature failed to identify a suitable appraisal framework for MOCHA, because none of the frameworks focused on child primary care in its own right. This led the research team to devise an alternative conceptualisation, at the heart of which is the core theme of child centricity and ecology, and the need to focus on delivery to the child through the life course. The MOCHA model also focuses on the primary care team and the societal and environmental context of the primary care system.

This paper offers an overview of the defining traits of the Spanish National Health Service (Sistema Nacional de Salud, in Spanish), as well as an account of its current trends in both spending and organisational changes. Beyond a thorough description of the Spanish public health-care system and its main quantitative indicators, we offer a critical review of the ongoing decentralisation process of health-care provision and its recent trends in pharmaceutical spending.

The text is organised in the following two parts. Part 1 provides an overview of the Spanish health-care system, structured in several sections. It starts by placing Spain within a classification of international health-care systems and is followed by an account of the importance of public provision in the Spanish case. A relation of the guiding principles of the Spanish public system concludes the first part. The second part focuses on two key developments that have shaped the evolution of the Spanish health-care system in the recent decades. The first is the process of decentralisation of health-care; the section explains the challenges arising with the transference of health-care provision responsibilities from the central to regional governments. The second section critically reviews the recent expansion of drug-related spending in the Spanish health-care system, and the policy responses to attempt to contain health-care costs.

The long-term financial stability of hospital systems represents a “grand challenge” in health care. New ownership forms, such as private equity (PE), promise to achieve better financial performance than nonprofit or for-profit systems. In this study, we compare two systems with many similarities, but radically different ownership structures, missions, governance, and merger and acquisition (M&A) strategies. Both were nonprofit, religious systems serving low-income communities – Montefiore Health System and Caritas Christi Health Care.

Montefiore's M&A strategy was to invest in local hospitals and create an integrated regional system, increasing revenues by adding primary doctors and community hospitals as feeders into the system and achieving efficiencies through effective resource allocation across specialized units. Slow and steady timing of acquisitions allowed for organizational learning and balancing of debt and equity. By 2019, it owned 11 hospitals with 40,000 employees and had strong positive financials and low reliance on debt.

By contrast, in 2010, PE firm Cerberus Capital bought out Caritas (renamed Steward Health Care System) and took control of the Board of Directors, who set the system's strategic direction. Cerberus used Steward as a platform for a massive debt-driven acquisition strategy. In 2016, it sold off most of its hospitals’ property for $1.25 billion, leaving hospitals saddled with long-term inflated leases; paid itself almost $500 million in dividends; and used the rest for leveraged buyouts of 27 hospitals in 9 states in 3 years. The rapid, scattershot M&A strategy was designed to create a large corporation that could be sold off in five years for financial gain – not for health care integration. Its debt load exploded, and by 2019, its financials were deeply in the red. Its Massachusetts hospitals were the worst financial performers of any system in the state. Cerberus exited Steward in 2020 in a deal that left its physicians, the new owners, holding the debt.

Purpose – This chapter argues that the concept of agility is an effective robust framework for designing sustainable health care systems.

Design/methodology/approach – This case study of Alegent Health was based on 7 years of data collection. It includes observations of meetings, large-group interventions, and other activities; site visits to different hospitals in the system to observe changes in practice; interviews with Alegent Health executives, primary care physicians, hospital presidents, specialist physicians and physician groups, and health systems staff and nurses; and a variety of archival data including meeting minutes, video tapes, conference proceedings, and web site material.

Findings – The Alegent Health system has evolved over time according to the principles of agility. It built a series of new capabilities that contribute to improved clinical outcomes, sustained financial results, and more socially and ecologically responsible results. Designing health care systems based on agility is a more effective and sustainable approach than relying on legislative or other criteria.

Originality/value – The discussion of sustainability in health care has focused primarily on specific projects or how to respond to specific technological, regulatory, or clinical changes. Alegent Health's experience provides important lessons, opportunities, and challenges that can help advance our understanding of effective health care and use organizational agility to create more sustainable health care systems. This chapter provides health care system administrators an alternative design option.

Purpose – This chapter provides a reflective synopsis of the chapters in the volume and highlights the learning from the cases about the development of new orientations, design configurations, and learning mechanisms. It charts directions for further research and possible managerial actions.

Design – The chapters in this second volume of the book series “Organizing for Sustainable Effectiveness” capture a rich set of cases in which organizing for sustainable health care was the central focus. Each chapter illuminated the development of a distinct health care system in a unique cultural and national context, and had a special focus on reporting theoretically informed and rigorously explored knowledge to guide purposeful design and learning approaches. Collectively the chapters highlighted the processes, organization and design, system regulation, and continuous learning approaches in complex organizational and multi-organizational health care systems that enable focus on and advancement of economic, social, and ecological outcomes.

Findings – Several critical themes have emerged from the cases, and from the broader literature on health care transformation: the importance of purpose; the need to overcome fragmentation; the need for alternative business models; technology as an investment in sustainable health care; the centrality of knowledge management; the importance of partnership and collaboration; the role of self-organization and leadership; and the criticality of building change capabilities.

Sociology promotes and describes public health, helping to explain macro-social dynamics of mental health care through studies of organizations, networks, and systems of care.

This chapter summarizes sociological research on mental health care organizations and systems, illustrating a macro-social perspective by examining the problem of transitions in care for young adults. Summary findings from a regional mental health services research project describe a system of care that includes 100 organizations. This system helps young adults with mental health needs.

The scope and management of care involves a focus on modes of treatment supported by research evidence and delivered effectively by people with cultural competencies. Care and continuity of care are delivered through coordinated systems of inter-organizational networks, linking organizations and providers. Active inter-organizational linkages are needed to support mental health for young adults during challenging and sometimes difficult transitions.

This research summarizes original and regional data on mental health care organizations within a regional system of care. Practical implications include support for the importance of coordination, transition planning, and cultural competence within and among organizations. Sociological and original research on organizations and systems should continue to elaborate the needs and values of mental health services for regional planning and public health.