For centuries, a reductive approach to health care divided patients into components: organs, tissues, cells, organelles. Doctors would identify the parts responsible for illness and attempt to treat those parts. Only recently have treatment approaches begun to recognize that patients don’t just break into smaller systems; they exist within larger ones.1 Centuries after John Snow removed the handle of the Broad Street Pump,2 we still rely on curious clinicians to identify patterns among the population, and we still diagnose and treat patients roughly like we’d fix a broken car. But health care can do more than just conceive of an ideal body, compare it to the patient, and address the faulty parts.
Advances in medical science have improved our understanding of complex biological systems and how they contribute to disease and dysfunction. We’ve also learned that human health is influenced profoundly by factors such as pollution, the built environment, and economic conditions.3
As costs continue to rise, health care systems everywhere face pressure to meet increasing demand with limited resources.4 Cost savings from prevention thus look extremely tempting. To reap these benefits, many governments are exploring what we’re calling “whole health,” an approach centered on wellness rather than illness.5 A whole-health approach emphasizes the many external factors involved in human health and encourages community investments that foster it. It stresses communication, collaboration, and integration across health services, sectors, and agencies.
The whole-health approach is not altogether new—for decades, health leaders have coordinated care to manage chronic conditions like diabetes, and more recently, health-financing models are beginning to prioritize population health.6 Today, governments across the globe are committing to creating capacity for populations to invest in their goals, satisfy their needs, and optimize their health and well-being.
Whole health can help improve health outcomes, reduce health care costs, and enhance the experiences of both patients and caregivers.7 It attempts to unite the aims of public health and health care, aligning the often-competing incentives of the two sectors behind shared objectives. Many agencies today are working with multiple partners to improve population health while increasing the value and reach of their investments, with shared mechanisms for governance, accountability, and funding.
To leverage a whole-health approach, governments can help support care recipients, care deliverers, and the entire health ecosystem.
The World Health Organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”8 Yet, our health systems are still designed largely to target and treat disease, not to optimize whole health. Given ever-rising health care expenditures, policymakers are seeking new ways both to improve population health and reduce costs.9
A whole-health approach often implies integrating care across different organizations and settings, linking hospital and community-based services, physical and mental health services, and social care.
In 2022, England’s National Health Service (NHS) established 42 geographically based Integrated Care Systems across England as part of a statutory reorganization.10 These systems were designed to connect NHS providers and commissioners with local authorities and other area partners to plan, coordinate, and administer health and social care services; each receives a budget based on an assessment of local needs.
Other organizations apply a personalized approach to care. In 1998, Anchorage, Alaska’s Southcentral Foundation (Southcentral) introduced the Nuka System of Care, an award-winning and globally influential approach to health. According to the foundation, “The Nuka System of Care focuses on understanding each individual’s unique story, values, and influences.”11 The entire staff takes core training in Alaska Native storytelling culture; patients in turn use stories to relate to their health and continue their personal stories in treatment. Patients make care decisions in conjunction with their families and a team of care providers. This focus on the patient’s individual history, self-image, and relationships helps the system identify and address factors such as access to housing, food, and safe neighborhoods.12
Southcentral has achieved a 98% patient satisfaction rate, reached the 95% percentile in national standards of diabetes care, and sustained a 58% reduction in visits to specialist clinics.13 Nearly 900 organizations and 33 nations around the world have studied the Nuka system for best practices.14 Taking a more holistic approach to health, as well as addressing gaps in equity, is a key goal of New Zealand’s health reforms. The Pae Ora (Healthy Futures) Act 2022 provides a new vision for holistic care and Māori health.15 The legislation aims to provide a platform to address health inequities faced by Māori and better health outcomes for all, by encompassing three key elements:
These elements of Pae Ora are interconnected and mutually reinforcing. The reforms aim to bring decision-making to the local level through place-based strategies; Māori Iwi Partnership Boards play a key governance role in development of locality-based plans. These plans extend beyond just health care needs and consider social, housing, and other service needs through a community-led consultation process.
To help address the large gaps in equity, Pae Ora centers on the importance of mātauranga Māori, or Māori knowledge, being critical for finding a pathway forward. It emphasizes Māori leading their own health gains and strategic direction for the future: Māori solutions developed by Māori for Māori.
American veterans are twice as likely as the general population to die from opiate overdose. Drug abuse problems are particularly complex, often involving both physical conditions and social factors. In 2018, the US Veterans Health Administration (VHA) introduced its Whole Health program, which works with veterans to develop personal health plans and teaches them skills for ongoing self-care. An integrated clinical care team helps manage each veteran’s treatment and seeks to account for factors such as the veteran’s sense of purpose, psychological profile, and physical health.
Veterans meet with fellow veterans trained as peer facilitators to discuss their lives and aspirations. They also can take advantage of evidence-based complementary health approaches offered in their communities, such as acupuncture, meditation, yoga, and tai chi.
VHA piloted the program at 18 sites, reaching more than 130,000 veterans. In two years, 31% of veterans with chronic pain had used whole-health services. Average opioid use among the participants fell by 38%, versus just 11% for nonparticipants. Veterans who used whole-health services also reported less stress and increased healthy behaviors, indicating improvements in overall well-being.
Common fee-for-service payment models can limit the transformative potential of integrated care approaches. Some US states are legally restricted from billing for both primary care and behavioral health services on the same day, and Medicare coverage of collaborative care can be inadequate. Startup costs to implement integrated care, including staffing and technology, are not always reimbursable.
To realize savings through integrated care, some health systems now link payments with results through value-based care models that reward physicians for the quality of care provided, rather than the number of patients treated. Value-based care allows patients to drive their own care and considers them in context of their families, communities, and the entire health ecosystem. These models have picked up steam over the last decade; investments in them quadrupled during the COVID-19 pandemic.16 Figure 1 visualizes the whole-health approach in a value-based care framework.
Health leaders increasingly seek to prevent health problems before they occur. Clinicians care for the whole person by screening for social and environmental risk factors linked to health outcomes. A recent US Bureau of Labor Statistics survey found that 70% of community health centers screen for these risk factors.18
One model is Developmental Understanding and Legal Collaboration for Everyone (DULCE), currently in use at 13 sites across the United States.19 Since families are most likely to visit the doctor during a child’s first six months, those entering the program are screened for a set of social-related health needs and then connected to a multisectoral care team of specialists that meets weekly to review each case.20 Each team includes clinical care workers, a representative of a community early-childhood organization, a family specialist trained in evidence-based and empathetic care and a legal expert to help with access to programs.21
A randomized-controlled trial of the program found that it resulted in quicker access to supports, better completion rates for well-child visits and immunizations, and reduced use of emergency room care by DULCE families.22
Whole-health care requires a capable and healthy workforce. Yet many health workers face growing workloads, daunting administrative burdens, inadequate funding, and mental and emotional exhaustion.23 A 2020 survey of more than 2,700 health professionals in 60 nations found that more than half reported signs of burnout.24 Many health professionals are leaving the field; in 2023, the United States alone may face a shortage of up to a million nurses.25 Some have posited that health worker burnout is not just a matter of individual emotional exhaustion but could also involve inadequate and outdated systems.26 The current workforce crisis represents an opportunity to rebuild our care delivery systems and refocus on meaning and value in health care work.27
A better-supported workforce can better support its patients. Australia’s Stability, Encompassing, Endurance and Direction (SEED) program is a team-based approach to health worker wellness codesigned by health workers to meet their specific needs.28 The model works to create a supportive workplace atmosphere to foster collective resilience, by encouraging personnel to look after their own well-being while on the job.
Examples of some of the activities SEED has implemented include a “S(Crap) Notebook” communal journal allowing frontline staff to reflect and share their stressful and unique stories during the pandemic. Another example is a handcrafted wooden “Reflection Tree” placed upon the wall to reflect the growth of a hospital after it was endangered by bushfires. Staff used the tree to post acts of kindness or thoughts of gratitude. SEED’s Wellness Warrior Training trained staff members in ways to create a supportive work environment, such as purposeful listening to colleagues’ concerns. Participating staff have described a sense of human flourishing as a result of SEED.29
Diversifying and expanding the workforce can also help relieve some of the pressures on health workers.
Some governments are redefining “health care worker” to include nontraditional workers, such as faith leaders, barbers, teachers, and other community members, expanding the workforce in ways that increase community connections. Community health centers have long led the way in bringing community members, or peers with lived experience, into health care through the incorporation of “promotores” or community health workers.30 This approach can help ensure the values and priorities of the communities served are embedded into care delivery.
Community members can also be trained in mental health awareness to identify common concerns and help treat people in the community or refer them to care. In Zimbabwe’s Friendship Bench program, “grandmothers” offer problem-solving therapies to community members, stationing themselves at benches. Participating older women are taught to identify the symptoms of common, easily managed mental health conditions and offer support. The Friendship Bench has demonstrated promising results, with one study of more than 500 participants finding that after six months only 14% of those assigned to the Friendship Bench reported depression versus 50% assigned to standard psychiatric care.31
In short, caring for the whole health of care workers—and expanding the definition of who can be a health worker—can lead to a more resilient, satisfied workforce better equipped to go beyond disease-centric care to creating healthier communities.
Whole health should be a collaborative effort, linking health aims, data, and incentives with services such as housing, transportation, education, and social supports. Federal, state, and local agencies can partner with the private sector, nonprofits, and local communities to leverage population data about what factors drive health and scale effective programs.
The pandemic forged a number of relationships between health agencies and nonhealth sectors.32 Some countries created new infrastructure to enable data-sharing and communication between health agencies and health care entities.
The US Centers for Disease Control and Prevention funds cross-cutting initiatives to help bolster the infrastructure for future pandemic preparedness.33 The program has scaled up a number of efforts to modernize public health data, including electronic case reporting, a method for real-time data-sharing between health care entities and health agencies. The effort also resulted in the creation of a national center for epidemic forecasting and outbreak analytics, which acts as a hub for advanced disease modeling which can disseminate data rapidly for public health decision-making.34
In Sweden, the Hope platform offers a one-stop destination for health data. It enables communication and data-sharing between patients and health care and research entities. Through the HOPE app, patients can share their data, book appointments, receive notes and reminders, and access records from all of their care providers in a single place.35
Linking health services with multiple government services like housing, transportation, education, and social care can equip government to make whole health a collaborative aim. Various federal, state, and local agencies are partnering with the private sector, NGOs, and local communities to address social determinants of health and scale programs.
The US Department of Health and Human Services launched in 2023 a first-of-its-kind Federal Plan for Equitable Long-Term Resilience and Recovery (ELTRR), which details a whole-of-government strategy for federal agencies to collaboratively strengthen the vital conditions for community well-being and resilience across the United States.36 The 35-member interagency work group is composed of senior leaders in both health and nonhealth agencies. The plan aims to foster community-centered collaboration within and outside of government to achieve the aim of “all people and places thriving, no exceptions.”37 Notably, the plan also recommends adapting steady-state and other current funds to transform systems and enable wellness. Leveraging existing flexibilities across federal assets can allow for more efficient and impactful spending toward whole health.38
In Los Angeles, the Magnolia Community Initiative (MCI) exemplifies a whole-health, whole-of-community approach to care. More than 75 partners including local nonprofits, government agencies, early-childhood care providers, universities, and faith-based organizations, collaborate to co-design policies and practices for improving child health and educational outcomes.39 The initiative serves 35,000 children living in a neighborhood where 50% of children live in poverty, 35% are overweight, and 70% are not proficient in reading by the third grade.40 Leveraging data from a population dashboard that measures actions toward improvement, MCI developed a daily reading practice tracker, with family support programs, teachers, and families tracking children’s daily reading routines. The program works to increase child language acquisition and reduce childhood vulnerability.41
MCI has also become a physical and virtual one-stop-shop center for family support. Residents enter information only once to access all community-based services. When families visit MCI, they have access to a range of educational, health, and social service providers in one location.42 The halls are covered with cheerful murals, a nature center allows for exploration, and once a week, a farmers’ market is stationed on site with subsidized produce.
Likewise, the Healthy Chicago initiative began with an effort to directly address the social determinants of health, creating strategies to increase access to healthy foods and create more walkable neighborhoods. Hundreds of community partners from different disciplines contributed to more than 200 coordinated strategies. The Chicago Department of Transportation, for instance, began redesigning streets to make them more walkable for the elderly in low-income neighborhoods. In the next iteration of the initiative, Healthy Chicago 2025, partners are working to develop a citywide equity dashboard to measure progress against a set of indicators for health and racial equity. The dashboard will serve as a North Star for planning, implementation, and evaluation of all city programs.
On-the-ground knowledge and shared purpose of community can complement government and medical expertise to help create a whole health ecosystem. Data collection and sharing can render this combination more powerful. Communities, health organizations (public and private), and government services each have important roles to play.
Globally, health care is often a convoluted patchwork of misplaced incentives, interwoven social conditions, and urgent, real-life needs. Keeping one community healthy may rest on the shoulders of neighbors, community organizations, schools, nurses, counselors, insurers, employers, health departments, and city planners.
Aligning their different interests isn’t easy. And that’s why the public sector should explore alternate funding models, such as broadening the use of value-based care models and incentivizing interagency collaboration, and recognize the influence of social determinants of health on patient wellness. Connecting the big picture to the acute problem can save money, produce better health outcomes, and hopefully improve some of society’s interrelated problems.
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