Bobby Milstein

Director, System Strategy

Over the next seven weeks, The ReThinkers’ Blog will explore the components of a comprehensive regional strategy. This post is the first in the series. Over the course of the series, we will delve deeper into topics including:

  • Developing a theory of system change and building an interdependent portfolio of interventions
  • Defining and setting clear system boundaries to help guide decisions
  • The value of system prototyping, to allow us to identify, provoke, and learn about the interactions in a given system
  • Overcoming the conflicts that arise when leaders come together to develop a comprehensive strategy 

We’ll also introduce ReThink Health’s Regional Transformation Strategy Assessment Tool, which can help groups working toward regional transformation gain a better understanding of their own strategies and more effectively work toward change. 

Describe the health system in any region of the United States and the word “fragmented” is likely to be among the main adjectives used. The American way of producing health and well-being is notorious for its hyper-fragmented assortment of uncoordinated efforts. As just one example, in many regions—typically defined as one or more cities or counties—disconnected organizations are managing long lists of uncoordinated programs intended to address particular diseases, risk factors, body parts, and population sub-groups. The results of such fragmentation are understandably disappointing: high levels of illness, injury, and vulnerability; excessively expensive care; glaring disparities among certain sub-groups; and dramatic differences in health outcomes within and across regions.

In any given region, there will always be myriad organizations pursuing multiple priorities. Most of these organizations have developed strategic plans of some sort–and some are actively pursuing them. Unfortunately, leaders from different organizations rarely ask how their various activities fit together and how they might play out to affect the region and its people as a whole. This lack of communication and coordination creates a risky blind spot because, acknowledged or not, there is always a de facto strategy being enacted across a region, sometimes for better but often for worse.

The Appeal of a Comprehensive Regional Strategy

To reduce fragmentation and improve health and well-being, all those who live and do business in a region could come together to design a comprehensive strategy for the entire community. A comprehensive regional strategy incorporates both a theory of system change—in effect, a plan for how to produce desired outcomes for the region—as well as a portfolio of interventions (i.e., the policies, programs, practices, and investment priorities needed to bring that theory to life).  

The idea of developing a strategy for an entire region may seem daunting, if only because it requires that we see things in common and work together differently. Some may contend that we cannot make such connections—that we are too individualistic, too short-sighted, too beholden to separate funding, and too protective of vested interests to ever organize around a common strategy. Considering the current crisis facing our health system, it may be tempting to lower expectations for these reasons. However, that is one the of surest ways to perpetuate the status quo.

Fortunately, there are plenty of reasons to believe that an ambitious, comprehensive, region-wide strategy is possible. Many early steps toward regional integration are already occurring across the U.S. health sector, including instances of public health and primary care linkages, community health financing hubs, data sharing across sectors, and an emerging generation of accountable communities for health. And convincing evidence shows the likely benefits. Compared to enacting singular programs, combined regional investments—including simultaneous efforts to deliver higher-value care, enable healthier behaviors, and expand socioeconomic opportunities—would likely yield far greater and more equitable gains.

That ought to be enough to spur a sense of possibility, but in case not, it might help to remind ourselves of a time when we had even higher expectations: a time just after World War II, when one of the most famous strategic decisions in U.S. history helped to transform Western Europe from a fragmented assortment of deeply damaged countries into an economically interdependent, prosperous, and unified region.

Embracing Possibility: Insights from Marshall’s Strategy for European Recovery

In 1947, Europe’s infrastructure had been decimated, agricultural and industrial production were down, food was in short supply, inflation was high, and the economies of more than a dozen Western European countries were weak. U.S. Secretary of State George Marshall understood that Europe’s recovery depended on reversing all of these problems through actions such as rebuilding infrastructure, boosting production, expanding foreign trade, modernizing industry, and blocking the spread of communism, among others. Each objective was critical, and in Marshall’s view, none could be achieved in isolation. Instead, he saw them as distinct parts of a single, comprehensive strategy to steer Europe away from a spiral of decline, toward a more interdependent and prosperous future.

Marshall was a gifted statesman and perhaps an even better strategist. He understood that a single, comprehensive strategy—not plural, disconnected strategies spread across each country—would be the key to Europe’s recovery. His unconventional approach required delicate negotiations with both opponents and allies; and, once secured, the strategic design of U.S. aid rapidly stimulated recovery across Europe. Within the first two years of the Plan’s implementation, economic production increased by nearly one-quarter, with additional benefits accumulating over subsequent decades. As historian David Elwood tells the story in The Marshall Plan: A Strategy That Worked, “Experience would show that this was a long-term structural shift in the continent’s economy, which within a few years would spur political demands for European integration.”

Marshall won the Nobel Peace Prize in 1953; and the European Union (EU) eventually emerged from the ashes of war to connect 28 sovereign states, forming the second largest economy in the world. The EU won its own Nobel Peace Prize in 2012. Even now, in the wake of Britain’s narrow vote to exit, the EU remains intact.

Scholars still argue about the extent to which the Marshall Plan caused the EU to form. But for our purposes here, it is clear that Marshall’s vision to transform an entire region (rather than restrict the goals to help each previously disconnected entity) created at least some of the conditions for short-term economic cooperation to emerge across the continent. As those conditions took hold, ingenious leaders across Europe discovered for themselves the benefits of cooperation, which then laid the foundations for more formal interdependence to evolve.

Escaping the Spiral of Eroding Goals and Hyper-Fragmentation

A similar move toward multisector interdependence is beginning to surface across the United States. This shift may be more modest than reconstructing an entire region of the globe, but it requires the same sort of broad stewardship backed by sound strategy and sustainable financing to escape the spiral of eroding goals and hyper-fragmentation.

More and more local leaders, along with allies like our team at ReThink Health, view health system stewardship through a wide regional lens. Rather than focus on each seemingly separate program or project managed by every organization in town, a new generation of stewards are thinking about how to design and enact a comprehensive strategy for equitable health and well-being in their region as a whole.

If diverse leaders in your region share ambitious, transformative goals but are struggling to bring those aspirations to life, then a productive next step might be to develop a comprehensive regional strategy. For an inspiring example, in our next post, we will consider the story of King County, Washington. In response to rapid growth that is displacing longtime residents and deepening divides that compromise everyone’s health and well-being, a widening circle of leaders in King County have devised a novel strategy to make sure that the region they love remains a place where everyone feels that they belong and can contribute.

In the meantime, we encourage you to reflect on your own region: How well are leaders working together? Have they articulated a comprehensive strategy that incorporates goals for the entire region? Rather than pursue a patchwork of small projects, would it help to elevate aspirations and engage others in a more unifying endeavor? Share your answers in the comments section or send them to us at

The personal views and opinions expressed in this blog (and in any comments) are those of the original authors only, and do not reflect the opinions of The Rippel Foundation or ReThink Health. Neither The Rippel Foundation nor ReThink Health is responsible for the accuracy or validity of any of the information contained in the blog or any comments. All information is provided on an “as-is” basis.

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