Health System Governance Case 4: Perspectives on
defining health
Leonardi: The definition of health is not just a theoretical issue, because it has many implications
for practice, policy, health services, and health promotion.
The definition of health affects health professionals, and in turn they strongly affect how
health is socially constructed in modern societies. The social representations of health
influence the demands and expectations of health, the health care systems, the policy
makers, and many other key aspects of health.
In short, the definition of health has a strategic importance in all health fields.
Health: tends to dissolve in a lot of smaller aspects. People try to describe health in different ways:
1. Most people try to describe it in different dimensions (e.g. physical, mental or emotional
health). So it is difficult to define health
2. As general sense of wellbeing (e.g. feeling healthy, resilient, positive, balanced)
3. Instrumental to do other important things as a person(e.g. to be able to cope, work and live a
healthy life)
Study was done in which stakeholders (e.g. patients, policy makers, healthcare providers,
researchers etc) were asked to rate dimensions of health (e.g. quality of life, daily functioning,
mental functioning etc). A few interesting things emerged from this study:
Different opinion between patients (with actual disease) and general citizens: patients score
all of dimensions high whereas citizens some aspects are not as high
You see this difference more, when you move further away from the patients (e.g. to
insurers, policymakers).
They all agree that physical health is important, however when it comes to softer dimensions
like spirituality and social participation, this is rated as less important by groups of insurers
and policymakers in comparison to patients
Why is health conceptualization important?
1. Health system boundaries
2. Arrangement of functions (resources that you need to generate, maintain, respond or
improve health depend on what you constitute as health. Same goes what you finance, and
how you do this. Has a lot to do with how you define health)
What different models exist to define health and how has our definition of health changed over time?
Formal models for defining/conceptualizing health (Larsson, 1999):
1. Medical model
2. Holistic model
3. Wellness model
4. Environmental model
1 is the narrowest definition whereas environmental model is the broadest
Also constitute development over time (medical is oldest whereas environmental is newest)
In lecture we are focussing on the first 2 because of strong impact on health systems.
1
, Currently, we are still at holistic perspective but moving to broader perspectives (last two)
Medical model: oldest conceptualization of health
René Descartes: credited with developing mind-body dualism (‘’Cartesian dualism’’)
Mind and body are unlike substances that exist apart from each other and not in unity
Mind: immaterial, thinking, indivisible (whole) = self (who you are as human being)
Body: material, unthinking, divisible = machine (you can use body as machine)
Why is this relevant to how we view health in our health system?
Before Cartesian dualism, the most prevalent views of mind-body relationships were those of
orthodox Christian views
Christian views: mind and body could not be separated (souls in heaven)
This shifted (=critical conceptual leap) to a biomedical model (based on cartesian dualism)
later in which humans are seen as biological organisms (machines) and no longer as spiritual
beings
Critical conceptual leap (=separation from mind and body) enabled a lot of scientific progress in
medicine, because it allowed the human body to be studied (e.g. pathology and anatomy)
-In this case, the body is seen as a machine which means:
Disease = malfunction
Definition of health: ‘’Health = absence of disease or infirmity (no malfunctions)’’
This is the perspective of the Medical model
Impact of medical model on current health system can be recognized by:
Reductionism: e.g. specialization (neurology, oncology, immunology) and fragmentation (e.g.
departments due to specialization) in which specialization can be seen as positive whereas
fragmentation is a negative effect
Mechanical approach: have led to dehumanization (hart as a pump) & disempowerment
(patients have been neglected in care process for a long time, e.g. in their spirituality,
personal circumstances, health beliefs)
Governance of health system (how boundaries are set and who is involved in healthcare
provision): narrow view on care continuum
-Focus on: curing, neglecting promotion, rehabilitation and end-of-life care. Also health as a
non-political concept (full responsibility with medical professional, government not involved)
Medical model (narrow perspective):
Focus on disease, prevention and cure (latter the most)
Medical professionals as main actors
2
defining health
Leonardi: The definition of health is not just a theoretical issue, because it has many implications
for practice, policy, health services, and health promotion.
The definition of health affects health professionals, and in turn they strongly affect how
health is socially constructed in modern societies. The social representations of health
influence the demands and expectations of health, the health care systems, the policy
makers, and many other key aspects of health.
In short, the definition of health has a strategic importance in all health fields.
Health: tends to dissolve in a lot of smaller aspects. People try to describe health in different ways:
1. Most people try to describe it in different dimensions (e.g. physical, mental or emotional
health). So it is difficult to define health
2. As general sense of wellbeing (e.g. feeling healthy, resilient, positive, balanced)
3. Instrumental to do other important things as a person(e.g. to be able to cope, work and live a
healthy life)
Study was done in which stakeholders (e.g. patients, policy makers, healthcare providers,
researchers etc) were asked to rate dimensions of health (e.g. quality of life, daily functioning,
mental functioning etc). A few interesting things emerged from this study:
Different opinion between patients (with actual disease) and general citizens: patients score
all of dimensions high whereas citizens some aspects are not as high
You see this difference more, when you move further away from the patients (e.g. to
insurers, policymakers).
They all agree that physical health is important, however when it comes to softer dimensions
like spirituality and social participation, this is rated as less important by groups of insurers
and policymakers in comparison to patients
Why is health conceptualization important?
1. Health system boundaries
2. Arrangement of functions (resources that you need to generate, maintain, respond or
improve health depend on what you constitute as health. Same goes what you finance, and
how you do this. Has a lot to do with how you define health)
What different models exist to define health and how has our definition of health changed over time?
Formal models for defining/conceptualizing health (Larsson, 1999):
1. Medical model
2. Holistic model
3. Wellness model
4. Environmental model
1 is the narrowest definition whereas environmental model is the broadest
Also constitute development over time (medical is oldest whereas environmental is newest)
In lecture we are focussing on the first 2 because of strong impact on health systems.
1
, Currently, we are still at holistic perspective but moving to broader perspectives (last two)
Medical model: oldest conceptualization of health
René Descartes: credited with developing mind-body dualism (‘’Cartesian dualism’’)
Mind and body are unlike substances that exist apart from each other and not in unity
Mind: immaterial, thinking, indivisible (whole) = self (who you are as human being)
Body: material, unthinking, divisible = machine (you can use body as machine)
Why is this relevant to how we view health in our health system?
Before Cartesian dualism, the most prevalent views of mind-body relationships were those of
orthodox Christian views
Christian views: mind and body could not be separated (souls in heaven)
This shifted (=critical conceptual leap) to a biomedical model (based on cartesian dualism)
later in which humans are seen as biological organisms (machines) and no longer as spiritual
beings
Critical conceptual leap (=separation from mind and body) enabled a lot of scientific progress in
medicine, because it allowed the human body to be studied (e.g. pathology and anatomy)
-In this case, the body is seen as a machine which means:
Disease = malfunction
Definition of health: ‘’Health = absence of disease or infirmity (no malfunctions)’’
This is the perspective of the Medical model
Impact of medical model on current health system can be recognized by:
Reductionism: e.g. specialization (neurology, oncology, immunology) and fragmentation (e.g.
departments due to specialization) in which specialization can be seen as positive whereas
fragmentation is a negative effect
Mechanical approach: have led to dehumanization (hart as a pump) & disempowerment
(patients have been neglected in care process for a long time, e.g. in their spirituality,
personal circumstances, health beliefs)
Governance of health system (how boundaries are set and who is involved in healthcare
provision): narrow view on care continuum
-Focus on: curing, neglecting promotion, rehabilitation and end-of-life care. Also health as a
non-political concept (full responsibility with medical professional, government not involved)
Medical model (narrow perspective):
Focus on disease, prevention and cure (latter the most)
Medical professionals as main actors
2
