Managing the Health Commons
Can a nobel prize in economics be good for your health?
Elinor Ostrom, PhD, the 2009 Nobel Laureate in Economic Sciences, identified eight design principles commonly found among communities that successfully manage resources critical to their own survival. To help leaders and communities be better stewards of the health commons, Mike McGinnis, PhD, is leading an effort in collaboration with Dr. Ostrom building on the lessons from fisheries, forests and grazing lands, as well as the experience of health collaborations in regions across the country. In the process, they hope to determine whether stakeholder groups can more constructively engage in the collaborative stewardship of common health resources to improve outcomes, deliver higher quality care, lower costs, and expand access.
While political debates on health reform have primarily focused at the national level, health care is an intrinsically local or regional matter. Even as researchers continue to document the wide range of regional variation in costs and quality of care, communities like Grand Junction, CO, demonstrate the potential to deliver high-quality care at costs well below the national average. Presumably, someone in that community has done something that contributed to these positive outcomes. Indeed, community leaders long ago developed informal mechanisms of collaborative stewardship of the health care resources that they share in common.
Managing the Health Commons, a project of ReThink Health, seeks a fuller understanding of health and health care as a commons. In a commons, stakeholders often have conflicting interests in the levels and forms of resource use, but also share a common interest in maintaining the long-term viability of the resource system as a whole. Collaborative stewardship of the commons requires that a team of stakeholders takes ownership of the challenge of sustainability and works out ways to coordinate their resource usage and replenishment activities over time.
In 2009, Elinor Ostrom, PhD, won the Nobel Prize in Economic Sciences for her insights into the governance of sustainable common resources. Notably, she found that sustainability is best achieved not by government or by the market, but by communities themselves. She identified eight design principles commonly found among groups of people that successfully manage resources critical to their own survival. Quite simply, they must communicate on a regular basis and have sufficient autonomy to craft, revise, and enforce their own rules.
Importantly, Dr. Ostrom’s work and Managing the Health Commons are reframing the lessons of “The Tragedy of the Commons,” an influential article by Garrett Hardin published in Science in 1968. Hardin explored the dilemma that arises when individuals, acting independently and in their own self-interest, deplete a shared limited resource, even though depletion is not in any of their long-term interests. The concept of the “commons” goes back to medieval practices of land tenure in which herders shared common land to their mutual benefit, but many types of commons remain vital components of modern society.
Recognizing that a commons exists when a group shares access to a resource or system of resources which they either jointly consume or use as a pool from which they take resources for their private use, it is not surprising that problems arise. Any of these common resources can be depleted or degraded by over-use or by under-investment. In addition, efforts to replenish or maintain resources are costly, and these costs are only willingly paid by those who have strong interest in ensuring the sustainability of the resource into the future.
Health is a particularly complex commons, encompassing several types of resources and many kinds of goods and services. Certainly, the health commons encompasses shared resources that include:
- Health care facilities and physical capital such as emergency rooms, hospitals, clinics, testing facilities, advanced technology
- Financial resources such as publicly funded programs, private employers, insurance companies, social service support
- Human capital such as health care professionals and health-conscious citizens
- Social capital such as trust among health professionals, community leaders, and citizens
For these resources, limited supply and the lack of appropriate alternatives can be sources of conflict. Social capital, which provides the foundation for any group’s capacity for collective action, can also be degraded by pursuit of divisive purposes. While any of these resources might be reallocated to more efficient or equitable outcomes, meaningful reform will face stubborn resistance from entrenched interests. The critical question is: Who can act as stewards of these common resources? And how can the success of their collaboration be enhanced?
Working with Dr. Ostrom as an advisor, a team of researchers led by Michael D. McGinnis, PhD, of Indiana University’s Workshop on Political Theory and Policy Analysis is partnering with other ReThink Health members to investigate principles that are relevant for sustainably managing those resources most critical to health. The team is also working to develop a set of analytic and self-assessment tools for use by communities across the country.
For additional insight into health as a commons, a paper by Dr. McGinnis can be found here.