The unrelenting rise in healthcare costs over the past 50 years has caused policymakers to respond. Their reactions have led to a gradual economic transformation of medicine. As a result, detailed billing, quality controls, financial incentives, savings targets and digitalisation are now putting increasing pressures on the nursing and medical staff. In addition, the humanity of care of the patient–doctor and/or patient–nurse interactions has been cast aside to a great extent. Therefore, the immaterial side of care has been neglected or even removed from these relationships. These changes are now perceived as intolerable by most health workers and patients. Yet healthcare costs are still rising. This paper presents a hypothesis that should enable healthcare systems to respond more effectively. It proposes the introduction of the Meikirch model, a new comprehensive definition of health. The Meikirch model takes human nature fully into account, including health and disease. The inclusion of the individual potentials, the social surroundings and the natural environment leads to the concept of health as a complex adaptive system (CAS). Care for such a definition of health requires medical organisations to change from top–down management to bottom–up leadership. Such innovations are now mature and ready for implementation. They require a long-term investment, a comprehensive approach to patient care and new qualifications for leadership. The Meikirch model reads: ‘To be healthy a human individual must be able to satisfy the demands of life. For this purpose, each person disposes of a biologically given and a personally acquired potential, both of which are closely related to the social surroundings and the natural environment. The resulting CAS enables the individual to unfold a personal identity and to develop it further until death. Healthcare has the purpose to empower each individual to fully realize optimal health’.This hypothesis postulates that the new definition of health will further develop healthcare systems in such a way that better health results at lower costs.

Rising healthcare costs are major concerns in most high-income countries. Yet, political measures to reduce costs have so far remained futile and have damaged the best interests of patients and citizen. We therefore explored the possibilities to analyze healthcare systems as a socially constructed complex adaptive system (CAS) and found that by their very nature such CAS tend not to respond as expected to top-down interventions. As CAS have emergent behaviors, the focus on their drivers - purpose, economy and behavioral norms - requires particular attention. First, the importance of understanding the purpose of health care as improvement of health and its experience has been emphasized by two recent complementary re-definitions of health and disease. The economic models underpinning today's healthcare - profit maximization - have shifted the focus away from its main purpose. Second, although economic considerations are important, they must serve and not dominate the provision of healthcare delivery. Third, expected health professionals' behavioral norms - to first consider the health and wellbeing of patients - have been codified in the universally accepted Declaration of Geneva 2017. Considering these three aspects it becomes clear that complex adaptive healthcare systems need mindful top-down/bottom-up leadership that supports the nature of innovation for health care driven by local needs. The systemic focus on improving people's health will then result in significant cost reductions.

Health is an adaptive state unique to each person. This subjective state must be distinguished from the objective state of disease. The experience of health and illness (or poor health) can occur both in the absence and presence of objective disease. Given that the subjective experience of health, as well as the finding of objective disease in the community, follow a Pareto distribution, the following questions arise: What are the processes that allow the emergence of four observable states-(1) subjective health in the absence of objective disease, (2) subjective health in the presence of objective disease, (3) illness in the absence of objective disease, and (4) illness in the presence of objective disease? If we consider each individual as a unique biological system, these four health states must emerge from physiological network structures and personal behaviors. The underlying physiological mechanisms primarily arise from the dynamics of external environmental and internal patho/physiological stimuli, which activate regulatory systems including the hypothalamic-pituitary-adrenal axis and autonomic nervous system. Together with other systems, they enable feedback interactions between all of the person's system domains and impact on his system's entropy. These interactions affect individual behaviors, emotional, and cognitive responses, as well as molecular, cellular, and organ system level functions. This paper explores the hypothesis that health is an emergent state that arises from hierarchical network interactions between a person's external environment and internal physiology. As a result, the concept of health synthesizes available qualitative and quantitative evidence of interdependencies and constraints that indicate its top-down and bottom-up causative mechanisms. Thus, to provide effective care, we must use strategies that combine person-centeredness with the scientific approaches that address the molecular network physiology, which together underpin health and disease. Moreover, we propose that good health can also be promoted by strengthening resilience and self-efficacy at the personal and social level, and via cohesion at the population level. Understanding health as a state that is both individualized and that emerges from multi-scale interdependencies between microlevel physiological mechanisms of health and disease and macrolevel societal domains may provide the basis for a new public discourse for health service and health system redesign.

Rising healthcare costs are major concerns in most high-income countries. Yet, political measures to reduce costs have so far remained futile and have damaged the best interests of patients and citizen. We therefore explored the possibilities to analyze healthcare systems as a socially constructed complex adaptive system (CAS) and found that by their very nature such CAS tend not to respond as expected to top-down interventions. As CAS have emergent behaviors, the focus on their drivers – purpose, economy and behavioral norms – requires particular attention. First, the importance of understanding the purpose of health care as improvement of health and its experience has been emphasized by two recent complementary re-definitions of health and disease. The economic models underpinning today’s healthcare – profit maximization – have shifted the focus away from its main purpose. Second, although economic considerations are important, they must serve and not dominate the provision of healthcare delivery. Third, expected health professionals’ behavioral norms – to first consider the health and wellbeing of patients – have been codified in the universally accepted Declaration of Geneva 2017. Considering these three aspects it becomes clear that complex adaptive healthcare systems need mindful top-down/bottom-up leadership that supports the nature of innovation for health care driven by local needs. The systemic focus on improving people’s health will then result in significant cost reductions.

Das Buch behandelt einen wichtigen Mangel heutiger Gesundheitssyteme: Niemand kann wirklich sagen, was Gesundheit ist. Alle bisherigen Definitionen sind ungenügend. Das Meikirch-Modell beschreibt ein neues, umfassendes Verständnis der Gesundheit, das vielversprechende Perspektiven eröffnet.

Das Meikirch-Modell definiert einen Menschen als gesund, wenn er in der Lage ist, die Anforderungen des Lebens zu erfüllen. Um dies zu realisieren, verfügt jeder Mensch über Ressourcen, d.h. über ein biologisch gegebenes und ein persönlich erworbenes Potential, die beide dauernd mit der Gesellschaft und der Umwelt in Verbindung stehen. Politik, Forschung und Therapie haben sich bisher vorwiegend auf das biologisch gegebene Potential konzentriert und die anderen Aspekte der Gesundheit mehr im Hintergrund gelassen. Wird das sowohl in der Public Health als auch in der Individualmedizin ausgeglichen, darf erwartet werden, dass sich die Gesundheit der Menschen deutlich verbessert und sich die Gesundheitskosten entsprechend vermindern.

Journal of Evaluation in Clinical PracticeVolume 23, Issue 1 p. 222-224 COMMENTARY “Multimorbidity” as the manifestation of network disturbances. From nosology to the Meikirch model† Johannes Bircher MD, Johannes Bircher MD Emeritus Professor Department of Hepatology, University of Bern, Bern, SwitzerlandSearch for more papers by this authorEckhart G. Hahn MD, Eckhart G. Hahn MD Emeritus Professor Department of Medicine 1, University Hospital Erlangen, Erlangen, GermanySearch for more papers by this author Johannes Bircher MD, Johannes Bircher MD Emeritus Professor Department of Hepatology, University of Bern, Bern, SwitzerlandSearch for more papers by this authorEckhart G. Hahn MD, Eckhart G. Hahn MD Emeritus Professor Department of Medicine 1, University Hospital Erlangen, Erlangen, GermanySearch for more papers by this author First published: 13 September 2016 https://doi.org/10.1111/jep.12633Citations: 4 †For the purpose of readability only the male gender is used. By implication it applies equally to the female gender. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume23, Issue1Special Issue: 2017 EBM ThematicFebruary 2017Pages 222-224 RelatedInformation

Over the past decades, scientific medicine has realized tremendous advances. Yet, it is felt that the quality, costs, and equity of medicine and public health have not improved correspondingly and, both inside and outside the USA, may even have changed for the worse. An initiative for improving this situation is value-based healthcare, in which value is defined as health outcomes relative to the cost of achieving them. Value-based healthcare was advocated in order to stimulate competition among healthcare providers and thereby reduce costs. The approach may be well grounded economically, but in the care of patients, “value” has ethical and philosophical connotations. The restriction of value to an economic meaning ignores the importance of health and, thus, leads to misunderstandings. We postulate that a new understanding of the nature of health is necessary. We present the Meikirch model, a conceptual framework for health and disease that views health as a complex adaptive system. We describe this model and analyze some important consequences of its application to healthcare. The resources each person needs to meet the demands of life are both biological and personal, and both function together. While scientific advances in healthcare are hailed, these advances focus mainly on the biologically given potential (BGP) and tend to neglect the personally acquired potential (PAP) of an individual person. Personal growth to improve the PAP strongly contributes to meeting the demands of life. Therefore, in individual and public health care, personal growth deserves as much attention as the BGP. The conceptual framework of the Meikirch model supports a unified understanding of healthcare and serves to develop common goals, thereby rendering interprofessional and intersectoral cooperation more successful. The Meikirch model can be used as an effective tool to stimulate health literacy and improve health-supporting behavior. If individuals and groups of people involved in healthcare interact based on the model, mutual understanding of and adherence to treatments and preventive measures will improve. In healthcare, the Meikirch model also makes it plain that neither pay-for-performance nor value-based payment is an adequate response to improve person-centered healthcare. The Meikirch model is not only a unifying theoretical framework for health and disease but also a scaffold for the practice of medicine and public health. It is fully in line with the theory and practice of evidence-based medicine, person-centered healthcare, and integrative medicine. The model offers opportunities to self-motivate people to improve their health-supporting behavior, thereby making preventive approaches and overall healthcare more effective. We believe that the Meikirch model could induce a paradigm shift in healthcare. The healthcare community is hereby invited to acquaint themselves with this model and to consider its potential ramifications.

Background: In a number of indigenous villages in Orissa, India, the possibility was explored that teaching of a new definition of health, the Meikirch model, might improve health behavior of inhabitants beyond what can be achieved by ordinary teaching. Methods: For this purpose, teaching about the Meikirch model was given in twenty experimental villages and conventional teaching about health in twenty control villages. Results: After 2½ years, health behavior in the two groups of villages was compared. Improvement of nutrition, wearing of slippers during use of latrines, washing of hands before meals, availability of latrines, childhood vaccination, use of mosquito nets, and attention to mother/child care were much better in experimental than in control villages (all P< 0.001). Yet, in several aspects of the experimental villages, there was room for further improvement. Conclusion: It is concluded that the Meikirch model was understood by the inhabitants of the villages and they improved their health behavior. These preliminary results justify formal studies with larger samples to validate the results and possibly to improve teaching methods.

Background: In a number of indigenous villages in Orissa, India, the possibility was explored that teaching of a new definition of health, the Meikirch model, might improve health behavior of inhabitants beyond what can be achieved by ordinary teaching. Methods: For this purpose, teaching about the Meikirch model was given in twenty experimental villages and conventional teaching about health in twenty control villages. Results: After 21⁄2 years, health behavior in the two groups of villages was compared. Improvement of nutrition, wearing of slippers during use of latrines, washing of hands before meals, availability of latrines, childhood vaccination, use of mosquito nets, and attention to mother/child care were much better in experimental than in control villages (all P < 0.001). Yet, in several aspects of the experimental villages, there was room for further improvement. Conclusion: It is concluded that the Meikirch model was understood by the inhabitants of the villages and they improved their health behavior. These preliminary results justify formal studies with larger samples to validate the results and possibly to improve teaching methods.

This paper explores the diagnostic and therapeutic potential of a new concept of health. Investigations into the nature of health have led to a new definition that explains health as a complex adaptive system (CAS) and is based on five components (a-e). Humans like all biological creatures must satisfactorily respond to (a) the demands of life. For this purpose they need (b) a biologically given potential (BGP) and (c) a personally acquired potential (PAP). These properties of individuals are embedded within (d) social and (e) environmental determinants of health. Between these five components of health there are 10 complex interactions that justify viewing health as a CAS. In each patient, the current state of health as a CAS evolved from the past, will move forward to a new future, and has to be analyzed and treated as an autonomous whole. A diagnostic procedure is suggested as follows: together with the patient, the five components and 10 complex interactions are assessed. This may help patients to better understand their situations and to recognize possible next steps that may be useful in order to evolve toward better health by themselves. In this process mutual trust in the patient-physician interaction is critical. The described approach offers new possibilities for helping patients improve their health prospects.

This paper explores the diagnostic and therapeutic potential of a new concept of health. Investigations into the nature of health have led to a new definition that explains health as a complex adaptive system (CAS) and is based on five components (a-e). Humans like all biological creatures must satisfactorily respond to (a) the demands of life. For this purpose they need (b) a biologically given potential (BGP) and (c) a personally acquired potential (PAP). These properties of individuals are embedded within (d) social and (e) environmental determinants of health. Between these five components of health there are 10 complex interactions that justify health to be viewed as a CAS. In each patient, the current state of his health as a CAS evolved from the past, will move forward to a new future, and has to be analyzed and treated as an autonomous whole. A diagnostic procedure is suggested as follows: together with the patient, the five components and 10 complex interactions are assessed. This may help the patient to better understand his situation and to recognize possible next steps that may be useful for him to evolve toward more health by himself. In this process mutual trust in the patient-physician interaction is critical. The described approach offers new possibilities to help patients to improve their health.

Background: Current dilemmas of health care systems call for a new look at the nature of health. This is offered by the Meikirch model. We explore its hypothetical benefit for the future of medicine and public health.Meikirch model: It states: “Health is a dynamic state of wellbeing emergent from conducive interactions between individuals’ potentials, life’s demands, and social and environmental determinants.” “Throughout the life course health results when an individuals’ biologically given potential (BGP) and his or her personally acquired potential (PAP), interacting with social and environmental determinants, satisfactorily respond to the demands of life.”Methods: We explored the Meikirch model’s possible applications for personal and public health care.Results: The PAP of each individual is the most modifiable component of the model. It responds to constructive social interactions and to personal growth. If an individual’s PAP is nurtured to develop further, it likely will contribute much more to health than without fostering. It may also compensate for losses of the BGP. An ensuing new culture of health may markedly improve health in the society. The rising costs of health care presumably are due in part to the tragedy of the commons and to moral hazard. Health as a complex adaptive system offers new possibilities for patient care, particularly for general practitioners.Discussion: Analysis of health systems by the Meikirch model reveals that in many areas more can be done to improve people’s health and to reduce health care costs than is done today. The Meikirch model appears promising for individual and public health in low and high income countries. Emphasizing health instead of disease the Meikirch model reinforces article 12 of the International Covenant on Economic, Social and Cultural Rights of the United Nations – that abandons the WHO definition - and thereby may contribute to its reinterpretation.

L’économie de marché désigne l’échange de marchandises contre de l’argent. Or lorsque des professionnels de la santé s’engagent également sur le plan humain et contribuent, grâce au travail relationnel, à soulager le patient, il n’est plus possible d’évaluer leur activité uniquement sous l’angle de l’économie de marché. Fort de ce constat, l’auteur souligne le rôle de l’économie du don.