Cover Page


Series Editor

Bruno Salgues

The Management of Chronic Diseases

Organizational Innovation and Efficiency

Pierre Huard



I wish to make reference to the following French journals: “Pratiques et Organisation des Soins” and “Santé Publique”, for allowing me to use passages of text and figures used within articles [HUA 11a, HUA 11b, HUA 14].

I wish to thank my friend (and co-author of the articles above), Dr. Philippe Schaller, creator and manager of “Réseau de Soins Delta” and the health center “Cité Générations” in Geneva, Switzerland, for a long collaboration and without whom this book wouldn’t have come to fruition.


This book details a general reflection on the management of chronic diseases1, and more specifically, the organizational forms that are likely to promote its effectiveness and efficiency. This reflection is based on the premise that chronic diseases are increasing in the morbidity pattern as well as the difficulties that the health system is encountering while dealing with this problem and thus seeks to define new care models.

An extensive literature addresses these issues; in most cases, it adopts an approach that is both descriptive and prescriptive. More specifically, it describes the characteristics of alternative forms (Health Maintenance Organization, Care Networks, Multiprofessional Health Homes, etc.) and gives recommendations on the conditions to be met in order to improve the quality of chronic disease management.

However, these descriptions and recommendations list conditions (required or sufficient?), but do not provide much information as to the way to practically implement them in order to obtain effective and efficient care schemes.

This is why, while subscribing to this research approach, particular attention is here given to the analysis of the dynamic change processes that are likely to help the development of these innovative schemes (ISs).

More specifically, the reasoning presented is divided according to the following stages: (1) situation and issues linked to chronic disease management: Chapters 1–3; (2) quality-effectiveness conditions for chronic disease management: Chapters 4 and 5; (3) the development dynamics of an IS: Chapters 6–8; (4) IS organizational structure: Chapters 9 and 10; (5) IS implementation and transformation of the health system organization: Chapters 11 and 12.

I.1. Situation and issues linked to chronic disease management

In this section, we will recall the place of chronic diseases, the specific requirements for their care and the unsuitability of traditional organization (individual medical practices and hospitals) to address them (Chapter 1). In Chapter 2, we will mention the different categories of experiences, recommendations and models seeking to develop organizational forms that are better suited to these treatments. In Chapter 3, we examine the technical, social and cultural obstacles for the adoption of these new forms.

I.2. Quality-effectiveness conditions for chronic disease management

In Chapter 4, we will redefine the quality of chronic disease management by differentiating: (1) the intrinsic quality of procedures, (2) the diversity and relevance of the range of care and services that can be mobilized in order to meet patients’ needs, (3) the cooperation capacities of actors and the coordination of their interventions. Then (Chapter 5), we will try to identify the activities helping to put the three quality conditions just presented into practice. These activities can be described as “specific” since they are absent or only play a secondary role in the operation of traditional schemes, even though they are fully part of care quality. These include, for example, prevention, patient therapeutic education, a cooperation–coordination management function, multiprofessional quality circles, medico-social services, etc.

I.3. Development dynamics of an IS

In Chapter 6, we will create a process combination model allowing for efficient management. Care quality and scheme size seem to play a significant part in configuring these relationships. In Chapter 7, we will complete the model by paying close attention to the funding issue, and by considering in particular how capitation lump sum funding makes an endogenous development possible for IS. Chapter 8 is dedicated to a slightly detailed illustration, in which we analyze the development of a scheme that implements some of the relationships presented in the model.

I.4. IS organizational structure

Chapter 9 will recall the main aspects of an organization and, in particular, the differentiation of the activities and their coordination, as well as the generic forms they help to build (markets, hierarchies, networks). Cooperation and coordination conditions are detailed, as well as the need arising from them for a steering function. Chapter 10 concerns the different types of relationships, especially the contractual ones, which are structuring IS. It also focuses on the area configurations drawn up by different densities of relationships and, finally, the organizational dynamics through the various forms of collaboration.

I.5. IS implementation and transformation of the health system organization

Chapter 11 will provide strategic information in order to develop an IS, which is illustrated with the example of the success of an initially doomed reform (the 1991 British reform). We will detail a development strategy linked to the size of the scheme, and the corresponding strategic management. Chapter 12 is devoted to the possible IS role as an intermediary structure in the desirable development of the system organization. Finally, we mention the measures, principles and obstacles related to the promotion of a reform, which is explicitly intended for the effectiveness and efficiency of chronic disease management.

Of course, the model presented does not claim to be the solution to all the problems posed by chronic disease management. By developing a simple analysis through stages, which is illustrated with practical examples, we propose recalling some options that are likely to usefully inform the debate.