Health care reforms: control knobs framework

Health care reforms is for the most part governmental policy that affects health care delivery in a given place. Health care reform typically attempts to:

  • Broaden the population that receives health care coverage through either public sector insurance programs or private sector insurance companies
  • Expand the array of health care providers consumers may choose among
  • Improve the access to health care specialists
  • Improve the quality of health care
  • Give more care to citizens
  • Decrease the cost of health care

“Control knobs” theory of health care reforms

In “Getting Health Reform Right: A Guide to Improving Performance and Equity,” Marc Roberts, William Hsiao, Peter Berman, and Michael Reich of the Harvard school of public Health aim to provide decision-makers with tools and frameworks for health care system reform. They propose five “control knobs” of health reform, that is, financing, payment, organization, regulation, and behavior. These control knobs refer to the “mechanisms and processes that reformers can adjust to improve system performance”. The authors selected these control knobs as representative of the most important factors upon which a policymaker can act to determine health system outcomes.

Their method emphasizes the importance of “identifying goals explicitly, diagnosing causes of poor performance systematically, and devising reforms that will produce real changes in performance”. The authors view health care systems as a means to an end. Accordingly, the authors advocate for three intrinsic performance goals of the health system that can be adjusted through the control knobs. These goals include:

  1. Health status: This goal refers to the overall health of the target population, assessed by metrics such as life expectancy, disease burden, and/or the distribution of these across population subgroups.
  2. Customer satisfaction: This goal is concerned with the degree of satisfaction that the health care system produces among the target population.
  3. Financial risk protection: This goal refers to the health system’s ability to protect the target population from the financial burden of poor health or disease.

Control knobs: Performance measures of health care reforms system goals

The authors also propose three intermediate performance measures, which are useful in determining the performance of system goals, but are not final objectives. These include:

  1. Efficiency:
    1. Technical efficiency: maximum output per unit cost
    2. Allocative efficiency: a given budget maximizes health system user satisfaction or other defined goals
  2. Access: effective availability by which patients receive care
  3. Quality of care: consideration of both the average quality and distribution of quality

The five control knobs of health care  reforms

These control knobs are not only the most important elements of a healthcare system, but they also represent the aspect that can be deliberately adjusted by reforms to affect change. The five control knobs are:


which encompasses all the mechanisms and activities designed to raise money for the health system. With respect to mechanisms, the financing knob includes health-related taxes, insurance premiums and out-of-pocket expenses among others. Activities refers to the institutional organization that collects and distributes finance to participants in the health sector. In other words, financing is about the resources available to the healthcare system, who controls them and who receives them. The financing knob has clear implications for the health status of the population and particular groups in it, as well as the access to health care and protection from financial risk that these groups, and the population as a whole, have. The financing knob involves numerous potential financing mechanisms and processes that should be selected in accordance with a country’s social values and politics.


refers to the mechanisms and processes through which the health system or patients distribute payments to providers, including fees, capitation and budgets on the part of the government and fees paid by patients. Payment is about the distribution of available resources to the providers of health services. Health care reform can implement a variety of incentive schemes for both providers and patients in a way to optimize limited resources.


of the health system refers to the structure of providers, their roles, activities and operations. Essentially, organization describes how the health care market is set up. That is, who are the providers, who are the consumers, who are the competitors, and who runs them. Changes in the organization of a healthcare system happen at multiple levels at both the front-line and managerial level.


It refers to actions at the state level that modify  the behavior of various actors within the health care system. The actors may include health care providers, medical associations, individual consumers, insurance agents, and more. Regulations are only effective when enforced. Therefore laws that are “on the books” but are not implemented in practice have little effect on the system as a whole.


Behavior of healthcare actors includes actions of both providers and patients . It involves changing individual behavior through population-based interventions. Healthcare reform with respect to behavior revolves around the behaviors that can be used to improve the outcomes and performance of the health care system. These behaviors include health-seeking behavior, professional/doctors’ behavior, treatment compliance, and lifestyle and prevention behaviors.

The five control knobs of health care reform are not designed to work in isolation; health care reform may require the adjustment of more than one knob or of multiple knobs simultaneously. Further, there is no agreed-upon order of turning control knobs to achieve specific reforms or outcomes.

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