Table 2 Illustrative action points for key stakeholders in different phases of healthcare system transitions

Health service manager

Promote healthcare that is respectful of patients and families

Redesign services to meet requirements of acute and chronic conditions

Strengthen coordination of care; promote interdisciplinary teamwork for managing multi-morbidities

Promote institutional policies that minimize disruptions of effective communications and foster customized/ individualized care

Policy maker

Formulate policies to systematically integrate vertical programs into general healthcare services

Establishing task forces/working groups at national level to align interventions for acute and chronic conditions simultaneously

Establish policies and programs to support generalists and inter-professional education for managing multi-morbidities

Setting targets that will allow healthcare leaders to measure progress toward customized/individualized care

Donor

Provide more funding on and technical assistance for strengthening general healthcare services

Provide funding and technical assistance for designing strategies and services to address acute and chronic conditions simultaneously

Provide technical assistance for strengthening integrated primary care for multi-morbidities

Provide platform for sharing best practices in customized/individualized care

Scientific community

Provide evidence for shifting toward more horizontal health system; Develop integrated clinical diagnosis and treatment algorithm

Investigate potential synergies in policies, programs and services for addressing acute and chronic conditions

Studies to develop guidelines for care of patients with multiple conditions; models of coordinated care; shared decision-making and strategies to deal with conflicting priorities

Studies to support continuous enhancement of efficient flexible care management system that can respond to patients’ needs for different levels of support