The Hexagonal Aim

Expanding the Transformational Aim Framework for Positive Health Outcomes

by Global Health Systems

While the Triple Aim (Berwick et al., 2008) established a foundational framework for transformational change in healthcare delivery systems—improving individual care, enhancing population health, and advancing cost-effectiveness— to produce positive healthcare outcomes, emerging existential crises worldwide and global drivers of health outcomes demand a more expansive vision for healthcare policy and clinical practice. Contemporary challenges such as human-induced climate change, widening inequities in vulnerable and marginalized populations, and workforce burnout and increasing prevalence of diseases of despair underscore the need for a broader, more integrated approach.

The Hexagonal Aim (Alami et al., 2023; Bréchat et al., 2024) builds on earlier frameworks of transformational healthcare system change (Berwick et al., 2008; Bodenheimer & Sinsky, 2014; Nundy et al., 2022) by incorporating six interdependent goals: improved patient care and experience; disease surveillance and population health management; provider care and wellness; cost reduction; health equity and health democracy; and planetary health, stewardship, and sustainability. Together, these six aims offer a comprehensive framework for building cost-effective, equitable, and sustainable health systems worldwide.

Improved Patient Care and Experience

At the center of the Hexagonal Aim is a commitment to patient-centered care (Abid et al., 2024). This involves designing open, complex, and adaptable health systems around patient needs, values, and preferences, with primary health care serving as the cornerstone of effective essential healthcare services (Starfield, Shi, & Macinko, 2005; WHO-UN, 2018). Patient-centered approaches emphasize accessibility, comprehensiveness, continuity, and coordination across care settings, thereby strengthening trust between patients and providers. Incorporating shared decision-making, culturally responsive communication, and mechanisms for patient feedback not only enhances the individual patient experience but also contributes to system-wide quality improvement of care (Epstein & Street, 2011, IOM, 2001).

Disease Surveillance and Population Health Management

Health systems must extend beyond individual encounters to address the needs of populations as a whole. Today, this requires strong disease surveillance systems, big data analytics, and integrated care models that enable early detection, prevention, and intervention (Kindig & Stoddart, 2003). Population health management focuses on reducing health disparities by addressing health-related social needs and other determinants of health, implementing community-based interventions, and leveraging data and information to guide limited healthcare resource allocation. By integrating traditional medical care with essential public health services and community-based services, global health systems can both improve long-term outcomes and build resilience against global health threats such as pandemics and natural disasters (Frieden, 2010).

Provider Care and Wellness

A resilient healthcare system depends on the health and wellness of its workforce. Rising rates of professional burnout, depression, and other “diseases of despair” among healthcare professionals threaten quality, safety, and continuity of care (Shanafelt & Noseworthy, 2017). The Hexagonal Aim emphasizes initiatives that support provider wellness, including mental health resources, flexible scheduling, reduced administrative burdens, and collaborative team cultures. By investing in the health and satisfaction of healthcare providers, health systems can improve recruitment and retention, enhance patient safety, and foster a more compassionate and sustainable healthcare environment (West, Dyrbye, & Shanafelt, 2018).

Cost Reduction

The sustainability of global healthcare systems also hinges on cost management. Escalating expenditures pose risks to accessibility and affordability, necessitating strategies to reduce per capita costs without compromising quality. Value-based care and alternative payment models, which reward outcomes rather than volume, are central to this approach (Porter, 2010). Cost containment is further achieved through improved care coordination, expanded preventive services, telehealth and m-health adoption, and the reduction of unnecessary procedures. When financial incentives align with health outcomes, efficiency improves and the burden on patients and societies is significantly reduced (Wang et al., 2023).

Health Equity and Health Democracy

Equity and inclusivity are foundational to just and effective global healthcare systems. The Hexagonal Aim incorporates the concept of health democracy, emphasizing that individuals and communities must have agency and autonomy in their health decisions (Toosi et al., 2025). Advancing health equity requires dismantling systemic barriers, structural racism, addressing determinants of health, and integrating culturally competent principles and practices (Braveman et al., 2017). Shared decision-making, informed by empathy and humility, ensures that diverse perspectives are respected in care delivery (Elwyn et al., 2012). Integrated models of care that prioritize underserved and vulnerable populations are vital to reducing the ever-widening gap of health disparities and achieving equitable outcomes across demographic and socioeconomic groups.

Planetary Health, Stewardship, and Sustainability

Finally, the Hexagonal Aim recognizes that human health is inseparable from planetary health. Environmental degradation, human-induced climate change, and biodiversity loss are urgent threats that undermine both global health and system sustainability (Whitmee et al., 2015). Stewardship in healthcare involves minimizing ecological footprints, adopting renewable and sustainable practices, and embracing nature-based solutions such as green infrastructure and ecosystem restoration (Horton et al., 2014; Block, 2025a). By integrating environmental sustainability into healthcare delivery, systems can safeguard ecosystem services essential for human survival while promoting resilience and long-term well-being for people and the planet alike (Alami et al., 2023; Bréchat et al., 2024; Block, 2025b)

Conclusion

The Hexagonal Aim offers a forward-looking framework that addresses both enduring and emerging global health challenges by recognizing the complexity and interconnectedness of modern global health systems. By simultaneously focusing on patients, populations, providers, costs, equity, and planetary sustainability, the model provides a comprehensive and pragmatic guide for efficient, equitable, and effective health system transformation worldwide. Each dimension reinforces the others: patient-centered care is strengthened by healthier populations; resilient and well-supported providers enable better outcomes; cost management ensures accessibility; equity and health democracy expand inclusivity and fairness; and planetary health secures the environmental foundations upon which all human well-being depends.

This holistic vision underscores the inextricable interdependence of human health and planetary health (Block, 2025c), reminding us that sustainable global healthcare delivery cannot be achieved solely through advances in medicine or technology, but also requires stewardship of ecosystems, equitable governance, and workforce resilience. By embedding cultural humility, empathy, and sustainability into its aims, the Hexagonal Aim moves beyond incremental reform to chart a path toward transformative system-wide change.

In doing so, the Hexagonal Aim is not merely an expansion of earlier frameworks but a vital evolution that aligns the delivery of essential healthcare services with the urgent demands of the twenty-first century. It challenges policymakers, practitioners, and global institutions to think systemically, act collaboratively, and measure success not only in terms of individual outcomes but in the collective health of people, communities, and the planet. As such, the Hexagonal Aim provides both a roadmap and a moral imperative for reimagining global health systems capable of delivering effective, equitable, and sustainable care for generations to come.

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