The Six Levels of Healthcare Fragmentation

In the first article in this series, we argued that “is this system fragmented” is the wrong question, because nearly every health system is, to some degree. The useful question is where. Fragmentation does not show up as one problem; it shows up at several distinct levels, and a system can be fragmented at some of them while relatively coordinated at others. Here is a practical map of the six levels, followed by two cross-cutting patterns worth knowing on top of them.

Level 1: Structural fragmentation This is the most visible form: different organizations simply operate independently of one another. Public hospitals separated from private hospitals. Ministry of Health services separated from social security services. NGO-run services operating outside government systems entirely. The diagnostic question is simple: are these institutions connected organizationally, or are they islands?

Level 2: Financial fragmentation Here, multiple payers fund healthcare through different mechanisms — public insurance, private insurance, employer-based coverage, and significant out-of-pocket payment, often all in the same country at the same time. The consequence is that different benefit packages produce unequal access and create incentives for cost-shifting between payers. Countries such as Lebanon and the United States, along with many middle-income countries, experience this acutely.

Level 3: Service delivery fragmentation Services are delivered in silos: primary care disconnected from hospitals, mental health separated from general health, maternal health separated from chronic disease management. The patient experiences this directly and describes it in a single sentence: “I have to tell my story repeatedly at every provider.”

Level 4: Clinical fragmentation This is arguably the most common form patients encounter. Providers caring for the same patient simply do not coordinate around that patient. A diabetic patient might see a cardiologist, an endocrinologist, a nephrologist, and an ophthalmologist, each managing their piece of the case, with little or no communication between them.

Level 5: Information fragmentation Health information is not shared: separate electronic medical records that do not talk to each other, paper records still in use in parts of the system, a general lack of interoperability. The downstream effects are concrete: duplicate tests, medication errors, and delayed clinical decisions made without the full picture.

Level 6: Governance fragmentation Decision-making authority is dispersed across multiple ministries, regional authorities, insurance funds, and professional bodies, each acting largely independently. This level deserves particular attention because governance fragmentation tends to be upstream of the other five: when no single entity is steering the system toward shared goals, structural, financial, service, clinical, and information fragmentation all tend to follow.

Two cross-cutting patterns

Layered on top of these six levels are two directional types of fragmentation worth naming separately, because they call for different fixes.

Vertical fragmentation occurs between levels of care, primary, secondary, and tertiary. Poor referral systems are the classic cause: a patient is referred to a specialist or a hospital and the connection back down to primary care and follow-up is weak or absent, so the patient falls between levels.

Horizontal fragmentation occurs across organizations operating at the same level. Several hospitals in the same city competing rather than collaborating is one example. Separate public health programs for HIV, tuberculosis, and maternal health running with little coordination between them is another.

Why the map matters

None of these six levels is independent of the others, and few systems are uniformly fragmented across all of them. A system can have relatively strong structural integration (public and private providers cooperate reasonably well) while having severe information fragmentation (their records still can’t talk to each other). That combination calls for a very different intervention than a system with the opposite profile.

This is also why we described fragmentation in the first article as something better expressed as a profile than a single verdict. Knowing that a system is fragmented is a start. Knowing which of these six levels, plus whether the pattern runs vertical or horizontal, is what turns a vague diagnosis into a plan.

The next article in this series looks at what these different levels of fragmentation actually cost the people moving through the system: the patients.

At B&I, VAO exists to make this map visible and measurable for a given health system, rather than left as a general impression. If mapping your own system’s fragmentation profile would be useful, we would welcome the conversation.