Marginal patients, marginal delivery systems and health systems plans

Marginal patients are those who are either denied access to medical care or who have chosen not to utilize medical care for their health problems. Marginal delivery systems have at times been developed by these marginal patients to meet their own needs as they define them. The structure and ideas of eight such marginal systems in Alameda County, California, are examined. Structurally, these systems are characterized by their notions of mandate, their unique development and evolution, individuality, independence, consumer control and short existence. The ideas held in these systems include new definitions of health, an expanded definition of appropriate health promoting activities, different definitions of clientele groups, new notions of division of labor and personnel, new forms of governance and decision making, different insights into the financing of health care and refreshingly new notions of medical politics.