I must have drawn the “short straw” to be slotted in to offer ideas on solutions rather than the easier task of identifying “current issues”!
The outline for Session 1 summarizes a daunting set of global health challenges representing well some of the key issues making up today’s broader vision for global health, which the Canadian Insitute’s for Health Research has recently termed “Global Health 3.0 Collective Action to Address Shared Risks and Responsibilities”1. These include (my paraphrasing) global cooperation and more effective response to pandemics; meeting the challenges of climate change; addressing disparities within and between countries; and broadening approaches to improving public health to address behavioral determinants and the health effects of products. There are certainly other challenges gaining recent attention, but these are plenty to tackle.
A recent comment in The Lancet noted “…health systems should be reimagined to…better serve the purpose of preparing and responding to anticipated (and unanticipated) future hazards and risks, and to produce healthier and more resilient societies.”2 This timely call for broadening our thinking is welcome in light of current issues, but we should also be mindful of the significant constraints to expanding action, especially in lower and middle income countries, and the unmet goals represented by the different elements of SDG 3 among others. In light of this, I will try to offer some suggestions that could guide both broader framing of health systems but also recognize practical limitations that must be considered to avoid overly ambitious and ultimately discouraging results.
Reframing health system goals
As the referenced recent Lancet comment noted, health systems frameworks have been developed at particular points in time and reflect to varying degrees the priorities prevalent at those times. For example, during the 1990s, there was wide interest in health sector reform and health care financing (see for example, WHR 20003 and Roberts, et al Getting Health Reform Right4 ). During the 2000’s, the Millennium Development Goals (MDGs) focused attention on progress in a defined set of health outcome priorities, especially those related to maternal and child health and survival and communicable disease control. WHO responded with its widely used “health system building blocks” framework5, which emphasized a more normative model of inputs and health system elements. And some frameworks emphasized more the complexity and interaction amongst health system change strategies and specific health system elements6
The adoption of the Sustainable Development Goals (SDGs) coincided with global attention to Universal Health Coverage which is SDG 3.8. The SDGs reflect a more comprehensive set of goals than the MDGs, reminding us that “health” encompasses more than the bases of physical health and survival. And today, current and emerging crises introduce new elements of resilience to shocks (COVID-19) and a broader time dimension and sustainability (climate change).
A fundamental element of health systems frameworks, however, remains the framing of the goals nations and societies set to guide their efforts. Conceptualization of these have varied less. It shouldn’t surprise that I am partial to the thinking that went into the goals framed in Roberts et al.(2003) (the GHRR framework) of which I was a co-author. These are reprised in Figure 1:
Figure 1: Ultimate Outcomes (Goals) Comprising Health Systems Performance
Let’s consider some of the ideas underpinning these goals in light of today’s newer understanding of the scope and responsibilities of health systems. Fundamentally, this new understanding has broadened the scope of what health systems are being asked to do at a time when there has been only modest progress in increasing their resources and capacities. That makes creative thinking about goals even more important.
The GHRR framework recognizes at the highest level the universal importance of equity in relation to the different ultimate outcomes that define health system performance. Framing equity as “distribution” recognizes that different dimensions of disparities (e.g. income, gender, geography, ethnicity) may have salience in different places and times. We have also become increasingly aware of the “intersections” of these dimensions in populations.
The GHRR framework also gives equal initial recognition to three dimensions of ultimate outcomes which we felt all health systems seek to achieve to differing degrees or with different weights: population health, financial risk protection, and satisfaction of perceived needs of populations including things like a sense of trust, caring, and accountability.
A fundamental tenet of the GHRR approach is that different nations and societies may define their preferences for these outcome goals and their distributions in different ways. This is the responsibility of each polity and differences should be recognized and accepted. This is especially important when needs and goals dramatically outstrip resources, as they do in most countries and especially in lower and lower-middle income countries. And this need to set locally-appropriate goals is further intensified by the broadening of health system responsibilities as reflected in the “issues” identified for this meeting as noted in a recent publication.7
This also introduces the challenge of the time dimension. How to balance the acute needs for health care to treat current illness with the deferred impacts of investments in prevention, future capacities, resilience and sustainability (potentially underused capacities to being able to respond to uncertain future shocks)?
I think this poses a key challenge to the global community and one of the main points I would like to emphasize – recognizing and accepting the need for local framing of goals and priorities, and supporting local priorities, is a key step for the next generation of global initiatives to address health and development. This implies that, while ambitious and comprehensive global goals may help to keep our attention on a better future, we must respect and support differences in the paths different polities may choose to take on the journey. What must we do to enable that flexibility?
Clearly to encompass a broader agenda of issues we need to expand our notion of what comprises the “systems” to address these issues. Acute illness treatment and communicable disease prevention lead us to focus primarily on health services delivery systems. NCDs, chronic conditions, nutrition, multi-morbidity (increasing present in aging populations), mental health – these engage systems and services outside the typical activities of health services providers and the departments/ministries that support them.
Let’s consider three broad categories of “health system performance supporting actions” (recalling WHO’s earlier definition of the health systems as all the people, resources, etc. that carry out health actions).
Clinical services – largely treating disease in individuals
Personal services to prevent disease and promote health – again largely provided to individuals
Non-service activities impacting population health – this includes areas like mass communications, climate effects mitigation, broader social supports such as those related to income, housing, employment, which impact health, etc.
What are the “systems” that develop and deliver these actions? How do they interface with the goals identified by nations and societies as priorities? How can domestic and external actors best support actions in these different areas?
This broader vision of “health system performance supporting actions” necessitates some new thinking about the organization and governance of the actors enabling these actions. This is needed at global, national, and local levels. Are our sectoral structures and silos up to this task? Will simply expanding the scope of responsibilities of Ministries of Health be the right strategy?
This is my second element of moving towards new “solutions” – new visions of organization and governance to address broader population health needs.
Recognizing Key Constraints
It is often argued that idealistic and ambitious goals have an important role in motivating change. Most recently, we who are working in global health have seen this in the global movement advocating for universal health coverage (UHC) – defined as the ideal of everyone receiving all the health care they need without facing financial hardship as a result.
My own view, sometimes controversial, is that while idealistic and ambitious goals have their place in stating our aspirations for a better and fairer future, they are sometimes put forward with insufficient respect for fundamental constraints, especially those faced by lower and middle income nations. In the case of UHC, I believe this led to a number of countries launching highly ambitious comprehensive health insurance schemes that, should their promises be realized, they could not financially afford, nor did they have the service delivery capacities to provide. The consequences, still being assessed, may have been a shift of limited resources towards clinical services with an emphasis on secondary and tertiary care despite concurrent calls to prioritize primary health care. And this may have shifted resources away from the other two types of actions – an implicit prioritization of needs that may not be optimal with regard to the new needs facing many countries.
So another element of developing solutions to achieve better health system performance may lie in more explicit recognition of key constraints. These include at least the following areas:
Financial and physical constraints. Per capita health expenditure levels in total and for governments in most lower income countries are not sufficient to finance a comprehensive package of clinical and personal preventive services that could reasonably be called UHC. This is why the framing of SDG 3.8 refers to UHC with “essential” services, although without defining what that means, except for some measures of indicators purportedly representing this package. The capacity to deliver universally the intended package of personal clinical and preventive services is also lacking in many settings. An unintended consequence may have been that resources flowed disproportionately to areas and populations more capacitated to deliver these services than to those most in need of them.
Sufficient attention to the greater financial and physical resource requirements to address distributional disparities. Many governments plan and budget for health and allocate resources based on population averages, such as per capita allocations to provinces or districts. Remediating disparities may often require significant departures from these averages, reducing allocations for some services and areas in order to achieve greater equity for others.
Balancing current needs with investments in future capacities. Leaders face pressures to address current needs, especially when their tenure in office is brief. This may inhibit investments that would give greater returns in the future. Pressures on development partners to produce results in five-year project cycles reinforces this tendency. One result is less investment in underlying systems and capacities that are needed to produce benefits in the future and remedy inequities reflecting historical disparities.
Dangers of dependence. Lower and middle income countries need the additional resources they receive in development assistance. But too many countries depend too much on these flows of funds to support basic elements of their health systems. They are too vulnerable to the slowing or even reduction of aid flows we have observed in recent years. New needs – COVID-19 vaccination, climate change mitigation, emerging health problems of aging populations and changes in diet and environment are creating new demands for funds and other resources. Nations providing development assistance have incurred unprecedented levels of domestic debt in response to COVID-19 as well as increasing demands from their citizens to remedy their own distributional problems. I think one lesson of the past 18 months for many LMICs has been that they will need to find a new balance between getting assistance and assuring sufficient self-reliance to be able to withstand future shocks and chart a sustainable forward path.
A third point, then, is the need to be much more practical in recognizing the constraints facing today’s expanded agenda for health and set priorities and objectives accordingly.
Public Health Systems: Is Their Development a Means to Address New Challenges?
To conclude with something more specific – is the development of public health systems one of the remedies for how health systems can meet new challenges?
We don’t currently have a good conceptualization of public health systems. The concept of “essential public health functions” includes some elements that are central to public health systems, like disease surveillance, but also others that overlap with larger health system responsibilities, like policy development.
One key attribute of public health systems is the centrality of a “population health” focus. To me, that means measuring health needs and changes in health at the level of populations, both in aggregate but also with attention to specific sub-populations, bringing in the expression of those “distributional” issues. Perhaps they should be called Population and Public Health Systems?
The traditional population and public health focus has been primarly on the second and third type of actions mentioned above. Of course, individual clinical services contribute to population and public health, but more in terms of summative contributions from individual outcomes rather than addressing more generally distributed causes of poor health outcomes.
Where can population and public health systems contribute differentially to the “new” issues identified in the earlier session? Some of the following:
Strengthen research capacities to analyze needs and trends on the levels of populations
Introducing population perspectives into policy development. The “health in all policies” movement has been one example of this.
Integrating interventions reflecting the second and third types of actions more directly into clinical care models. The team-based or integrated primary health care model is an important example of this. Population and public health systems capacities work together with clinical service delivery capacities to achieve a more comprehensive and sustainable health state.
Public communications. COVID-19 has taught and is still teaching us many lessons about the dangers of misinformation and the challenges of gaining the public trust needed to assure health-promoting behavior at the level of populations.
My concluding point, then, is to emphasize that states, localities, and international actors may need to devote much more in resources and action to supporting organizations and programs that explicitly focus on population health in broader terms, not simply include this within those organizations providing primarily clinical services.
Professor Peter Berman (M.Sc, Ph.D) is a health economist with forty years of experience in research, policy analysis and development, and training and education in global health. He is Professor at the School of Population and Public Health, University of British Columbia in Vancouver Canada where he was also Director from 2019-21, and Adjunct Professor in Global Health at Harvard T. H. Chan School of Public Health, Harvard University. He is also affliated as Adjunct Professor at the Public Health Foundation of India (PHFI) in New Delhi, India and as advisor to the China National Health Development Research Center for health care financing and health accounts.
Prof. Berman was also the founding faculty director of Harvard Chan’s new Doctor of Public Health degree. He is the author or editor of five books on global health economics and policy and more than 60 academic papers in his field and numerous other working papers and reports. He has led and/or participated in major field programs in all regions of the developing world. He is co-author of Getting Health Reform Right: A Guide to Improving Performance and Equity (Roberts, et al, Oxford University Press, 3rd edition, 2018), co-editor of the Guide to the Production of National Health Accounts (World Bank, World Health Organization, and USAID, 2003), and co-editor of Berman and Khan, Paying for India’s Health Care (Sage, 1993).