Time to reconceptualise health systems
Authors: Zubin Cyrus Shroff, Robert Marten, Jeanette Vega, David H Peters, Walaiporn Patcharanarumol, Abdul Ghaffar
Journal: The Lancet (2021)

The COVID-19 pandemic continues to expose tremendous vulnerabilities in every country's health system. It also highlights deficiencies in existing conceptualisations of health systems that overlook health security and health promotion. The global spread of COVID-19 has focused attention on roles of health systems in managing health emergencies. At the same time, more than 70% of deaths are now caused by non-communicable diseases. Investing in both health security and health promotion is acute and urgent. Considering the goals of health security and health promotion separately, however, frames policy decisions as making investments in one or the other, which is a false dichotomy obscuring the interconnected and central role of health systems in addressing both goals and achieving universal health coverage.1Frenk J Gómez-Dantés O False dichotomies in global health: the need for integrative thinking.Lancet. 2017; 389: 667-670Summary Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 2Ooms G Flores W Mulumba M Sarker M Van de Pas R Jahn A False and real, but avoidable, dichotomies.Lancet. 2017; 390: 647-648Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar When health systems contribute to managing epidemics, they create healthy populations, which in turn are better able to mitigate continuing and future epidemics. For example, communities with high burdens of obesity and chronic diseases have greater COVID-19 risks, whereas healthier populations are less susceptible to COVID-19. But a singular focus on managing health emergencies can also limit efforts to create healthy populations. COVID-19 control measures can reduce physical activity, create social isolation, and cause economic hardship among other implications. COVID-19 will not be the last pandemic. Health systems need to prepare for new and evolving crises. Policy makers also need to be empowered to address health risks beyond the health sector. Yet a predominant focus on individual health care within existing health systems frameworks has neglected community engagement and ignored how policies, programmes, and systems could be designed to address health emergencies and create healthier populations. Health systems frameworks are contested products of their time.3van Olmen J Marchal B Van Damme W Kegels G Hill PS Health systems frameworks in their political context: framing divergent agendas.BMC Public Health. 2012; 12: 774Crossref PubMed Scopus (92) Google Scholar Existing frameworks predate the Sustainable Development Goals and COVID-19 eras, and largely focus on delivering clinical services responding to people's rightful demand for care. However, health systems should be reimagined in light of the pandemic to go beyond this, and better serve the purpose of preparing and responding to anticipated (and unanticipated) future hazards and risks, and to produce healthier and more resilient societies. This reconceptualisation matters because frameworks shape policy and investments. Reconceptualising health systems means shifting future investments into these functions to strengthen health systems and prevent further fragmentation of competing parallel investments in health security and health promotion. The Alliance for Health Policy and Systems Research is seeking to reimagine health systems frameworks to better address these goals in an integrated way. Building on ongoing efforts to overcome fragmented health systems,4Ooms G Ottersen T Jahn A Agyepong IA Addressing the fragmentation of global health: the Lancet Commission on synergies between universal health coverage, health security, and health promotion.Lancet. 2018; 392: 1098-1099Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar the Alliance's 2022 flagship report will reassess existing frameworks, develop an integrated framework, and provide approaches for action. We hope to move beyond the false dichotomy of investing in health security or health promotion and instead focus on how strategic investments reinforce each other to strengthen health systems that move towards universal health coverage and achieve Sustainable Development Goal 3 to ensure health and wellbeing. JV is the chair of the Alliance for Health Policy and Systems Research Scientific and Technical Advisory Committee. DHP is the chair of the Alliance for Health Policy and Systems Research board. WP is a member of the Alliance for Health Policy and Systems Research board. ZCS, RM, and AG declare no competing interests. ZCS and RM contributed equally. False dichotomies in global health: the need for integrative thinkingDuring the 20th century, international health was strongly influenced by a set of dichotomies that limited the advancement of the health agenda. In an attempt to force choices, actors in the international arena presented several options to address the dominant health challenges as if they were mutually exclusive. It was a clear expression of a century divided by ideological affections. The list of dichotomies is anything but short: prevention versus treatment, vertical versus horizontal, primary care versus specialised care, infections versus non-communicable diseases (NCDs), knowledge versus action. Full-Text PDF