From health systems to systems for health: much more than semantics

There’s something in the air. Ministries of health in the Bahamas, Barbados, and Botswana have added wellness to their titles—they are now ministries of health and wellness. They are not alone, so too have Belize, Jamaica, and Mauritius. India recently relaunched its health centres as health and wellness centres. Meanwhile the department of health in South Australia has become that of health and wellbeing. Dr Tedros, Director-General of the World Health Organisation (WHO), recently observed that “by and large, the world’s health systems do not deliver health care. They deliver sick care.” In response, Dr Tedros called for “fundamental changes,” to prevent disease by tackling the conditions that shape the health of people—which can be done “at a fraction of the cost of treating them.”1 The new Alliance for Health Policy and Systems Research report calls for the re-imagining of health systems as “systems for health.”2 Might we be witnessing a shift in the public health gaze from sickness to health, from wellness and to wellbeing?

Well not so quick. The report cautions against false dichotomies. In particular, it argues that it is counterproductive to pit investments against one another in Universal Health Coverage (UHC), pandemic preparedness, and actions that keep people healthy. It argues that investments must be aligned and can be synergistic. The report authors highlight a weak spot in the prevailing health systems approach with its emphasis on healthcare services. The report explicitly seeks to provide a unifying framework to support WHO to deliver on its triple billion targets (i.e. health security, UHC, and healthy populations).3 Implicitly, it might serve as a guide for ministries seeking to extend their mandates to wellness in a way that will inspire rather than alienate the UHC community.

Eyes may roll at the proposal of yet another health framework. But frameworks have implications—particularly those that are more normative than descriptive or analytical. They can raise and keep health issues on or off agendas. Beyond this, they can determine who makes which decisions and who benefits from them. The six building blocks of the UHC framework4 have been highly influential in making health systems more concrete and thereby influencing how ministries of health organise and go about their work. However, the building blocks approach may have inadvertently distracted from the importance of investing in healthy populations. The framework focused on individual access to healthcare and financial protection rather than managing the upstream structural determinants of health and wellbeing. The systems for health approach attempts to correct this shortcoming with a more holistic approach.

The underpinning ideas the “systems for health” can be traced back to the public health movements of the 19th and 20th centuries and were expressed in the Alma Ata Declaration and the Ottawa Charter on Health Promotion. The Alliance framework builds on this extensive literature but also incorporates more recent developments such as the digital revolution. The framework considers trust and power, the role of communities and rights-based approaches and acknowledges the transnational impacts on the systems that create health. These considerations may have been less explicit or entirely absent in previous articulations of systems for health and health systems frameworks.

A systems for health approach will require ministries of health (and wellness) to engage more systematically with the systems that determine health outcomes and equity. Most obvious are the decent work, welfare, social protection and social care systems as well as the food, water, sanitation, and housing systems.

The AIDS movement has long mobilised these systems to address the drivers of HIV, demonstrating that it is achievable and can be effective.5 The movement also tapped into and supported community and mutual support systems6 while challenging the prevailing intellectual property systems. It was in no small part responsible for the Doha Declaration on TRIPs flexibilities and access to generic medicines.7 The legal and justice systems are another avenue to promote health and social justice8—in the case of HIV, activists pushed for decriminalisation of gay sex, drug use and sex work and encouraged marginalised communities to know their rights. This was a gateway to prevention, care, and treatment services that helped curb the epidemic. There is similar scope for the public health movement to leverage human rights and accountability systems as well as systems of rule and governance themselves—in the service of inclusion and democratisation of institutions and systems that impact on health.

The Joint United Nations Programme on AIDS (UNAIDS) and the national multi-sectoral HIV responses were based on a systems for health (and social justice) logic. The public health community has been slow to learn from that experience—perhaps due to the perception of AIDS exceptionalism. There is some truth in that exceptionalism; given the tendency to defer to disciplinary and professional hierarchies in the health establishment, the activism was somewhat unique. The AIDS movement effectively leveraged systems not as a result of any particular conceptual framework, but because it adopted an overtly political approach that demanded that these systems work to protect the health of people living with, at risk of, or affected by HIV, as opposed to serving the status quo.9 This is a critical lesson to those seeking to identify and realise the potential of a systems for health approach.

Steps towards the systems for health approach would include investment in boundary spanning personnel, identifying priorities and divisions of labours for cross-sector work, increasing use of multifunctional frontline staff, engaging with communities to understand their perspective and priorities for disease prevention and health promotion. But above all, it will require challenging systems to deliver on their potential despite vested interests that benefit at the expense of people and planet.

Clearly, the shift from health systems to systems for health is more than just semantics. It has profound consequences for people and groups most at risk of ill health—the poor, the marginalised and the discriminated against, who are living in conditions that often are least conducive to health. Although a systems approach may be more complex and challenging than the building blocks approach, it represents a much needed step change to enabling more people to live healthier and longer lives with dignity and wellbeing. If the Alliance’s conceptualisation can get traction, it will go some way to fostering healthy societies by fixing systems, not people.10