Reflection on developments, challenges, and opportunities in Global Health Systems and Research
Professor Goran Tomson is a leading voice in global health systems research. His remarkable career, first practicing medicine and later research in health system changes to improve quality of care, spans over thirty years and crosses countless borders. In this piece, he reflects on the developments he has observed in Global Health Systems Research and presents his perspectives on challenges and opportunities in the future.
Developments and challenges in Global Health Systems Research
Health Policy and Systems Research (HPSR) has benefitted significantly from increased recognition of the importance of robust health systems to health outcomes. The field has demonstrated a remarkable maturation over the past 20 years, and the number of researchers engaged has grown substantially now also in low and middle-income countries (LMICs) not least facilitated by the Alliance for Health Policy and Systems Research. Developments I have observed include the growing interest in “evidence-informed decision making”. This field of study has made policymakers and practitioners more aware and increased their capacity to employ evidence in policy- and decision making. It has brought the field of HPSR closer to diverse stakeholders – policymakers, program, and health system managers, health workers and civil society groups.
The Health Systems Global professional association launched less than ten years ago has markedly strengthened the field, as has Alliance for Health Policy and Systems Research, EVIPNet, and different institutions in China, India, Mexico, South Africa and Thailand.
Another recent development is the shift from disease or service-specific ways of viewing health services in many LMICs towards a more integrated and systems-focused perspective. This is embodied both in Universal Health Coverage and the Sustainable Development Goals (SDGs) which have increased demand for evidence.
Despite these developments, significant challenges remain. First lack of definitions and clarity about how different subsystems fit together. Second, health research funding has had a strong bias towards biomedical and clinical research. The Commission on Health Research for Development (1990) underlined the neglect of "policy and social science and management research" and, in preparing for what became the Alliance for Health Policy and Systems Research, the necessity of multi- and interdisciplinary approaches were emphasised. We all know the difficulty of this type of research which also necessitates institutional arrangements fostering HPSR be it as part of Schools of Public Health, separate Institutions or arrangements linked to health ministries. These challenges demonstrate the need for capacity building at both individual and institutional levels. It is yet to be seen what the changing global landscape, not least with increasing engagement in Global Health from China and India, will mean for HPSR and its researchers.
Global Health Systems challenges and opportunities
WHO has characterised health systems as comprising of six subsystems (service delivery; human resources; information; medicines & technologies; financing; and leadership/governance). The model is somewhat limiting, as health promotion and prevention tend to be underemphasised.
The conceptual ecological framework in the figure below that I have created incorporates the subsystems, put patients/people in the centre but goes further to depict the complex nature of health systems fully. Systems components interact dynamically, creating a complex patient-centered system, influenced by and influential of external drivers. Globalisation means things such as mobility of ideas, goods, and microbes resistant to antibiotics, which all influence local as well as national health systems - hence the concept "glocalisation." One needs to think and act both globally and locally!
Globalisation leads partly to the erosion of power within the state often in favor of multinational companies and international institutions. On the other hand, health systems are context-specific with their own culture, history, and socioeconomic situation. There is also the opportunity to strengthen the performance of existing national health systems by investigating the role played by global actors. Having a sound understanding of the different parts and functions is truly important for policy development and implementation in national health systems. System functions do not lie so much in the parts but in their interactions.
Fig.1 - G.Tomson 2010
Multilevel governance is another challenge. From a country perspective, the vertical dimension refers to higher (supranational) and lower (regional) government levels, while the horizontal dimension constitutes interactions with other states, NGOs, international organisations and the private sector. Tobacco control and containment of antibiotic resistance (ABR) are illustrative examples , where there is a WHO Framework Convention and Global Action Plan respectively, as well as many national action plans being developed. One unresolved issue is how the fast-food industry behavior in LMICs changes dietary habits resulting in an epidemic of non-communicable diseases (NCDs) such as diabetes and hypertension challenging already fragile health systems. We have yet to see effective global action to counteract this.
In order to steer this “complex adaptive system” there is a need, for strong leadership, health systems thinking, well-functioning institutions and information technologies that enable more evidence-informed policies to be implemented in health systems.
Conclusion – opportunities ahead
The UN Agenda 2030, with SDGs, provides excellent potential for coherence. SDG 3.8 on Universal Health Coverage supported by the WHO general program of work 2019-23 aims to have 1 billion more people benefiting from UHC and thus offers the best possible platform for improving health services for all and reducing inequities with its financial protection. However, many other of the targets under SDG3 need population-level health interventions and governance approaches outside the health sector, requiring multisector collaboration and systems thinking. For example, targets for communicable diseases (including ABR), NCDs, alcohol (3.3-3.5) sexual and reproductive health (3.7) and tobacco (3.a) call for broader largely non-clinical measures such as taxation, control of marketing, and restriction of sales of harmful products.
Value-driven policies that emphasise social justice, human rights, equity, and responsive systems pose challenges at different levels globally and locally. SDG 16 has accountable and transparent institutions as one target, SDG 17 global partnerships as another. It is time for the global community to step up its efforts here. Enabling dynamic partnerships between universities in HICs and LMICs is one such opportunity for capacity building. The work of the Alliance for Health Policy and Systems Research (AHPSR) constitutes another. National systems interventions need to address both global and local challenges.
Finally, we need a "global innovation flow" within health systems development. This includes "reverse innovations" with HICs learning from LMICs including on areas such as rural health service delivery, task shifting, and innovations in information technology.
About the author
Professor Goran Tomson is a Distinguished Fellow at The George Institute for Global Health, Councelor UN 2030 Agenda at Karolinska Institutet, Senior Advisor at Swedish Institute for Global Health Transformation, SIGHT, Royal Swedish Academy of Sciences, Stockholm, Sweden
Professor Tomson is a leading voice in global health systems research. His remarkable career, first practicing medicine and later research in health system changes to improve quality of care, spans over thirty years and crosses countless borders. In this piece, he reflects on the developments he has observed in Global Health Systems Research and presents his perspectives on challenges and opportunities in the future.