In complex and rapidly changing health systems and societies, there are no realistic transferable blueprints to guide countries’ strategies for accelerating progress towards Universal Health Coverage (UHC). Instead, governments must work with a range of actors through innovative partnerships to understand, learn from and navigate these transformations and their implications for health and health systems.
In 2008, Hilary Standing and I co-authored a paper looking forward to what we called “Future Health Systems”. We identified three important trends likely to influence future strategies for strengthening health systems: the emergence of mixed (public/private) health systems, the rapid development of digital health and the growing importance of large middle-income countries.
Fifteen years on and seven years before the Sustainable Development Goals 2030 endline, the United Nations General Assembly will host a High-Level Meeting on Universal Health Coverage (UHC) on 21 September 2023. While efforts to tackle infectious diseases like HIV and malaria led to expansion in coverage from 2000 to 2015, advances have since slowed.
In 2021, about 4.5 billion people, more than half of the global population, were not fully covered by essential health services. And this estimate does not yet reflect the potential long-term impacts of the COVID-19 pandemic. If countries and partners are to reinvigorate progress towards delivering health for all, their discussions and decisions must engage with these significant transformations.
Emergence of pluralistic health systems
Since the publication of our Future Health Systems paper in 2008 there has been a growing recognition that most health services include a complex mix of providers, in terms of their ownership, their mandate and their relationship to regulatory structures. In 2020, a WHO report entitled “Engaging the Private Health Service Delivery Sector through Governance in Mixed Health Systems” clearly acknowledges this.
That report outlines an approach for incorporating the non-state sector into national strategies for improving access to effective and affordable health services. It outlines how service providers and governments will need to engage with each other in new ways to improve the performance of the health system. It emphasises that governments need to build a capacity to establish effective health system governance. It also acknowledges the important role that local communities and citizens can play in holding the health sector to account.
Digital health transformations
Our paper signalled the likely importance of digital technologies in future health systems. Since its publication, there has been a lot of investment in digital health by the private sector. Development agencies and philanthropies have also financed many proof-of-concept interventions in low- and middle-income countries. As a result, the technology has matured greatly. Several influential reports have presented visions of a digitally enabled health system and the WHO has published a “Global Strategy on Digital Health.”
The rapid expansion of telemedicine and the widespread use of smartphone applications to strengthen surveillance and the uptake of vaccinations during the Covid-19 pandemic demonstrated the growing possibilities for major change. This was recognised by the G20 this year, by launching an initiative to support the rapid development of digital health.
The IDS has collaborated with the Public Health Foundation of India in producing a report entitled: “Towards Digital Transformation for Universal Health Coverage”. It argues that digital transformation can create major opportunities for increasing access to effective and affordable health services but that there are also risks that it could result in increased inequalities, major problems with the treatment of data and a loss of trust in the health system.
It highlights the need for effective collaboration between the health and information technology sectors. This will involve new kinds of partnership between organisations in the two sectors and new approaches for governance and regulation. Measures to ensure effective governance of digital transformation will need to be an important element of strategies for accelerating progress towards UHC over the next few years.
The growing importance and influence of large middle-income countries
Fifteen years ago, our paper highlighted the increasing importance of the BRICs and their role in developing new approaches for strengthening their health systems. It emphasised the degree to which countries were developing innovative approaches for meeting the health needs of their population. It called for measures to enable mutual learning to ensure that other countries could learn from these innovations.
Since then, the influence of the BRICS and other middle-income countries has grown. This has been underlined by the recent decision to increase the number of countries in the BRICS grouping. Two examples of the influence of these countries on strategies for strengthening health systems are China’s increasing engagement in the health sector of many countries and the recent decision by India to take the lead in the development of strategies for digital transformation.
Another change has been the growing capacity of a number of countries to produce drugs and diagnostic equipment and undertake cutting-edge research and development. This underlines the importance of opportunities for mutual learning and collaboration to address global health challenges.
Innovative partnerships for learning
Without clear and replicable blueprints for health systems strengthening and progress towards UHC, initiatives, such as the Mutual Learning for Mixed Health Systems platform, involving researchers and analysts alongside policymakers, health systems leaders and innovators, are necessary.
Taking a learning approach to the management of change in health systems needs all stakeholders to participate in building a full picture of a rapidly changing reality and help to build a consensus on socially desirable policies and actions, so that the likes of digital transformations are aligned with national policy priorities and mechanisms for adjusting implementation based on experience and evidence are instituted.
Finally, greater knowledge will be critical. Not only in terms of the generation of evidence and the stimulation of new thinking on innovative ways to improve health service performance, but also the building of national capacities to manage these transformations and benefit from opportunities for mutual learning between countries.
Future health systems are right here, right now.
