Future-proofing health systems – a proposal for #HSR2020
By Renzo Guinto (@RenzoGuinto), a Doctor of Public Health candidate at Harvard, an Emerging Voices for Global Health alumnus, and student member of the Editorial Advisory Board of The Lancet Planetary Health
During the closing plenary of the Fifth Global Symposium on Health Systems Research (#HSR2018) in Liverpool, I pointed out that current discussions around health systems and universal health coverage (UHC) remain detached from the evolving and inevitable backdrop of climate change. During #HSR2018, the UN Intergovernmental Panel on Climate Change released an alarming report saying that global warming beyond 1.5 degrees Celsius will produce “long-lasting or irreversible changes” in social-ecological systems, and that “rapid and far-reaching” transformations – we were only given 12 years to act – would be required to avoid breaching this threshold. Unfortunately, there was only one session abstract in #HSR2018 that mentioned “climate change.” The only other occasion when “climate change” was mentioned was when Professor Anthony Costello referred to the new report during the opening plenary. “Our species extinction will be televised,” he remarked. (Prof. Costello chaired the landmark 2009 Lancet Commission which called climate change “the biggest global health threat of the 21st century.”)
The next Global Symposium – #HSR2020 – must be forward-looking, more ambitious, and closely attuned to the bigger transformations that now unfold and shape the world’s health systems. During the side meeting of the Emerging Voices for Global Health network, it was noted that topics covered by the Symposium are becoming more of the mainstream and less of the new stream. For sure, many of the topics covered during #HSR2018 are legitimate, longstanding issues that currently confront health systems. This time, #HSR2020 must push the frontiers of health policy and systems research (HPSR), help it innovate for the future while it solves contemporary challenges today.
Health systems in the planetary health era
As already implied, climate change is perhaps the grandest of all threats to the sustainability of future health systems. Various reports, such as the one by WHO, have already estimated the negative impacts of climate change on human health, but the health systems community is yet to examine how these impacts can exert additional stress on already overburdened health systems and even lead to reversals in health gains worldwide. In the past five years, there have been initial efforts to link climate change and health systems (such as WHO’s climate-resilient health systems framework), but the climate and health discourse is still yet to move from the traditional environmental health discipline to the young field of HPSR. At the recent Global Conference in Astana, Kazakhstan, I even proposed expanding “Primary Health Care” to “Planetary Health Care” – “integrating the care for the human family with the management of the planetary household.”
Here are some questions that the HPSR community may want to investigate:
- How can we make health systems climate-resilient to health impacts, as well as low-carbon so that they do not contribute to global warming?
- What financing and delivery measures can help “climate-proof” UHC and the Sustainable Development Goals?
- How can health systems work with other systems to adopt ‘nexus’ approaches that solve multiple human and planetary health challenges altogether?
- How can health systems be a vital force towards creating a “Doughnut Economy” – one that meets humanity’s social needs without violating planetary boundaries?
In my own way, I am trying to address some of these questions in my doctoral thesis on climate-smart local health systems. I hope that #HSR2020 becomes not only the venue where I can present my findings, but more importantly an exciting platform for reimagining future health systems in the era of climate change and planetary health.
Health systems in motion – for people on the move
I may have made a strong case for climate change and planetary health to be a prominent feature of #HSR2020, but I propose a much broader concept – future-proofing health systems – to capture other emerging challenges afflicting future health systems. Migration – also linked to climate change – is another emerging issue that the HPSR community has started to look into. And Dubai, located in a region where massive population mobility occurs – from Syrian refugees to labor migrants – provides an appropriate location for this delicate yet important topic. The timing is equally fitting – this year, the UN passed the Global Compact for Safe, Orderly and Regular Migration, which called for incorporating the “health needs of migrants in national and local health care policies and plans.” The HPSR field can aid in realizing the health goal of this historic migration agreement.
In the 21st century, people move but health systems don’t, and countries are faced with the dilemma between fulfilling migrant health needs and ensuring long-term sustainability of health systems. Despite being branded as a policy for realizing the right to health, UHC as an idea is far from being universal, as countries design UHC systems on the basis of citizenship, thereby excluding non-citizens within their territory. Here are some questions:
- How can UHC, as a global imperative, be achieved beyond borders, beyond citizenship?
- What innovative policies can be implemented by source and destination countries, as well as the global community to ensure migrant-inclusive and sensitive healthcare?
- How can recipient health systems sustain good performance and achieve positive health outcomes for citizens and non-citizens alike?
There is a need to present the evidence and hold a broad and deep discussion on the ethical, legal, political, economic, and technical dimensions of the nexus between migration and health systems. #HSR2020 can be the place for an open and frank, values-infused and evidence-informed deliberation on redesigning health systems in motion for people on the move.
Artificial intelligence – and artificial health systems?
Another development that we will surely continue to witness in the next decades is the emergence of new technologies such as artificial intelligence (which includes machine learning and natural language processing), as well as personalized medicine and “precision public health.” While these advancements offer great promise in revolutionizing healthcare and improving population health overall, they should also be examined with a critical eye, as they could become a double-edged sword. There are fears that such technologies might replace the health workforce, or turn community health workers into mere app technicians, or alter the patient-provider encounter. While big data can be good for evidence-based decision-making or large-scale research, it requires necessary safeguards to protect patient privacy and dignity.
The HPSR community must begin interrogating this evolving technological transition before it is too late. There are many questions that HPSR sub-areas such as economic evaluation/health technology assessment, implementation research and program evaluation, and even political economy analysis can provide answers to, including:
- What are the benefits and costs of healthcare digitalization, and who will gain from it and who must pay for it?
- How can these technologies – from expert systems to wearables – help achieve UHC – or do they incur additional burden and unnecessary costs?
- And how does personalized medicine complement – or conflict – with traditional public health services that are already hugely under-resourced and even need further boosting up to this day?
The rapid growth of such technologies in high-income countries may create enormous pressure on poorer countries and may even potentially widen not just the digital divide but also the global health divide.
There are certainly other external forces and internal stresses that health systems need to be future-proofed from – aging populations, rapid urbanization, emerging infections, economic shocks, and political shifts are just a few. As an Emerging Voice for Global Health, my intellectual gaze is as laser-focused on the future – which I will certainly be an active part of – as it is deeply concerned with the present. If HPSR wants to become a field that is proactive, anticipates emerging challenges and envisions future worlds, then we need a truly inspirational theme for our next conference. The right place for that is Dubai – a city that always looks to the future.
