Health systems – of the people, by the people, for the people

ANKUR CHHABRA

The health system is the backbone of healthcare service delivery. At a national level, health systems provide the foundation for health policy and legislative framework, resource allocation (financial and human), monitoring and governance mechanisms, provision of healthcare services (primary care, essential medicines, medical products and technologies, life saving vaccines, etc.), and health information systems, among others [22].

Based on the current state of global affairs, my understanding is that the health systems are designed to deal with the aspects of healthcare delivery mentioned above, leaving out all the rest. Although the building blocks of health systems seem comprehensive, it does not ensure that these systems are completely immune to intrinsic and extrinsic risk factors. This article will explore gaps in the current global health systems – high-income countries, and low-and middle-income countries, especially humanitarian and conflict-affected settings. It will also shed light on the need to design ‘conflict-proof’ health systems for robust healthcare delivery.  

There is a common notion that high-income countries have robust health systems, but this is far from the truth. For instance, the United States (U.S.) is marred by unequal and inequitable health outcomes due to disparate health sub-systems, and discriminate social determinants of health [23], such as employment [9,1], income [13], education [11, 21], crime rates [17, 20, 5], poverty [13, 7], health insurance [19], among others. In particular, the high number of uninsured people in the U.S., make it one of the most expensive and inefficient health systems in the developed world [12, 8]. This certainly raises the question as to how well a developed and rich country like the U.S. is placed to provide adequate financial risk protection for poor and vulnerable populations. Furthermore, in Canada, though there is publicly funded healthcare, healthcare delivery is fragmented, leading to long wait times [18], and particularly poor health outcomes among First Nations communities, as a result of living in ‘third world conditions’ [14]. An example of such conditions is the national systemic failure to provide potable water, which is one of the critical factors that has led to poor health outcomes among these communities [14, 16]. 

The above cases of healthcare system failures in high-income countries depict health disparities due to the inadequate investment in upstream factors such as primary care, social determinants of health, etc. Increased enforcement mechanisms, and enhanced focus on social and human infrastructure is as important as investments in physical infrastructure (institutions, hospitals, etc.). Global health systems need to be designed in a way that ensures health care and not only sick care. This is particularly critical in countries experiencing war and conflict.

In fragile states, the negative externalities of weak health systems are particularly gruesome. For instance, much of the conflict in Yemen is collateral damage as a result of the U.S. foreign policy. The ulterior motives and selfish interests of the U.S are an implicit factor for a weak political and health system in Yemen [4]. Involvement of foreign governments in Yemen, and Saudi Arabia’s ‘inhumane’ foreign policy have further exacerbated the conflict, especially in the Middle East [2]. Saudi Arabia and the United Arab Emirates have not only bombarded Yemen, but have also intentionally blockaded humanitarian aid (indirectly supported by the U.S.) from reaching millions in need [2]. Over 14 million people (i.e. half of the country’s population) are currently on the verge of starvation [2]. In this case, the United Nations (UN) has also failed miserably in its humanitarian response [24, 15]. This has had further ramifications on Yemen’s fragile health system. Yemen’s case depicts how geopolitics and foreign policy is also a determinant of national health systems. It is high time that the UN addresses this issue by revisiting international humanitarian law frameworks and ensuring those are upheld rather than just ‘managing’ the situation in Yemen and other humanitarian emergency and conflict-affected settings. 

Lastly, the World Health Organization must take a lead on this and reorient health systems, both in research and practice, to counter such crises. The biggest concern is that the current understanding of health systems is limited in scope and design. What is considered essential to be part of a health system and what is excluded and on what basis? Should humanitarian law, human rights principles, and geopolitical factors be an intrinsic part of health systems? 

Current social, economic, political and legal systems, especially in conflict-affected settings, do not seem to bridge the gap. This results in further paralyzing already weak health systems; increasing foreign participation and privatization; and fragile states’ overdependence on unsustainable development aid. Development aid agencies must support such states with adequate interventions that aim to support and strengthen weak healthcare systems.  That said, these agencies must ensure maintenance of state sovereignty and autonomy, and sustainability of such systems in the long run. This requires investment in internal health systems strengthening human resources, as well as financial resources. 

A key element of human resources is investing in women, that is, healthcare system leadership by women, women-centred health research, and gender-based medicine. These factors are pertinent to strengthen the healthcare systems in both the developing and developed world. An important facet of reorientation of health systems is to incorporate gender equitable norms, in health and medicine research and development. In the U.S., the National Institutes of Health Revitalization Act was passed in the year 1993, however, two decades later a research study found that the proportion of minority patients enrolled in clinical trials still remains persistently low [6] . Further, in Canada, there is a growing concern for inclusion of racial health data [3, 10]. Thus, it is equally important to make the medico-legal system an intrinsic part of the health systems across the globe. Healthcare system researchers and leaders need to advocate for, and monitor adherence to health-related legislation to ensure scientific rigor via equal representation of minorities, among other vulnerable population sub-groups. Thus, doing away with gender-biased medicine and making way for gender-based medicine must be the way forward.

In conclusion, in order to close the healthcare gaps, it is pertinent to understand that the sum of parts is greater than whole. Strengthening every component of the health system, guided by the principle of ‘gender parity’ must inform future health systems’ thinking and design processes. Health systems must be of the people, by the people, and for the people.

References

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