Intended for healthcare professionals


Reimagining health systems as systems for health

BMJ 2022; 379 doi: (Published 16 December 2022) Cite this as: BMJ 2022;379:o3025
  1. Robert Marten1,
  2. Zubin Cyrus Shroff1,
  3. Kara Hanson2,
  4. Sally Davies3,
  5. Srinath Reddy4,
  6. Jeanette Vega5,
  7. David H. Peters6,
  8. Abdul Ghaffar1
  1. 1Alliance for Health Policy and Systems Research, WHO, Geneva, Switzerland
  2. 2London School of Hygiene and Tropical Medicine, London, UK
  3. 3Trinity College, Cambridge University, Cambridge, UK
  4. 4Public Health Foundation of India (PHFI), New Delhi, India
  5. 5Independent Consultant, Santiago, Chile
  6. 6Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA

While health systems are fundamental to creating health and wellbeing, the covid-19 pandemic has exposed an outdated view of health systems. The boundaries of health systems are rapidly evolving and expanding. Social media and digital innovations are revolutionizing how governments and the private sector engage people and communities. They are also revolutionizing people’s and communities’ interaction and engagement with health systems.1 Yet current thinking on health systems remains focused on access to medical services and financial protection, key metrics for measuring universal health coverage (UHC), but insufficient to capture the determinants of health. The ongoing covid-19 pandemic has focused global attention on services that are needed to ensure and sustain health. This presents an opportunity. We can envision how health systems can move beyond being concentrated on treating illness. While continuing to provide health treatment services, health systems must be reimagined as “systems for health” by ensuring health security and encouraging healthy populations.

The 2022 Alliance for Health Policy and Systems Research Flagship report is focused on “systems for health.”2 It considers how to develop them and argues against the false dichotomy of investing in either health security or healthy populations.3 It defines systems for health as those ready to respond to both known and unknown, present and future threats. Effective systems for health must anticipate and address social, economic, environmental, and commercial drivers of health to promote healthier societies and protect against threats to health. Systems for health should coordinate efforts, leverage technology and work with people and communities to improve health.

A systems for health approach could accelerate progress by bringing a more holistic approach towards universal health coverage, ensuring health security and creating healthy populations. These goals together make up the World Health Organisation’s Triple Billion strategy to achieve the Sustainable Development Goals (SDGs). As the covid-19 pandemic continues to illustrate, the goals are interconnected, all of which require attention to the drivers of human and planetary health and well being.4 Population-wide access to services is the core of universal healthcare and is critical to ensuring health security.5 However, health security must move beyond merely controlling disease outbreaks to include a much wider remit that encompasses an ever-growing range of threats to humans. Such threats include nuclear proliferation, antimicrobial resistance and climate change.6 Promotive, preventive, curative, and rehabilitative services are subsystems of universal healthcare, and play a crucial role in ensuring a healthy population, but they must be extended beyond the realm of the healthcare system.

A systems for health framing could potentially allow for wider support across all countries compared to interventions focused solely on health security or healthy populations. For example, health security interventions are sometimes considered within low- and middle-income countries (LMICs) as an imposition from high-income countries (HICs). Conversely, LMIC efforts to control commercial drivers of health through taxes on tobacco and sugar-sweetened beverages routinely face resistance from HIC-based multinational corporations. Interventions addressing both health security concerns and passing measures to establish healthy populations should reconcile the common interests of both HICs and LMICs.7 A systems for health approach would minimize parallel programmes currently implemented at national and sub-national levels that each have their own reporting requirements, funding streams, supply chains, and human resource policies leading to significant inefficiencies. Replacing parallel agendas would also provide a single entry-point for health ministries to engage other sectors, potentially facilitating multisectoral action.

The Alliance 2022 Flagship Report is a first step towards the realisation of systems for health. To this end it provides careful analysis and actionable recommendations targeted at policymakers, development partners and communities. We hope that the report inspires radical thinking to accelerate the achievement of the United Nations Sustainable Development Goal 3 goal of health and wellbeing and the broader sustainable development agenda.


  • Competing interests: none declared.

  • Provenance and peer review: not commissioned, not peer reviewed.