Intended for healthcare professionals


Trust and transformation: an agenda for creating resilient and sustainable health systems

BMJ 2023; 380 doi: (Published 20 March 2023) Cite this as: BMJ 2023;380:p651
  1. Hans Kluge, regional director1,
  2. Natasha Azzopardi-Muscat, director, Division of Country Health Policies and Systems1,
  3. Josep Figueras2,
  4. Martin McKee, professor of European Public Health3
  1. 1WHO Regional Office for Europe
  2. 2European Observatory on Health Systems and Policies, Eurostation
  3. 3London School of Hygiene & Tropical Medicine

Health systems are facing unprecedented challenges as they emerge from the covid-19 pandemic. How they have responded has varied greatly. Just as with SARS in 2003, when some Asian health systems redesigned facilities to be better prepared for a future pandemic,1 we have seen new ways of working, often taking advantage of new means of online engagement.2 But some have also struggled, unable to rebuild workforces that were already depleted by underinvestment, but with the additional burden of burnout3 and illness, including long covid.4

This situation, in part, reflects and is exacerbating a crisis of trust.5 This is apparent in three important sets of relationships.

Firstly, there is a loss of trust among the public that the health system will be there when they need it. In some countries people are struggling to access care due to overcrowded health facilities, long waiting lists, and substantial out-of-pocket payments,6 with evidence that this may be leading to avoidable deaths.7 Their experiences leave them vulnerable to the arguments by some that universal healthcare — to which governments have committed in the Sustainable Development Goals — is somehow unaffordable or unsustainable.89 Loss of trust has been fuelled by attacks on health workers — during and since the pandemic — typically from those opposed to the measures that were necessary to interrupt transmission of SARS-CoV-2.10 This has been facilitated by social media, spreading disinformation seeking to undermine trust in science and the health workers who use it to deliver evidence based care. If the public is to retain and regain trust, they must be confident that the system can transform in ways that allow it to meet their needs now and, as importantly, in the future.

Secondly, there is a loss of trust among health workers, working in difficult conditions and feeling uncared for. Many are exhausted and demoralised and have seen too many colleagues become severely ill or die. They feel neglected, leading some to look to other countries that offer improved conditions, while others reassess their work life balance—a process that can lead them to leave the workforce prematurely.11 This soon creates a vicious cycle as the work still has to be done by a now depleted workforce. If they are to stay, they will need confidence that their working conditions can transform in ways that reflect their changing needs and allow them to deliver the care they wish to see for those they are responsible for.

Thirdly, there is a loss of trust among politicians in the ability of health systems to transform in ways that respond to the changing health needs of the population, to adapt to new opportunities to intervene—in particular digital innovations—and to meet increasing public expectations. Without this trust, politicians will understandably be reluctant to make the case for the investments that are needed to address and overcome the challenges ahead.

These problems are not new. They have been building up for many years, but a combination of developments means that they can no longer be ignored. The experience of the pandemic has shone a light on weaknesses in health systems.12 Ageing of populations is reducing potential recruits to the health workforce and increasing the numbers of older people with health needs that require their care.13 Geopolitical developments are fuelling inflation and disrupting supply chains, adding to the pressures on health systems.

The question then is, what type of transformation is needed? If trust is the problem, then the solution must engage with those whose trust must be earned. This calls for new approaches that are person-centred, engaging with the public, health workers, and politicians. It must take account of how the work of health systems is becoming ever more complex, with the changing nature of disease, such as increasing multimorbidity,14 and of healthcare, with multidisciplinary teams bridging home and hospital, and bed and laboratory bench. In this situation, the task of those in charge of the health system must be to support those delivering and receiving care to ensure that the right mix of health workers, with the right skills and technology (including medicines), are in the right facilities, in the right place, at the right time to meet the needs of the (potential) patient. If this is to happen, health workers and managers must be incentivised, encouraged, and supported to work with patients, carers, families, and communities to co-create solutions,15 while those at higher levels of the system must facilitate this process. This requires a new approach to health systems, based on a commitment to include all stakeholders, invest the resources needed for change, and innovate with new models of care.16

So how do we make this happen? A first step is to challenge the sense of pessimism that has afflicted many health systems. There are many examples of innovative solutions to emerging challenges. Some of the most imaginative address the needs of those living in places with low population densities or groups who have fallen through the cracks in existing systems. Often, they involve task shifting, with health workers developing new roles, facilitated by technological advances, such as digital communication and remote sensing using wearables or near-patient testing, exemplified by the lateral flow tests that transformed the management of the pandemic.17 The next step is to learn the lessons from these examples to inspire and inform those seeking solutions to similar problems elsewhere. We are now embarking on a series of consultations on these issues with patients, health workers, and politicians that will culminate in a WHO Europe conference in Tallinn, Estonia, later this year.


  • Competing interest: NAM, JF, and HK are WHO employees. MM is Research Director at the European Observatory on Health Systems and Policies, a partnership that includes WHO. He is also President of the BMA but writes in a personal capacity.

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