This is a republication of the article “Tedros calls for a paradigm shift -what next on this political agenda?”, with the title above. The article is preceded by an Executive Summary, by the Editor of the site.
BMJ Opinion
The George Institute for Global Health,
Imperial College London
Kent Buse director, Healthier Societies Program
21 October 2022
Site Editor:
Joaquim Cardoso MSc.
health systems transformation — from sickness to health and well being
October 22, 2022
What is the problem?
- Ministries of “health” largely remain ministries of “sickness” … … and institutional inertia means that many global health organisations have continued to tackle Millennium Development Goal (MDG)-era priorities rather than the SDGs — let alone undertake the kind of transformations required to effectively attain them
- The pandemic, the fact that the SDGs are off track, growing inequality, climate breakdown, biodiversity loss, environmental degradation and other breaches to safe planetary boundaries may provide the catalysts required for the global public health community to reflect and act on its flawed model and work together to usher in the paradigm shift that Tedros calls for.
What is the paradigm shift?
- In a bold and unprecedented call, the director general of the World Health Organization encourages countries to reorient and rebalance their health systems.
- Here are five ways we can get behind the inspiring, timely, and daunting task to create healthy societies
What are the priorities for global health?
At the opening of the World Health Summit last weekend, Tedros Adhanom Ghebreysus, director general of the World Health Organization, outlined three priorities for taking global health to a new level:
- (1) a new global accord to better prepare and respond to epidemics and pandemics;
- (2) a new architecture;
- (3) and a new global approach “that prioritises promoting health and preventing disease, rather that only treating the sick.”
In relation to the third priority, Tedros called on all countries to make the needed “paradigm shift … recognising that health starts not in hospital and clinics, but in homes, streets, schools, and workplaces.” 1
What does it take?
- According to Tedros, the envisioned paradigm shift will involve a “reorientation and rebalancing of health systems” …
- and a recognition that “whole of government, and the whole of society” efforts are needed and that …
- such reorientation demands health “consideration in urban planning, tax policy, transport, education policy, commerce, trade, finance, infrastructure, and so on.”
- Tedros concluded that “health can no longer be a junior portfolio in government, as it is in many countries, but must be elevated, because healthy and secure populations are the foundation for healthy and secure societies and economies.”
What countries should do, to create healthy societies?
- Such societies support efforts to create the conditions in which people can grow, play, live, learn, and work to promote and protect their health and wellbeing, in harmony with a healthy planet.
- While recognising the universal right to healthcare, this is about acknowledging, elevating, and investing in universal rights to the determinants of health (which were recognised by the United Nations in 2000 6) and wellbeing more broadly, and includes the newly recognised right to a healthy environment. 7
What are the 5 priority tasks?
To put it crudely, healthy societies are about fixing systems, not people. 8
The challenges in fixing systems are not inconsiderable and five priority tasks stand out.
- First, while the wonders of medical sciences are to be celebrated and made more accessible, the paradigm shift demands that the health sector upend the prevailing and dominating view of the medical sciences being “first among equals” when it comes to creating health.
- Second, Tedros calls for action across governments on health promotion and disease prevention.
- Third, the public health community must recognise, confront, and support efforts to regulate the vested interests of those who benefit from exploiting, extracting, and maintaining — environments that make people sick.
- Fourth, healthy societies ultimately demand a fundamental reset of our economic systems — from those that are extractive and privilege growth at any cost, including to health and environment-to those that place wellbeing at their core.
- Fifth, we know from experience with progressive social change — for example around the banning of land mines or the banning of marketing of breast milk substitutes — that we need broad, values based coalitions, which include insiders and outsiders and organisations of all the talents-advocacy coalitions, in short.
Conclusion:
- The challenges of heeding Tedros’s call for a paradigm shift to focus on the conditions and environments that enable more people to live with health and wellbeing constitute a Herculean task.
- But the limitations of the prevailing approach make this an urgent, essential, and rewarding one that everyone in the public health community should rise to.
ORIGINAL PUBLICATION (full version)
Tedros calls for a paradigm shift -what next on this political agenda?
BMJ
Opinion
21 October 2022
In a bold and unprecedented call, the director general of the World Health Organization encourages countries to reorient and rebalance their health systems.
Here are five ways we can get behind the inspiring, timely, and daunting task to create healthy societies
At the opening of the World Health Summit last weekend, Tedros Adhanom Ghebreysus, director general of the World Health Organization, outlined three priorities for taking global health to a new level:
- a new global accord to better prepare and respond to epidemics and pandemics;
- a new architecture;
- and a new global approach “that prioritises promoting health and preventing disease, rather that only treating the sick.”
In relation to the third priority, Tedros called on all countries to make the needed “paradigm shift … recognising that health starts not in hospital and clinics, but in homes, streets, schools, and workplaces.” 1
In relation to the third priority, Tedros called on all countries to make the needed “paradigm shift … recognising that health starts not in hospital and clinics, but in homes, streets, schools, and workplaces.
According to Tedros, the envisioned paradigm shift will involve a “reorientation and rebalancing of health systems” and a recognition that “whole of government, and the whole of society” efforts are needed and that such reorientation demands health “consideration in urban planning, tax policy, transport, education policy, commerce, trade, finance, infrastructure, and so on.”
According to Tedros, the envisioned paradigm shift will involve a “reorientation and rebalancing of health systems” and a recognition that “whole of government, and the whole of society” efforts are needed …
… and that such reorientation demands health “consideration in urban planning, tax policy, transport, education policy, commerce, trade, finance, infrastructure, and so on.”
Tedros concluded that “health can no longer be a junior portfolio in government, as it is in many countries, but must be elevated, because healthy and secure populations are the foundation for healthy and secure societies and economies.”
Tedros concluded that “health can no longer be a junior portfolio in government, as it is in many countries, but must be elevated, …
… because healthy and secure populations are the foundation for healthy and secure societies and economies.”
Some of these ideas are not new, …
… having their roots in the writing of Friedrich Engels and the work of Rudolf Virchow (in whose name a new prize was awarded at the summit 2) and in the practice of social medicine movements in Latin America and elsewhere in the last century.
The ideas found expression in the WHO/Unicef Declaration of Alma Ata in 1978. That these approaches are not new doesn’t detract from their urgency.
The ideas found expression in the WHO/Unicef Declaration of Alma Ata in 1978. That these approaches are not new doesn’t detract from their urgency.
Already in 2015 when the Sustainable Development Goals (SDGs) were agreed, it was evident that a paradigm shift would be required if the goals were to be realised. 3
Such a shift has yet to transpire.
Ministries of “health” largely remain ministries of “sickness” and institutional inertia means that many global health organisations have continued to tackle Millennium Development Goal (MDG)-era priorities rather than the SDGs-let alone undertake the kind of transformations required to effectively attain them. 4
Ministries of “health” largely remain ministries of “sickness” …
… and institutional inertia means that many global health organisations have continued to tackle Millennium Development Goal (MDG)-era priorities rather than the SDGs — let alone undertake the kind of transformations required to effectively attain them
This is not surprising.
Worldviews and mindsets, and the institutions that sustain them, are hard to shake off-particularly when they seem to be making incremental inroads into the challenges of the day.
Thomas Kuhn, who studied scientific revolutions and coined the term paradigm shift was clear that prevailing models of thought must face crisis before they are questioned and give birth to a new paradigm. 5
Thomas Kuhn, who studied scientific revolutions and coined the term paradigm shift was clear that prevailing models of thought must face crisis before they are questioned and give birth to a new paradigm.
The pandemic, the fact that the SDGs are off track, growing inequality, climate breakdown, biodiversity loss, environmental degradation and other breaches to safe planetary boundaries may provide the catalysts required for the global public health community to reflect and act on its flawed model and work together to usher in the paradigm shift that Tedros calls for.
While Tedros has outlined some key elements of what countries should do, we can draw on evidence and experience in how to create healthy societies.
Such societies support efforts to create the conditions in which people can grow, play, live, learn, and work to promote and protect their health and wellbeing, in harmony with a healthy planet.
While recognising the universal right to healthcare, this is about acknowledging, elevating, and investing in universal rights to the determinants of health (which were recognised by the United Nations in 2000 6) and wellbeing more broadly, and includes the newly recognised right to a healthy environment. 7
To put it crudely, healthy societies are about fixing systems, not people. 8 The challenges in fixing systems are not inconsiderable and five priority tasks stand out.
To put it crudely, healthy societies are about fixing systems, not people. 8 The challenges in fixing systems are not inconsiderable and five priority tasks stand out.
- First, while the wonders of medical sciences are to be celebrated and made more accessible, the paradigm shift demands that the health sector upend the prevailing and dominating view of the medical sciences being “first among equals” when it comes to creating health.
- Second, Tedros calls for action across governments on health promotion and disease prevention.
- Third, the public health community must recognise, confront, and support efforts to regulate the vested interests of those who benefit from exploiting, extracting, and maintaining — environments that make people sick.
- Fourth, healthy societies ultimately demand a fundamental reset of our economic systems — from those that are extractive and privilege growth at any cost, including to health and environment-to those that place wellbeing at their core.
- Fifth, we know from experience with progressive social change — for example around the banning of land mines or the banning of marketing of breast milk substitutes — that we need broad, values based coalitions, which include insiders and outsiders and organisations of all the talents-advocacy coalitions, in short.
1.Upending the prevailing and dominating view of the medical sciences being “first among equals” when it comes to creating health.
First, while the wonders of medical sciences are to be celebrated and made more accessible, the paradigm shift demands that the health sector upend the prevailing and dominating view of the medical sciences being “first among equals” when it comes to creating health.
The health sector needs to elevate, value, and draw on other disciplines and professions to solve challenges that, although reflected in the body, have their roots in society.
Nancy Krieger has critiqued medical science as being “concerned mainly with decontextualised and disembodied ‘behaviours’ and ‘exposures’ interacting with equally decontextualised and disembodied ‘genes’.” 9
Now we must understand and address that context in more holistic ways.
This should involve integrating public health focused components into non-health training, such as in law and architecture.
It should involve more integrated approaches in medical and public health curriculums.
And given that other sectors and ministries look to the health sector for leadership, it will also require a humility among health professionals and a willingness to work with people who offer different skills, expertise, and experience, and respect the reality that they often have non-health goals to achieve.
Now we must understand and address that context in more holistic ways: (1) integrating public health focused components into non-health training, such as in law and architecture, (2) involve more integrated approaches in medical and public health curriculum, (3) … it will also require a humility among health professionals and a willingness to work with people who offer different skills, expertise, and experience, and respect the reality that they often have non-health goals to achieve.
2.Health promotion and disease prevention.
Second, Tedros calls for action across governments on health promotion and disease prevention.
With good reason, intersectoral policy integration has been likened to the holy grail of public administration. 10
Calls for policy integration for health are longstanding and reflected in initiatives such as health-in-all-policies and healthy public policy.
In a forensic interrogation of the terminology 11 and practice, 12 Evelyn de Leuuw rightly establishes the political nature of the intersectoral policy project and argues that its pursuit must be politically informed.
Tedros calls for the elevation of the ministry of health, presumably to enhance the prospects of compliance and results for multisectoral action; however, history suggests that while such institutional reforms may be helpful (think AIDS councils in the office of the president), they may not be sufficient without other methods of engagement and goal setting, and the development of shared norms across ministries.
Considerable work and investment are needed to shift from ministries of sickness to ministries of health and wellbeing.
Tedros calls for the elevation of the ministry of health, presumably to enhance the prospects of compliance and results for multisectoral action; …
however, … they may not be sufficient without other methods of engagement and goal setting, and the development of shared norms across ministries.
Considerable work and investment are needed to shift from ministries of sickness to ministries of health and wellbeing.
3.Regulate the vested interests of those who benefit from environments that make people sick.
Third, the public health community must recognise, confront, and support efforts to regulate the vested interests of those who benefit from exploiting, extracting, and maintaining environments that make people sick.
Often that entails addressing the underlying causes reflected in the commercial determinants of health. 13
These are not solely the health harming industries (eg, junk food, gambling, etc) but those determinants more pervasively produced and reproduced through unfettered capitalism and its consumptogenic environment.
This is a formidable task, but good levels of population health depend upon it. The public health community is not starting from scratch: policy levers exist across government to stop revolving doors between industry and government, to curb political finance, to close tax loopholes, to demand living wages and decent work, and so on. The challenge is to get the global health community to join these struggles.
4.Healthy societies ultimately demand a fundamental reset of our economic systems
Fourth, healthy societies ultimately demand a fundamental reset of our economic systems
- from those that are extractive and privilege growth at any cost, including to health and environment
- to those that place wellbeing at their core.
National and local experimentation with wellbeing economies is underway globally. 14 Policy toolkits have been developed. 15 Now the public health community must join others who share the goals of creating wellbeing economies for the health of people and planet.
5. We need broad, values based coalitions, which include insiders and outsiders and organisations of all the talents-advocacy coalitions, in short.
Fifth, we know from experience with progressive social change-for example around the banning of land mines or the banning of marketing of breast milk substitutes-that we need broad, values based coalitions, which include insiders and outsiders and organisations of all the talents-advocacy coalitions, in short.
Tedros’s call comes with the moral and formal authority of WHO, but he (and others) will need to work with a range of networks to build political support for this political project.
A starting point might be to enlist the UHC2030 platform to take on this paradigm shift.
But real success will likely come from working with the movements that are embedded, and calling for change across sectors such as education, housing, nutrition, and others.
But real success will likely come from working with the movements that are embedded, and calling for change across sectors such as education, housing, nutrition, and others.
The challenges of heeding Tedros’s call for a paradigm shift to focus on the conditions and environments that enable more people to live with health and wellbeing constitute a Herculean task.
But the limitations of the prevailing approach make this an urgent, essential, and rewarding one that everyone in the public health community should rise to.
Originally published at https://www.bmj.com on October 21, 2022.
