Framing health systems or health systems for frames? A reply to Marten et al

It’s a common literary device, switching parts of a phrase about. There’s even a word for it – antimetabole. A well-known example which I think has its origins in women and child health is “more money for health – more health for the money“. It’s pleasing to read, musical even, with the cadence lulling you into a smile. But it can also dull your critical faculties. Here’s WHO DG Tedros imparting some hokey wisdom a few years back: “More money for health is good. But more health for the money spent is even better”. Very wise; very wrong. More money for health is good AND investing that additional money sensibly is also good. We all know what Tedros is really getting at here: efficiency savings. And he uses antimetabole to get that message across without actually saying so explicitly. Plus it sounds nice, so you’re more likely to listen to it, nod your head and say ‘yeah, that sounds about right’.

We can see another example of antimetabole in a new Opinion piece in the BMJ by Robert Marten and colleagues: Reimagining health systems as systems for health. Here, in a similar vein to the generally panned report from The Lancet–University of Oslo Commission on Global Governance for Health (a report that went to great pains to distinguish global health governance from global governance for health), the authors use antimetabole to signal a conceptual intervention. Good-bye health systems; hello systems for health. So what’s changed? What are the authors bringing to the party? In a word, ‘security’.

To be honest, I struggled with the logic underpinning the analysis. It starts with some questionable assertions (which I suppose we could call the ‘premise’ of the argument). For example, has the covid-19 pandemic exposed an outdated view of health systems; is current thinking on health systems focused on access to medical services and financial protection? I’m not so sure. But from this starting point, the authors argue: “While continuing to provide health treatment services, health systems must be reimagined as ‘systems for health’ by ensuring health security and encouraging healthy populations”. If you don’t agree with the assertions, then there is no need to re-imagine anything. But even if you think the assertions are valid, does the ‘conclusion’ follow? Will the reimagining of health systems as systems for health that the authors argue is necessary require “ensuring health security”? Is health security the answer to all the challenges they identify?

The most insidious (and likely effective) attempt by the current UK Conservative government to undermine public health was its decision to change the name of Public Health England to the more catchy UK Health Security Agency and Office for Health Improvement and Disparities. Cynically taking advantage of the pandemic to scratch an ideological itch, UK Prime Minister Johnson was able to erase public health from the general discourse by simply changing the name of the State’s primary health institution. It’s difficult to exaggerate the significance of this move, not least because it facilitates a shift towards the dominance of a health security framing of public health. If our health institutions now have the phrase ‘health security’ in their title, then of course researchers are going to want to interrogate that phrase. My fear is that Marten et al are uncritically adopting the concept of health security and helping to assure its place as a dominant health systems frame.

I’m as prone as the next person to read too much into something. Plus, I’ve not had the opportunity to discuss this article with the authors. So, I could very easily be misinterpreting or simply failing to get the point of the article. But take a look at this sentence: “[The Alliance for Health Policy and Systems Research report] considers how to develop [systems for health] and argues against the false dichotomy of investing in either health security or healthy populations”. What do you see? Maybe you see a perfectly reasonable proposition – there’s no either/or here, let’s invest in both! I don’t see that. Instead, I see an example of deflection (i’m sure unintentional) to disguise what is clearly an example of agenda setting. ‘Look’, the authors say, ‘there’s a false dichotomy here, and we must avoid those’. ‘And the way to do that is to think of systems for health rather than health systems’. Hmmm, ok, but why are you encouraging us to reconcile health security and healthy populations as though that were the only option? In doing so, aren’t you deflecting attention away from considering whether ‘health security’ has a (or even any) role to play in a thriving health system?

Ok, so it’s at this point in the post that I realise that I’ve wandered into a minefield of essentially contested concepts (health systems, health security, public health, population health) and don’t see an exit point. Underpinning the AHPSR report are some weighty sources and analysis from many experts, representing lots of different disciplines. For example, in addition to the AHPSR report (Ch4 in particular), you also have a scoping review led by Wallace Brown and, of course, WHO’s 2007 World Health Report. I would encourage you to read these. Cutting to the chase (and circumventing a lot of steps in the argument) I’m quite happy to play my epistemic community card here and say that these big brains (many of whom I know personally, greatly admire and even like – talking to you Robert and Owain) are collectively speaking as one. I’m not wedded, as these authors are, to the validity of the concept of ‘health security’. I see it as inimical to public health, actually.

By way of an entry point into that perspective, let me ask you some questions about health security: who is providing it? Answer: ‘the State’ (which includes all the institutions of the State, including the government. And who benefits most from a health security frame? Answer: also ‘the State’. Are States benign or malign? If I were being generous, I would moderate my answer with a ‘it largely depends on the character of its government’ (but we could talk long into the night about that one). Then reflect for a moment on the UK Conservative government. Today, NHS nurses are on strike, joined for the first time since 1989 by the ambulance service. Do you feel secure? When I see the UK health institution’s new title The UK Health Security Agency, I can’t help but be reminded of that infamous staccato quote from Orwell’s Nineteen Eighty Four: “War is peace.  Freedom is slavery.  Ignorance is strength.”

Public health – the soul of health systems – is about prevention, promotion and community organisation. You might think that public health is also about protection, but it’s not (at least not directly). Protection is achieved by public health through promoting good health, preventing ill health and through coordinated, vibrant communities. It’s an outcome rather than a driver. I can see you reaching for your dictionaries, but beware – cave hic dragones!. This paper, for example, provides a definition of public health straight from the pages of Websters. But where did Websters get its definition from? Where do any dictionaries get their definitions from? My point is that dictionary definitions are not authoritative. Compare the dictionary definition to those provided in leading public health textbooks such as McKee and Krentel’s Issues in Public Health. The book barely mention health protection at all. I see ‘protection’ as either bottom up or top down. Is it a stretch to generalise that those coming from the health security camp understand protection as top down while public health-informed conceptualisations of protection see it as as bottom up?

Marten et al’s article is about health systems but doesn’t mention public health at all. That seems odd to me. Instead, the emphasis is on population health. Population health is not the same as public health; indeed, the former is a deliberately cultivated branch of the latter (think ‘selective’ vs ‘comprehensive’ primary health care). Tricco et al’s 2009 bibliometric study (linked above) is interesting, not least for the following explanation of the rise in studies in the 1990s adopting the concept of population health over public health: “The justification for intellectual development of population health was based on concern for rising costs of healthcare, and evidence that challenged the efficacy of the publicly available system” (p 470).

I guess what I’m trying to do in this post (successfully or not) is critically review a piece of writing that could become instrumental in redirecting future discussion on health systems. It’s already being described by some on social media as ‘the best commentary‘ on health systems of 2022. Time will tell. But while you’re thinking about that, here’s another sentence: “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”. I agree with this sentence but would just replace “effective systems for health” with “health systems”. Health systems should promote and prevent ill health, and do so through community organisation (supported, nurtured even, by government through the State). That is the way to protect the health of a population. And here’s the next sentence: “Systems for health should coordinate efforts, leverage technology and work with people and communities to improve health”. Or, ‘health systems’ should do all that. No need for any unnecessary antimetabole.

I can see interest waning, so let me just give you one more example. The authors argue: “Population-wide access to services is the core of universal healthcare and is critical to ensuring health security. 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”. Do you see what the authors did there? Health security moves from being a passive condition in the first sentence (a state in which the health of a population is secure) to an active driver in its own right in the second sentence (the concept of health security, and all that that entails, will ensure that the health of a population is secure). In the first sentence, it is undefined how health security is assured (at this point it could still be assured by other means, by public health for example); in the second, health security itself becomes the go-to frame, fully realised and pushing out other providers such as public health (and by extension health promotion, prevention and community organisation) as the route to achieve it.

I’m conscious that I’m not articulating myself very well. As I say, more than likely I’m just not getting what the authors are trying to say. Maybe I’m inadvertently expressing my ignorance ‘about a great many things‘. For me, the best way to ensure that the health of a population is secure is through a health system built on core public health principles. We don’t need to re-configure health systems so that they become systems for health, and then – having done that – bring concepts like population health and health security in through the back door. This might align with the creeping and increasingly dominant security framing of health, and it might be a gift for those governments ideologically sympathetic to health security and unsympathetic (even hostile) to the concept of public health, but this latest example of antimetabole doesn’t work for me.

Andrew

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