Task Force 6: Accelerating SDGs: Exploring New Pathways to the 2030 Agenda
Abstract
The transition from the COVID-19 pandemic offers a strategic opportunity to build back better and use the disruption to transform health systems. This Policy Brief calls on the G20 to take the lead in health systems transformation. Health systems need to reorient to primary health care to address fragmentation and deliver health services in a comprehensive manner. Further, the promotion of cultural integration in health systems to move beyond reductionism and elevate Indigenous practices on equal footing with Western traditions will help achieve a more holistic approach in public health interventions. Finally, there should be effective community participation in G20 policymaking that places people at the centre of health systems and ensures that health services are responsive to communities’ needs. India’s G20 presidency offers a unique opportunity to bring the Global North and South together in shaping the future of health systems in the true spirit of Vasudhaiva Kutumbakam—One Earth. One Family. One Future.
1. The Challenge
As countries aim to build back better in the aftermath of the COVID-19 pandemic, the theme of India’s G20 presidency, the Sanskrit phrase Vasudhaiva Kutumbakam (“the world is one family”) serves as a useful reminder. This idea of profound interconnectedness should serve as the guiding principle in efforts to transform health systems and accelerate holistic outcomes in the G20 and beyond. Three key health system challenges that were exacerbated during the pandemic are as follows.
Fragmented rather than comprehensive
The fragmentation of health systems due to silos in financing single disease programs, separation of tertiary care from primary care, and mismatch between domestic and global health priorities is a major factor in the enormous strain on health systems caused by the COVID-19 pandemic.[1] The cracks of inequities worsened as the pandemic disproportionately impacted the health outcomes of immigrants, people with disabilities, homeless communities, and other vulnerable groups.[2] There should be a reorientation of health systems towards comprehensive Primary Health Care (PHC) as envisioned in the Alma-Ata Declaration.[3] COVID-19 has shown pandemic response to be more effective in addressing health inequities when health systems adhere to the comprehensive PHC approach. Evidence from countries like Brazil has shown that PHC was instrumental in mitigating the negative impact of socioeconomic inequalities on COVID-19 vaccination rates.[4]
Reductionist rather than holistic
While biomedical sciences were instrumental in the rapid development of vaccines and treatment modalities that reduced COVID-19 case fatality rates, social and behavioural approaches were equally important for implementing effective pandemic management[5] and increasing vaccine confidence and trust in communities of colour with a history of mistrust in the medical profession. For example, there is growing recognition of the importance of culturally responsive interventions in addressing the mental health burden caused by the pandemic, especially as ethnic minorities experienced worse mental health outcomes because of prevailing inequalities.[6] Cultural competence and safety are important elements of a holistic healthcare policy for Indigenous peoples, as shown in Australia.[7] Culture could be understood to comprise the collective memories shared and passed on by groups of people.[8] However, the postcolonial legacy views Indigenous health knowledge and practice as unscientific, superstitious, and inferior to Western medicine. Tradition and culture are essential elements in building accessible and people-centric care from a transgenerational perspective that is consistent with Indigenous ways of knowing and being.[9]
Exclusionary rather than participatory
Rapid decision-making during the COVID-19 pandemic was dominated by policymakers and expert advisers at the exclusion of communities’ and people’s voices, resulting in a disconnect between governments and citizens in the enforcement of safety measures.[10] In some cases, lockdown and contact-tracing enforcement was violent and militaristic.[11] The marginalisation of communities increased people’s anxiety and helplessness amidst repeated lockdowns and confusion about the effectiveness of the policies.[12] The medicalised focus of PHC has been noted in several settings, such as in the Americas and Ghana, further emphasising the need for explicit attention to community-level actors, services, and partnerships to achieve health for all.[13] The PHC approach frames community participation as central to achieving equitable health outcomes through the exercise of people’s rights and responsibilities to gain agency over their health.[14] Decades of lessons from outbreaks such as the AIDS epidemic and the Ebola and Zika virus outbreaks have demonstrated that community participation contributes to holistic outcomes.[15]
2. The G20’s Role
The G20 should lead by example and use its influential position to support countries to transform their health systems from fragmented to comprehensive through PHC reorientation; from reductionist to holistic through cultural integration; and from exclusionary to participatory through community participation.
Primary health care reorientation
Health care systems performance rankings represent one option to assess status and guide the process of PHC reorientation. Current rankings, such as the one undertaken by the Commonwealth Fund,[16] focus on high-income countries, including six G20 countries based on 71 performance measures across the domains of access to care, care process, administrative efficiency, equity, and health care outcomes.
Figure 1: Health Care System Performance Ranking in 2021 by the Commonwealth Fund
Note: The G20 countries are represented in green.
There is an opportunity for the G20 to expand from these assessment exercises by initiating country-level comparisons with a focus on PHC. Establishing a system for measuring the robustness of health systems based on PHC will advance the reorientation of health systems towards PHC in the G20 and beyond. Dimensions to assess should improve from current assessments by closely aligning with the comprehensive elements of PHC, including holistic indicators for people and community empowerment and multi-sectoral policy and action. Data from the assessments will enable country benchmarking within and beyond the G20, help identify strengths and weaknesses, and mobilise resources to address the gaps through people-centred financing arrangements to strengthen PHC.
Cultural integration
Integrating culture in health systems requires recognition and respect for traditional knowledge systems. Having evolved in close contact with the environment and transferred from one generation to another, traditional knowledge systems emphasise ecological sustainability and regeneration, community, and multi-generational and transgenerational wellbeing. However, traditional and complementary medicine struggles with safety and quality issues, credible research, lack of funding, qualification of practitioners, and regulatory issues.[17] Furthermore, the evaluation of public health interventions uses logic models steeped in Western knowledge systems and their conceptions of health and wellbeing. Monitoring of health systems should be conducted in culturally responsive ways by integrating Indigenous evaluation and participatory approaches.[18] Table 1 provides examples of initiatives to integrate culture in health systems.
Table 1: Examples of Cultural Integration in Health Systems
| WHO Global Centre for Traditional Medicine |
| The WHO Global Centre for Traditional Medicine is a collaborative initiative between the WHO and the Government of India. The initiative aims to mainstream evidence and data regarding traditional and complementary medicine to inform national policy discourse and build regulatory and compliance frameworks for policy while ensuring respect for local heritage, resources, and rights as a guiding principle.[19] |
| Shaman Pharma: Ethno-bioprospecting for drug development and community wellbeing |
| Shaman Pharmaceuticals was a California-based pharmaceutical company specialising in the discovery and development of novel pharmaceuticals using native plants, relying on ethnobotany, natural product chemistry, and medicine and pharmacology to produce effective drugs, working in collaboration with communities across countries. The company established a Healing Forest Conservancy program to translate the benefits accrued from drug development back to the respective communities. The company conducted trainings on ethno-botany, conservation, and public health. In benefitting the communities that they work with, the company hoped to work with the idea that conservation opportunities are increased when local custodians of nature benefit from the sustainable use of their medicinal plants by others. Shaman Pharma’s innovative model was an example for several years in ethno-bioprospecting.[20] |
| Addressing diabetes through culturally based Indigenous interventions |
| The Kahnawake School Diabetes Prevention Project was a health promotion and community-based participatory program aimed at reducing the incidence of Type 2 diabetes in the community of Kahnawake (Mohawk territory, Canada). Culturally based interventions were carried out between 2007 and 2010, which provided participants with opportunities to experience change processes in traditional cooking and healthy eating, physical activity, mind focusing and breathing techniques, learning cultural traditions and spirituality, and socialising and interacting with the other participants of the program. A study has shown that these culturally based interventions addressed the mental, physical, spiritual, and social dimensions of health as a holistic concept relevant to the Indigenous perspective of wellbeing.[21] |
Community participation
In some G20 countries, such as Australia and Canada, community participation has shown promising results in improving health outcomes in Indigenous communities.[22] The use of First Nation Community Panels, for example, was effective in facilitating collaborative engagement in Australia.[23] Studies have shown that participation can take many forms, ranging from information provision, consultation, and participatory research, to the formation of health committees and advisory groups.[24] Various models and frameworks have been developed to influence and guide initiatives, such as Arnstein’s Ladder of Citizen participation, the Continuum of Community Engagement Approaches, and the WHO’s “Wheel of Participation.”[25] ‘Beyond the building blocks’ expanded framework specifically draws attention to improving responsiveness and efficiency while working towards healthy communities.[26] These frameworks can guide initiatives by assessing the level of community participation, identifying opportunities for improvement, informing monitoring and evaluation, and rebalancing power in participation.
3. Recommendations to the G20
Reorient health systems to PHC characterised by being comprehensive, holistic, and people-centred in its approach, together with a mechanism for comparative analysis to assess country performance and outcomes in achieving PHC goals and the mobilisation of financing to support the process of transformation
The G20 should revisit the spirit of PHC as envisioned in the Alma-Ata Declaration and apply it to the present situation. The public sector can aim to fulfil this mandate for comprehensive primary care on the basis that health is a human right and collaborate with the private sector to ensure Universal Health Coverage that leaves no one behind. The proposed mechanism to assess the quality and outcomes of PHC across the G20 countries should be institutionalised and funded to track progress, stimulate health competition through benchmarking between countries, and hold countries accountable for their performance. There is no need for another funding instrument to support this recommendation. Rather, the G20 should use its leverage in the Pandemic Fund, which is to be invested to strengthen the health systems of low- and middle-income countries in the aftermath of the pandemic. As of writing, the Pandemic Fund[27] has received total commitments of US$1,651.07 million, of which 94 percent were from 15 G20 members. The G20 must use the opportunity to steer the directions of the Pandemic Fund and ensure that part of it is used to establish the infrastructure and tap the human resources required for a multi-country health systems performance assessment based on PHC.
Facilitate cultural integration in health systems by investing in research and development dedicated to traditional and complementary medicine and promoting the use of culturally responsive evaluation approaches to the monitoring and evaluation of health system interventions
The G20 countries should invest in setting up or strengthening dedicated research institutes or think-tanks as well as interdisciplinary institutes dedicated to the research and development of traditional health and knowledge systems. The health ministries of member countries should coalesce with academia, civil society, and multilateral funds to create ‘strategic foresight committees’ to systematically study the gaps and opportunities for cultural integration. Special attention should be paid to the inclusion of under-represented communities, ensuring the dignity and rights of communities, participatory models of research, wealth creation for, and profit sharing of research and development with local communities, livelihood generation for local communities, sustainability, and regenerative practices to be mainstreamed within the production processes. Indigenous evaluation approaches imply the application of Indigenous worldviews across the monitoring and evaluation cycle of programs, beginning with project conception until evaluation of impact. These include judging program intervention impacts according to Indigenous standards of health and wellbeing, designing programmatic strategies in response to those needs and worldviews, and integrating community elders and traditions in the exercise of development interventions and research. The promotion of Indigenous evaluation can be attained through the national evaluation policies of member countries or mainstreaming the requirement within the monitoring and evaluation of government health policies and programs.
Invest in co-production and collaboration, legitimise, and incentivise community participation in the G20 decision-making process, and monitor and evaluate the process and outcomes of participation
The G20 should strengthen existing engagement mechanisms facilitated by the T20 to ensure that community voices are effectively integrated into the G20 policymaking and decision-making processes, especially in relation to health systems transformation. Funding should be provided for dedicated staff and resources to create spaces for meaningful and reflexive dialogues between policymakers, health workers, and community members. This funding support should be complemented by training, resources, and capacity-building workshops with stakeholders to address issues around knowledge, power, and control, legitimise community participation, and ensure that communities have the knowledge and the language to effectively communicate their perspectives and thus gain access to participate in decision-making relevant to health and wellbeing. Governments could offer incentives to encourage community members to participate in decision-making. For example, they could offer financial compensation or other benefits such as access to healthcare services, legitimise the role of community workers and community-based organisations in policy documents, and work on building and sustaining these partnerships. Localised and acceptable tools such as social media platforms connecting people to key resources and services, giving voice and visibility to community experiences, especially the marginalised, and open data and openness in adapting norms and standards are further means of empowering communities.[28] Finally, they could invest in participatory monitoring and evaluation activities aimed at understanding the context, mechanism, outcomes, and processes of community participation to provide lessons learned and build a robust evidence base. An independent G20 evaluation group (similar to independent evaluation groups such as the United Nations Evaluation Group or the World Bank’s Independent Evaluation Group) could be set up to facilitate community participation and accountability and document the outcome/impact evaluation of G20 talks.
There is an opportunity to leverage the influential role of the G20 to encourage countries across the world to use the disruption caused by the pandemic to transform health systems. India is in a unique position as a leading voice of the Global South to ensure the adoption of PHC in the G20 and beyond. Health systems transformation will set the stage for comprehensive, holistic, and participatory health systems that deliver quality health care and effectively improve people’s health during normal times as much as in the next pandemic. PHC reorientation, cultural integration, and community participation are key elements for this transformation, in the true spirit of Vasudhaiva Kutumbakam.
Attribution: Harvy Joy Liwanag et al., “Transforming Health Systems Towards Holistic Outcomes in the G20 and Beyond,” T20 Policy Brief, June 2023.
Endnote
[1] Arush Lal et al., “Fragmented Health Systems in COVID-19: Rectifying the Misalignment between Global Health Security and Universal Health Coverage,” The Lancet 397, no. 10268 (January 2, 2021): 61–67.
[2] Nneoma E. Okonkwo et al., “COVID-19 and the US Response: Accelerating Health Inequities,” BMJ Evidence-Based Medicine 26, no. 4 (August 1, 2021): 176–79.
[3] Susan B. Rifkin et al., “Primary Healthcare in the Time of COVID-19: Breaking the Silos of Healthcare Provision,” BMJ Global Health 6, no. 11 (November 3, 2021): e007721.
[4] Leonardo S. L. Bastos et al., “Primary Healthcare Protects Vulnerable Populations from Inequity in COVID-19 Vaccination: An Ecological Analysis of Nationwide Data from Brazil,” The Lancet Regional Health – Americas 14 (October 1, 2022): 100335.
[5] Jennie Gamlin et al., “Centring a Critical Medical Anthropology of COVID-19 in Global Health Discourse,” BMJ Global Health 6, no. 6 (June 14, 2021): e006132.
[6] Katharine Smith, Kamaldeep Bhui, and Andrea Cipriani, “COVID-19, Mental Health and Ethnic Minorities,” BMJ Ment Health 23, no. 3 (August 1, 2020): 89–90.
[7] Tamara Mackean et al., “A Framework to Assess Cultural Safety in Australian Public Policy,” Health Promotion International 35, no. 2 (April 1, 2020): 340–51.
[8] Jan Assmann, Cultural Memory and Early Civilization: Writing, Remembrance, and Political Imagination (Cambridge University Press, 2011).
[9] Michelle Pidgeon, “More Than a Checklist: Meaningful Indigenous Inclusion in Higher Education,” Social Inclusion 4, no. 1 (February 23, 2016): 77–91.
[10] Cicely Marston, Alicia Renedo, and Sam Miles, “Community Participation Is Crucial in a Pandemic,” Lancet (London, England) 395, no. 10238 (2020): 1676–78.
[11] Richard A. Aborisade, “Accounts of Unlawful Use of Force and Misconduct of the Nigerian Police in the Enforcement of COVID-19 Measures,” Journal of Police and Criminal Psychology 36, no. 3 (2021): 450–62.
[12] Tessa Richards and Henry Scowcroft, “Patient and Public Involvement in Covid-19 Policy Making,” BMJ 370 (July 1, 2020): m2575.
[13] Gisele Almeida et al., “[Primary health care in the Region of the Americas 40 years after the Alma-Ata DeclarationAtenção primária à saúde na Região das Américas 40 anos após a Declaração de Alma-Ata],” Revista Panamericana De Salud Publica = Pan American Journal of Public Health 42 (2018): e104.; Nana Nimo Appiah-Agyekum et al., “The Medical Nemesis of Primary Health Care Implementation: Evidence From Ghana,” Health Services Insights 15 (2022): 11786329221115040.
[14] Susan B. Rifkin, “Alma Ata after 40 Years: Primary Health Care and Health for All—from Consensus to Complexity,” BMJ Global Health 3, no. 3 (December 1, 2018): e001188.
[15] Kathryn M. Barker et al., “Community Engagement for Health System Resilience: Evidence from Liberia’s Ebola Epidemic,” Health Policy and Planning 35, no. 4 (May 1, 2020): 416–23.
[16] Eric C Schneider et al., “Mirror, Mirror 2021: Reflecting Poorly: Health Care in the U.S Compared to Other High-Income Countries” (New York City: The Commonwealth Fund, August 4, 2021).
[17] World Health Organization, WHO Global Report on Traditional and Complementary Medicine 2019 (Geneva: World Health Organization, 2019).
[18] Gladys Rowe, “Appendix C – Reflecting on Indigenous Evaluation Frameworks,” September 15, 2022.
[19] World Health Organization, “WHO Global Centre for Traditional Medicine,” 2023.
[20] Roger Alex Clapp and Carolyn Crook, “Drowning in the Magic Well: Shaman Pharmaceuticals and the Elusive Value of Traditional Knowledge,” The Journal of Environment & Development 11, no. 1 (March 1, 2002): 79–102.
[21] Jayne Murdoch-Flowers et al., “Understanding How Indigenous Culturally-Based Interventions Can Improve Participants’ Health in Canada,” Health Promotion International 34, no. 1 (February 1, 2019): 154–65.
[22] Grace Kyoon Achan et al., “Canada First Nations Strengths in Community-Based Primary Healthcare,” International Journal of Environmental Research and Public Health 19, no. 20 (January 2022): 13532.; Maria van der Merwe et al., “Collective Reflections on the First Cycle of a Collaborative Learning Platform to Strengthen Rural Primary Healthcare in Mpumalanga, South Africa,” Health Research Policy and Systems 19, no. 1 (April 19, 2021): 66.
[23] Kristy Crooks et al., “Engage, Understand, Listen and Act: Evaluation of Community Panels to Privilege First Nations Voices in Pandemic Planning and Response in Australia,” BMJ Global Health 7, no. 8 (August 2022): e009114.
[24] van der Merwe et al., “Collective Reflections on the First Cycle of a Collaborative Learning Platform to Strengthen Rural Primary Healthcare in Mpumalanga, South Africa”; Crooks et al., “Engage, Understand, Listen and Act”; Michelle Chino and Lemyra DeBruyn, “Building True Capacity: Indigenous Models for Indigenous Communities,” American Journal of Public Health 96, no. 4 (April 2006): 596–99.
[25] Sherry R. Arnstein, “A Ladder of Citizen Participation,” Journal of the American Institute of Planners 35, no. 4 (November 26, 2007): 216–24.; S. Katherine Farnsworth et al., “Community Engagement to Enhance Child Survival and Early Development in Low- and Middle-Income Countries: An Evidence Review,” Journal of Health Communication 19, no. 1 (2014): 67–88.; World Health Organization, Community Participation in Local Health and Sustainable Development: Approaches and Techniques (World Health Organization. Regional Office for Europe, 2002).
[26] Emma Sacks et al., “Beyond the Building Blocks: Integrating Community Roles into Health Systems Frameworks to Achieve Health for All,” BMJ Global Health 3, no. 3 (June 1, 2019): e001384.
[27] The World Bank, “The Pandemic Fund,” accessed June 1, 2023.
[28] Rene Loewenson et al., “‘We Are Subjects, Not Objects in Health’: Communities Taking Action on COVID-19,” (Training and Research Support Centre in EQUINET and Shaping Health, September 30, 2020).
