How health systems and social determinants of health can guide policy

IHME Director Dr. Christopher Murray and UCLA Chancellor Dr. Julio Frenk discuss The Lancet Commission on Health Systems Performance Assessment and how the information will allow policymakers and other decision-makers to use resources strategically and improve health outcomes.

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Transcript

Rhonda Stewart: Welcome to Global Health Insights, a podcast from IHME, the Institute for Health Metrics and Evaluation. I’m Rhonda Stewart.

In this episode, we’ll hear from IHME Director Dr. Christopher Murray and UCLA Chancellor Dr. Julio Frenk as they talk about the Lancet Commission on Health Systems Performance Assessment. The Commission’s work builds on a report by the World Health Organization in 2000 that analyzed and ranked the performance of health systems in WHO member states.

In the quarter century since the WHO report, the need to understand health systems performance has become more complex and more urgent. Disease burden has evolved along with health expenditure. Globally, low-, middle-, and high-income countries face unique challenges as well as challenges that cut across all countries.

The Commission is made up of experts from around the world. It will estimate the performance of countries’ health systems using the best available evidence and propose enhanced measurements of health system functions and goals. The information will allow policymakers and other decision-makers to use resources strategically and improve health outcomes.

Dr. Frenk and Dr. Murray, people are familiar with the components of a health care system, but what makes a health system broader, and what are those specific components?

Dr. Julio Frenk: Well, the health care system is a subsystem of the larger concept of the health system. Specifically, what most people come in contact with on a daily basis and as part of their personal experience is the health care system. Most people in the world today are born in contact with the health care system, will die in contact with the health care system, and will spend significant parts of their lives in the health care system.

What that refers to is the set of institutions that are mostly charged with providing what is conventionally defined as health services or personal health services or clinical services. The health system encompasses a broader set of institutions and actors and actions which we basically define as all those actors and institutions in a society whose primary intent is to improve health. And that includes most of the entities we call the health care system, hospitals, clinics, labs, the pharmaceutical industry, et cetera, et cetera. But it includes a broader set of institutions that are concerned with conserving, promoting, or improving health in a society.

Rhonda Stewart: Dr. Murray, anything to add on the components of a health system?

Dr. Christopher Murray: Well, there’s always a contingent of people who rightly point out that there are drivers of health like educational attainment, whose primary intent is not to improve health, but happen to be super important drivers. So the notion of the health system defined by primary intent does not deny the idea that there are broader social determinants of health. It just says there are these institutions in society who we have funded and created whose primary purpose is to improve health. And it is useful for us to look at that cluster of institutions and figure out who does well and what lessons we can learn about those primary institutions that are focused on improving health.

Rhonda Stewart: And in addition to educational attainment, are there other factors that are not technically part of a health system but influence health systems?

Dr. Julio Frenk: Yeah, there’s all kinds of what are called social determinants of health, which are other institutions. I mean, the economy, the economic forces, employment is a determinant of health, and housing is a determinant of health. But the purpose of housing is not directly to improve health, it is a determinant. When we talk of the health system as larger than the health care system, we’re talking mostly about other services that are not conventionally part of or even administratively part of the health care system. For example, a lot of what we do in public health, like the provision of clean water and sanitation, or some actions to improve the environment – because the primary intent of those actions is to improve health, they are part of the health system. There are also determinants of individual health status for the individuals that form that population.

But that’s distinct and different than the education or employment or housing that are outside of the health system, although they exert a determination on the health of a community and of the individuals that comprise that community.

Rhonda Stewart: And tell us, both of you, what prompted the creation of the Lancet Commission on Health Systems Performance Assessment?

Dr. Julio Frenk: Well, let me say it was 25 years ago, a quarter of a century since the World Health Report 2000 was published. And a lot has happened in these 25 years.

Now that World Health Report 2000 did two things. It developed a very, I think, well thought through conceptual framework to understand what is a health system, what are the goals of health systems, what are health systems for, what are the functions that a health system has to perform to achieve its goals, and how do you define and measure performance? It was a very clearly articulated conceptual framework that’s been quite influential. Associated with the framework, the framework was translated into a measurement exercise that was carried at WHO by a new area that was created since Dr. Gro Brundtland became the Director-General in 1998 called Evidence and Information Policy that I was leading. And then within that, we have the Global Program on Evidence that Chris Murray was leading.

And Chris’s team orchestrated or developed a set of measurements and implemented those. And for the first time, the health system performance of all 192, I believe, was the number of member states of WHO back then – all of those were assessed and compared to produce some rankings that were highly debated, very controversial in many parts of the world, but it was the first rigorous attempt to measure and compare the performance of health systems.

Nothing of that scope has been carried out in this quarter-century, and yet the reality of health systems around the world has been transformed profoundly. So it’s, I think, an exercise that’s overdue to now rethink the conceptual framework, see if there are adjustments that are needed with everything that’s happened, including for example, the appearance of artificial intelligence as a major technological development and societal development, and also to try to again attempt a measurement. In the intervening 25 years, both the datasets and the analytical tools to apply to those datasets have improved enormously.

So we thought this is a great time to carry out again a comprehensive assessment of the performance of health systems that encompasses the entire world. There have been other assessments, but they are focused on subsets of countries. And this would be the second time that such an exercise for all countries of the world would be carried out.

Dr. Christopher Murray: Yeah, I think there’s, as Julio said, much better data, much better methods. But it’s also pretty timely to look at health system performance because we’ve gone through this big shock in 2025 in global health where funding was abruptly cut for a number of low-income countries due to the reductions of USAID and a number of European donors. And that’s reignited the interest globally, and in in fora with ministers of health, are there lessons you can learn about how to better organize health systems to get more health for the money, as Julio has often described in the past? So I think both the possibility of doing a much better empirical assessment and the interest – there’s a willing audience out there for whatever insights are possible in how to deliver both public health and health care more effectively, more efficiently.

Rhonda Stewart: Let’s talk about some of the specific challenges that face different types of countries. And let’s talk first about health systems challenges in high-income and middle-income countries. What are some of those challenges?

Dr. Julio Frenk: Well, there’s a huge number of challenges on the evolution of the health conditions of populations. First of all, the aging of populations has been for about a century changing the epidemiologic profile. And now we really have a very mixed bag of health challenges, both in terms of communicable diseases – some people had predicted that with the rise of non-communicable diseases, we would see communicable or infectious diseases become irrelevant. Clearly, if we needed any reminder, the COVID-19 pandemic just reminded us that infectious diseases are not going anywhere. They’re there. They continue to be a threat not just as outbreaks or pandemics, but as comorbidities of chronic illnesses and as problems in and of themselves aggravated by phenomena such as antimicrobial resistance.

So the nature and the complexity of health conditions in populations have continued to evolve and are extremely complex because they demand interventions that are in general much more costly, and that adds pressure. And the demand side for services is just increasing throughout all countries in the world, but particularly in high- and middle-income countries. High-income countries in particular also face, and middle-income countries as well, fiscal crises of different magnitudes and natures. We’re still feeling the after-effects of the pandemic in terms of inflation and budget constraints from all the stimulus that was mobilized to deal with the economic consequences of the pandemic. And then there are longer-term structural forces in the economy.

And then we’re living in times of huge polarization. So measures like public health are being undermined, like public health measures. We are seeing growing vaccine skepticism. We’ve seen basic public health measures like wearing protective face covers during an epidemic become the subject of political debate. We didn’t have that, at least not to this extreme, before the pandemic. I think the pandemic really triggered a number of challenges. They affect all countries in the world, but high-income countries and middle-income countries are certainly not exempt from those. And there are others that I’m sure Chris can add.

Dr. Christopher Murray: Yeah, I would add to Julio’s list there two long-term, broad drivers of health challenge that many systems need to take on.

The first is quite universal, and that’s the rise of obesity, where we see in any of the forecasts that we tend to make that becoming an enormous determinant of ill health in the future. It’s rising everywhere. And so nobody’s really figured out a formula to put the brakes on increases in obesity.

And then the second one, which is much more specific to certain localities, unfortunately very often the lowest-income localities, is rising temperature, where we know that there’s an intersection between temperature and a number of chronic conditions – heart disease, diabetes, kidney disease. And that interacts with obesity, so that we expect to see really big increases in quite expensive disorders like chronic kidney disease and diabetes in many parts of the world that will tax the available resources to deliver meaningful care.

So again, back to that theme, that there is this rising recognition that demand for care is going to outstrip the ability of governments, in particular, to deliver services that the public expects. And I think that creates lots of social and political pressure on health systems to perform better.

Rhonda Stewart: And Dr. Murray, you just referred to low-income countries, and those countries do face some specific challenges, some challenges that are slightly different or very different in some cases than the challenges faced by high-income or middle-income countries. So what are some of those specific challenges for health systems in low-income countries?

Dr. Christopher Murray: Well, I’ll jump in first and let Julio respond. Remember, in the lowest-income countries, we still have really quite rapid population growth. So governments with very modest resources, less than they had before because of the reductions in development assistance for health, have to provide or attempt to provide services for a rapidly growing population. The most extreme case is the Sahel, where over the next one or two generations we will see multiples of the population increase in places that are already poor and have sort of marginal prospects for growth in income per capita. And what that means is that they will face the sort of ongoing challenges of the infectious diseases characteristic of the poorest places – malaria, pneumonia, diarrhea, others, TB, depending on where, HIV.

There’s been a lot of progress on those diseases due to development assistance for health. Now that those monies are reduced, there’s very little fiscal space in low-income countries to replace that money with their own resources. So we’ll be back to this theme – why do some countries in the low-income world, are they able to deliver the same service at a fraction of the cost of a neighboring country? And if can we learn from that and share those results so that you can see more service delivery achieved with the limited resources that are available?

Dr. Julio Frenk: And I would just add that we’re actually seeing major reversals of challenges that we were on the path of overcoming. And this is across the board – they’re more acute in low-income countries, but you see them in middle- and even in high-income countries. To give just one concrete example, my own country of Mexico is experiencing an epidemic of an outbreak of measles that has already led to children dying from measles. So before 2025, the last death from measles in Mexico occurred in 1995. There had been no deaths in 30 years. So after 30 years of sustained progress, thanks to massive vaccination campaigns, we now see the reappearance.

There are concerns in the United States of a reappearance of polio cases because there’s still polio around the world and with reduced vaccination. So you’re seeing not just challenges that arise from progress – you know, the fact that countries become wealthier and reduce their fertility and that leads to aging of the population. That’s actually a movement that has consequences for health systems, but it’s positive.

They’re also side by side with situations where we could say that we are victims of our own success. We are now seeing the backward movements in those successes and the re-emergence of problems that we thought had been controlled or we were very near to controlling, like the example of vaccine-preventable diseases. And that really poses a set of challenges. We were almost now unaccustomed to those issues. They were no longer part of our dashboard of concerns. And now all those red lights are turning on again after decades when they were pretty much subdued.

And I believe overall, I would reiterate that the polarization, the rise of populist governments who doubt science, that is probably the biggest challenge. And health systems, one of their most important impacts on societies is to produce evidence to guide people making decisions. And that includes decisions at the household level, like whether to vaccinate or not. And that is a challenge for health systems to actually elevate the health literacy of the population and avoid the sort of nefarious forces of voices that sometimes from the highest position of government are doubting the benefits of scientific research and lifesaving measures like vaccines.

Rhonda Stewart: Those are some very sobering developments that you mentioned, Dr. Frenk. Going back to the Lancet Commission, can you both give us an idea of the subject area expertise on the Commission and the geographic representation on the Commission?

Dr. Julio Frenk: Go ahead, Chris.

Dr. Christopher Murray: Yeah, we fortunately have a Commission of experts from every region of the world, a number of people who’ve published extensively on health system performance or health systems more generally, a number of current and past health system leaders, ministers of health, secretaries of health in the mix, and I think some people that have dug deeply into certain functions, as Julio mentioned, of health systems, like human resources, or on primary care and its role in making a well-functioning health system.

We have people from the major agencies, WHO, the World Bank, that have been very engaged over time in trying to foster improvements in health systems or investments in health systems. It’s a mixture of expertise from around the world that hopefully will trigger lots of vigorous debate, because I’m sure we don’t all agree on what are the biggest weaknesses in health systems and how we can address them.

But it’ll be a group, I hope, that shares the idea that we should foster the evidence building and share that evidence – like 25 years ago, but done much, much better, to be a stimulus to looking at health systems. We’ve gone through successful decades that have been very disease- or intervention-focused in the global health arena. And I think because of the budget cuts around the world or the perception of demand outstripping the available resources, we’re in a window where there’s a lot more interest in the system part in addition to the disease-, risk-, or intervention-specific issues that global health has largely focused on since the MDG [Millennium Development Goal] era started.

Rhonda Stewart: What will be the duration of the Commission’s work, and what will the Commission produce?

Dr. Christopher Murray: Well, like every Lancet Commission out there, the duration is a little bit a function of how much we both forge consensus across the group and stimulate a parallel set of research that will feed into the report.

And let me pass it over to Julio. I expect that in addition to the main report, which would be in two to three years, there’ll be a number of spinoff types of research articles and other types of communications targeting health system leaders that would follow from forging a new consensus around health system performance and what lessons can be learned to share more broadly. But I hope, Julio, that sounds about right to you.

Dr. Julio Frenk: Absolutely. You know, I think it’s important just to place this particular Commission in the context of what’s really been one of the most innovative aspects of an incredibly innovative leadership of The Lancet under Richard Horton, which have been this figure of Lancet Commissions. I participated in, I think, the second or third Lancet Commission, and that was around the year 2010. So we’ve seen now for a little bit more than 15 years, just the figure of Lancet Commissions flourishing and producing reports that have really been hugely influential.

So contrary to the last time, where the first assessment was done within the confines of a multilateral agency, the World Health Organization – the premier health agency in the world, nonetheless subject to a lot of political constraints and dynamics – this time we have much less restrictions on the possibility of pursuing even highly controversial ideas and making an impact.

Now, what we need to guarantee as a Lancet Commission is the effective translation of the results into actual impact on policies and practices around the world. And so even though the Commission itself will culminate for sure with what I hope would be a very impactful report like the one in the year 2000 was, this time, just like being in WHO had a constraint for the political dynamics, but it had the advantages that you were closer to the space of translation into policymaking. And we did see countries where actually the framework and the findings of the Commission prompted major health reforms.

And of course, I’m not just talking about my own case, since I became the Minister of Health of Mexico shortly after that. And of course, I took everything that we had done with the World Health Report 2000 to a very comprehensive, ambitious health reform. But I’m talking of countries like China who saw the assessment as evidence of the urgent need to reform their health systems. And we saw countries like the United States shocked by the relatively low ranking that went counter to what people were assuming. And again, it didn’t launch the kind of comprehensive reform, but it did lead to some important reforms like the Affordable Care Act. So we need to be planning from the beginning for the afterlife of the Commission. The product of a report is not the end – it’s meant to trigger action and reforms in countries around the world.

Rhonda Stewart: And so before we wrap up, let’s talk a little bit more about the actions and reforms that could result from this report. As you both mentioned, we are living in a time of greater political polarization and resource constraints. So how do you hope that this work might have influence and impact on policymakers and other decision-makers?

Dr. Julio Frenk: Did you want to start?

Dr. Christopher Murray: You know, I hope that the message of getting more health for the available resources is – and presuming that we learn some insights into how to do that – that is one that will transcend the political polarization in some, maybe not all, countries, because it’s hard to champion inefficiency or less health for the money. And if you can learn some of those lessons: Are there architectures for health systems that seem to do better? Are there ways of structuring human resource development and on and on across the different functions of health systems?

I think there will be a pretty ready audience in many places for that sort of message. And so, I think this will be a case where the audience is much more in the policy realm probably than strictly in the academic realm, because it is such a salient, urgent topic right now. And I think whether you’re a high-income, middle-income, low-income country health system leader, there’s real interest in how do you, essentially, balance the books, with increasing demand, no expectation of huge increase in resources in many settings.

Dr. Julio Frenk: And for me, my hope is that the Commission, first of all, will remind people of the growing importance of health systems. Health systems in the intervening years between the WHO report and today have only increased their share of the global economic product. It is definitely now the health system that is the largest sector of the largest economy in the world, the US economy. But globally, now it represents about 10% of the global economic product, and in every country in the world – just because of the demographic dynamic and the epidemiologic transition – it’s just consuming more and more resources.

And the big thing is, to use that famous phrase from Professor Ramalingaswami of India, it’s not just a matter of more money for health, it’s more health for the money. And at a time when we are facing new restrictions that may slow down that growth or even lead to reversals, I think the need to think of what is the value that all of those investments produce and to maximize that value with available resources has just become much more prominent than before. I also hope that the Commission will bring back, front and center, the idea that policy, public policy, while obviously occurring in a political matrix, needs to, in the end, base its fundamental decisions on the best available evidence. That’s an ethos that’s been eroding over the last few years with the erosion of trust in science and in institutions. And I hope we can make a compelling case.

Finally, I hope the Commission will also allow policymakers to anticipate some technological developments that offer huge promise. Artificial intelligence is of course the most salient of those, but it also offers huge challenges. There’s no question that well-applied artificial intelligence finds in health, and health care specifically, one of its most promising and beneficial applications. But it’s really going to depend on how we deploy those technologies. It’s happened with every technology. But I think in the case of artificial intelligence, it’s even more important that we actually are able to provide some glimpses into what that technology is.

And lastly, alongside that, I hope it will also place front and center the urgent need to close the equity gaps, the disparities that happen within and between countries. Because we have seen in many quarters a loss of focus on closing those gaps. And technologies themselves can widen the gaps, or they can help shorten them. Some technologies, like vaccines, have been the great equalizers when deployed globally. But when vaccines are not deployed in the right way, like during the COVID pandemic, they can deepen inequalities.

So technologies need to be placed in that framework of accelerating the realization of the ideal that access to high-quality health services for everyone and with protection against the financial consequences of disease – that access is a fundamental human right. And I hope this work will also help to elevate again the notion of the reason why universal health coverage is a core part of the human rights agenda at a time where all of those fronts – evidence-based decision-making, a commitment to science, and a commitment to closing disparities – when all of those are under attack from different quarters. I think we hope the Commission will make an enlightened contribution to put us back on a path of progress in health which was launched during the 20th century and needs to continue going forward.

Rhonda Stewart: Dr. Frenk and Dr. Murray, thank you so much.

Dr. Julio Frenk: Well, thank you.

Dr. Christopher Murray: Thank you.

Rhonda Stewart: Details about the Lancet Commission on Health Systems Performance Assessment can be found at healthdata.org.

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An independent population health research organization based at the University of Washington School of Medicine, the Institute for Health Metrics and Evaluation (IHME) works with collaborators around the world to develop timely, relevant, and scientifically valid evidence that illuminates the state of health everywhere. In making our research available and approachable, we aim to inform health policy and practice in pursuit of our vision: all people living long lives in full health. Learn more about IHME.

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