Can current interlinked crises stimulate the structural and policy choices required for healthy societies?

Systems and governance failures

The covid-19 pandemic caused at least 15 million deaths worldwide,3 with egregious inequities between and within countries.4 Lack of preparation and poor response illustrate the dysfunction in systems and governance that undermine health and health equity. Among the countries that have seen the greatest impacts, or the worst inequities, many are high income countries that were thought to be well prepared for a pandemic.5

Failures in systems and governance are further elucidated by the world’s inability to mount an effective response to mitigate climate change, even though it poses an existential threat and despite over 30 years’ evidence of the problem and remediation required.

The health co-benefits of key measures to mitigate climate change, including less air pollution, better diet, and enabling more physical activity, could prevent millions of deaths.6 Yet progress in action to realise these co-benefits is slow. Instead, the scale of these injustices shows how current policies have failed on equity and the urgency of choices to change direction. The world’s wealthiest 1% of people generate double the carbon emissions of the poorest 50%.7 Countries that provide the healthiest conditions for children currently have the greatest carbon emissions, compromising the futures not only of these children but also of those in countries that often have contributed least to climate change.8

Costs of poor choices

Societies’ failure to make the structural and policy choices needed imposes steep and unnecessary costs on all countries. A “toxic combination of poor social policies and programs, unfair economic arrangements, and bad politics”9 enable tobacco and alcohol use, unhealthy diets, air pollution, and insufficient physical exercise to contribute to 72% of all global deaths from non-communicable diseases.10

In the past decade, many countries have seen widening inequities and stagnation or reductions in life expectancy.1112 The increasing numbers of wars and conflicts have created unprecedented numbers of refugees, many of whom lack basic protection including access to health and social services. The groups with the worst health status globally are those in settings of chronic conflict or who face structural discrimination within their societies.

The economic and social costs of policy failure are also high. Since 1995, the wealthiest 1% of people globally have amassed almost 20 times more global wealth than the poorest 50%.13 The failure to tackle social determinants of health (living conditions and relative access to power, money, and other resources) and economic inequality drives increasing health inequities but also leads to reduced societal cohesion.14 This reduces solidarity and ability to act together in crises. The covid-19 pandemic has shown how societies with lower trust in government and within communities, often driven by greater inequality, performed worse in mitigating the pandemic’s impact.15

Globally, modelling analyses through to 2040 estimate that investment now in measures to tackle the social determinants of health and reduce health inequities could add $12tn (£9.4tn; €11tn) or 8% to total gross domestic product in 2040, through increased productivity of workers; improvements in their health and reductions in mortality, and would add 0.3% to global employment growth.16

How to create healthy societies

Drawing on previous discourse on primary healthcare, health promotion, and social determinants of health, and extensive discussions during the Wilton Park dialogues, we have identified broad features that healthy societies share (box 1).

Effective public health functions are necessary but not sufficient to enact all these features; healthy societies require contributions and actions involving all sectors. Unhealthy societies are not natural or inevitable but result from inadequate and inappropriate structural and policy choices at global, national, and subnational levels of governance, including inadequate responses to commercial determinants of health.

The covid-19 pandemic has shown that governments can make unprecedented, rapid, and effective transformations in crises. For example, the US implemented a child tax credit that reduced child poverty by 41%.17 South Africa put in place comprehensive alcohol control measures. Such measures have proved difficult to sustain, showing the challenges in making permanent the transformations needed.

Current crises have also intensified discussions on how to measure what is valuable to societies and what structures and policies are most important for health. In India and South Africa, concepts of wellness and wellbeing have been made central to the aims and functions of health ministries. There are calls and proposals to make more use of measures of societal progress other than gross domestic product, such as development and wellbeing indices.18

The importance to health of broader factors, beyond the remit of the health sector and healthcare, and the need for multisectoral action have long been understood.19 The covid-19 and climate crises have brought this to the attention of politicians and the public, although countervailing political and commercial interests and siloes in governance continue to obstruct action.

Perhaps most compellingly, the current interlinked crises have accelerated transformations in society, with impacts that are beginning to be understood—in particular, decarbonisation and digitalisation. Covid-19 has prompted advances in digital health including in telemedicine and systems rapidly to analyse, synthesise, and report data. The increasing pace of decarbonisation in Europe—for example, due to climate change and the war in Ukraine—shows that change is possible. However, digitalisation and decarbonisation will not necessarily improve health equity; indeed, inequities could worsen. Yet these transformations present opportunities to reduce air pollution and energy poverty and improve access to health and social services. Structural and policy choices are needed that capitalise on resultant changes in governance and society and ensure these transitions increase equity.

Implementing the policy choices needed

Creating healthy societies requires structural and policy choices to co-create systems for health and health equity (box 2).20 Implementing these policies is resisted by powerful interests that benefit from the status quo. These interests can be overcome only by principled political leadership and social mobilisation.

Building healthy societies is therefore not an abstract initiative. Instead, it needs to be communicated and developed in ways that make sense to people’s lives, to stimulate popular demand for social change. Crucial to success is co-creating healthy societies with communities that have local and indigenous knowledge,21 including learning lessons from existing community led initiatives.

Healthy societies depend on economic, social, and environmental stability and, most fundamentally, social justice so that social goods and services are distributed fairly. Healthy societies are not possible without all societal actors making substantial efforts to end inequities by tackling the inequitable distribution of power, money, and other resources and upholding human rights.

More than utopian ideals

The concept of healthy societies in box 1 may seem utopian. Can societies overcome the failures that have led to current crises? Can crises be catalysts for change? Consider the creation of welfare states after the great depression and the second world war or the mass provision of antiretroviral drugs in the HIV and AIDS crisis in response to the demands of an indomitable social movement.

Crises do not necessarily lead to societal transformation, however. They often lead to a focus on reactive measures that can make building or reinforcing systems conducive to health more challenging. The global financial crisis of 2007-09 did not lead to transformation of global financing or the dominance of neoliberal economic management. Instead, in many countries it led to austerity measures and a reduction in state functions.22 In the current crises, World Bank estimates show alarming reductions in fiscal space for health in many low and middle income countries.23 Austerity measures are again being introduced, with budget cuts in health and social services.

A vision of the right to health driving multisectoral efforts has been articulated before. Most famously, the codification of primary healthcare in Alma-Ata, 1978; the drafting of the first charter on health promotion in Ottawa, 1986; and the final report of the WHO Commission on Social Determinants of Health, 2008. Despite the progress each movement has engendered, it is fair to ask why success in realising these visions is any more likely now.

It is also fair to ask why the health sector itself may be any more successful now in advocating for and contributing to multisectoral action than it has been in the past. The focus of the health sector on healthcare, particularly, curative care, has proved stubbornly resistant to change. The capacity of health ministries to push for multisectoral action remains limited. In the covid-19 pandemic, health ministries have had unprecedented visibility but have routinely been bypassed in coordination of the multisectoral response.

Progress is possible

Progress now is possible because of the scale of the crises and severity of the threats faced; the magnitude of social inequality, particularly intergenerational inequality; and the consequent discontent, including in the dominant paradigms of our economic systems.

Also, the effects of the climate crisis will only intensify, forcing more and more people to demand action from their leaders. The level and shifting pattern of global inequality, with inequality within countries predominating, are already destabilising governance in many countries. Increasing misinformation and the polarisation of societies are difficult to counteract. The impact of the degree of societal transformation needed, and other shifts such as demographic change, is unknown but will have profound effects on societal organisation and geopolitics.

Analyses of the outcomes of past crises show that reforms to increase equity afterwards are not inevitable.24 A reversion to the status quo can occur, or crises can instead be used by vested interests to concentrate their power and increase inequities. Whether or not crises lead to improvements in equity is substantially determined by how the meaning of crises is framed and interpreted—that is, how the causes are understood, who is perceived to be responsible, and whether the crisis is considered to have been avoidable.24

For healthy societies to be an outcome of current crises, proponents of health equity should provide evidence to guide this framing of the causes and accountability for crises. They also should support social movements to demand action to influence policy outcomes, minimise indifference to the root causes of crises among communities, and direct blame for crises in ways that increase rather than detract from health equity.

Building healthy societies will require coalitions within countries and globally of governments, civil society, academia, and the private sector to present credibly what each part of government, each part of society, and each person can contribute, and to foster social mobilisation to support the improvements needed in systems and governance. We need to reach a consensus in our societies on the causes of current crises and what needs to be done. The health sector must urgently improve its capacity and performance to play its part, even though it is only one contributor, and often a minor one, in many of the required transformations. It will take humility and sensitivity to avoid being seen as using the resources of people and other sectors for narrow technocratic public health ends. Instead, the health sector will need to engage with the public’s interests and priorities and be willing to make trade-offs and persuade, generously and credibly with evidence and a spirit of solidarity, to get support for creation and preservation of healthy societies.