Explorations on people centredness in health systems

Health systems should ultimately seek to serve people and society. They must aim to bring value in people’s lives not only by caring for them when sick or giving support to prevent or limit illness and its effects, but also, more broadly, by offering the promise of economic security to all for times of great vulnerability. Health systems are also human systems. At their heart is a personal encounter, the interaction between the patient and the health provider—sometimes tenuous, often contested, but always with the potential for humanity and compassion. But many different types of people—individuals, groups and communities—make up health systems, ‘live’ within them, have roles, stakes and power in them, and are central to their existence and functioning. People make all the most important decisions in health systems—either by accessing services as patients, setting rules and allocating resources as policymakers, or enacting, coping with and subverting those rules, as implementers, managers, providers and service users. Communities and citizens influence these systems by shaping the social norms and contexts in which they operate. Community norms and behaviour drive health market forces and practices, influence how individuals and families access services, and can help hold systems accountable. Citizens may also influence system development through their electoral voting power, exercising the ‘long route’ to accountability. People centredness embraces this essentially human character of health systems. Yet, the term is surprisingly new in health system debate and the common response to its use is ‘what does that mean?’ This supplement advances the conversation by exploring varied perspectives on the concept of people centred health systems (PCHS). PCHS emerges as a multi-faceted concept, with ideological power and also carrying huge potential for practical thinking and change in health systems. While Universal Health Coverage has become emblematic globally for health systems change for better health care access and quality, and social protection, PCHS offers opportunities to elaborate and deepen our understanding of what such change should entail in the operational practices of health systems. The initial 11 articles in this collection, published as a printed supplement, begin to illustrate different aspects of the PCHS concept (further articles on the theme will be released in an online collection, and will be scattered through subsequent print editions of the journal). Four overarching themes that define and represent different aspects of PCHS emerge from this set of articles, and from other existing writing on PCHS and related themes. These aspects are summarized in Box 1, and also provide a framework for the subsequent discussions in this editorial. Box 1. Aspects of people centred health systems (PCHS) Putting people’s voices and needs first PCHS are ultimately shaped by community voices and needs. Participatory governance mechanisms can channel the power of communities to mould health systems in the public interest, and hold them accountable. People-centred governance can also confront entrenched power imbalances within health systems, and address their broader social determinants. People centredness in service delivery PCHS put people’s needs first in the design and delivery of health care and services. Important principles of this approach are quality, safety, longitudinality (duration and depth of contact), closeness to communities and responsiveness to changing requirements. Capacity building in PCHS focuses, foremost, on creating capabilities to respond to people’s health care needs. Relationships matter: health systems as social institutions PCHS are social institutions, which operate through chains of relationships between different health systems actors—including administrators, health care providers, service users and researchers—each acting in their respective contexts. As such, systems thrive on mutual trust, dialogue and reciprocity, and their effectiveness correlates to the quality of these human relationships. Values drive people centred health systems In PCHS, decision making is informed by people centred values around justice, rights, respect and equality, and the principles of primary health care. Values drive people’s decisions within the health system contributing to change, and conversely, system reforms can have impacts on people’s values within the system.

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