Global health systems are struggling to cope amid rising crises, according to a comprehensive synthesis released on January 12, 2023, that documents the combined effects of chronic under-investment, acute emergencies, workforce pressures, and evolving disease patterns on health systems worldwide. The report, published jointly by major international health bodies and drawing on data from more than a hundred countries, concludes that the cumulative strain now facing health systems represents one of the most serious collective challenges to the right to health since the establishment of the modern international health framework after the Second World War.

The synthesis describes a picture that is remarkably consistent across otherwise diverse health systems. High-income countries with long-established universal coverage, middle-income countries in varying stages of health system development, and low-income countries with chronically under-resourced systems are all reporting that their capacity to deliver essential services is being tested in ways that go beyond the ordinary pressures that health systems have always faced. What unites these diverse experiences, the report argues, is a combination of structural and situational factors that have together produced an environment in which even well-established systems are finding their resilience seriously compromised.

What the Data Show

The specific indicators documented in the report are striking. Waiting times for elective care have been rising in many countries, with patients in some systems waiting months or years for procedures that should be delivered within weeks. Emergency department pressures have been widely reported, with waiting times, patient-flow bottlenecks, and specific operational difficulties at the interface between ambulance services and hospitals producing conditions that frontline staff describe as among the most difficult they have experienced.

Access to primary care has been uneven and, in many systems, deteriorating. The share of people who report difficulty getting a primary care appointment within a reasonable timeframe has risen in many countries, producing downstream effects on secondary care and on population health outcomes. Management of chronic conditions — including diabetes, hypertension, cardiovascular disease, and specific cancers — has been disrupted in many systems, with consequences that are often slow to manifest but that accumulate into significant population health burdens over time.

Maternal and child health services, typically among the better-protected elements of health systems, have shown worrying indicators in specific contexts. Vaccination coverage has slipped in a number of countries, with specific catch-up challenges that have proven difficult to address. Antenatal care coverage, safe delivery, and postnatal support have all seen specific pressures in contexts where broader health system challenges have reduced the resources available for these services.

Mental health services, historically under-resourced relative to the scale of need, have experienced particular pressure as mental health needs have risen across populations. Demand for specialist services has exceeded supply in many systems, with waiting times for psychological therapies and psychiatric services in some cases extending into years. Primary care providers, who in many systems carry the bulk of mental health workload, have reported that the cumulative scale of the challenge has outstripped their capacity to respond effectively.

The Drivers of the Situation

The report identifies several interacting drivers of the current situation. Chronic under-investment in health systems in many countries has been a long-running feature of the landscape, reflecting a combination of economic constraints, political choices, and specific policy environments. Real spending on health has risen in many countries over recent decades, but growth has in many cases not kept pace with demand, demographic change, and the cost of modern health care.

Workforce pressures are prominent across the report. Health workforces in many countries are experiencing a combination of shortage, burnout, departure of experienced staff, and specific recruitment and training challenges. The training pipelines for specific roles — including doctors in particular specialties, nurses, specific allied health professionals, and other essential staff — have in many cases been too small to replace those leaving the profession, and the specific conditions of work in health systems have contributed to higher-than-expected departures.

The cumulative effects of recent emergency responses have also left specific residues in health systems. Backlogs of elective care accumulated during earlier periods of disruption have been growing in many systems. Specific services that were paused or reduced during acute phases have been restarting, but not always with sufficient resources to address both current demand and the accumulated deferred need. Equipment, facilities, and staff capacity that were stretched during emergency responses have in some cases not been fully restored.

Evolving disease patterns have been adding complexity to the situation. Ageing populations in many countries have been increasing the prevalence of chronic conditions and multi-morbidity, both of which are resource-intensive to manage. Climate-sensitive diseases have been expanding their range and altering their patterns, requiring health systems to develop new capabilities or adapt existing ones. Emerging infectious diseases, antimicrobial resistance, and specific non-communicable disease epidemics have all been adding to the demand on health systems.

Specific crises — including conflicts, natural disasters, displacement, and broader humanitarian emergencies — have produced acute additional pressures on affected health systems and on the international humanitarian system that supports them. These crises have been concentrated in specific regions but have had ripple effects elsewhere, including through the global movement of populations, through the disruption of supply chains, and through the diversion of international health resources to emergency response.

Inequities Within and Between Countries

A consistent theme of the report is the unevenness with which the pressures are distributed. Within countries, populations with specific vulnerabilities — low-income households, racial and ethnic minorities, rural residents, people with disabilities, older adults, children in low-income settings, and specific marginalised groups — have been disproportionately affected. These populations are more likely to face barriers to accessing care even in ordinary conditions, and those barriers tend to be amplified when overall system capacity is under pressure.

Between countries, the distribution of pressures has been equally uneven. Low- and middle-income countries, which typically have smaller health workforces, less well-developed infrastructure, and more constrained public health budgets, have in many cases faced the combined effects of domestic challenges and disruptions to international cooperation. Specific pressures — including on essential medicines supply, on migration of health workers to higher-income countries, and on the delivery of international assistance — have affected these systems in ways that the international framework has not fully addressed.

The report includes specific analyses of equity within health systems and of international health equity more broadly. It documents cases in which specific inequities have widened over recent years, and it identifies specific measures that could narrow them, including investment in primary care, strengthening of public health capacity, expansion of universal health coverage, and specific mechanisms to address disparities in access and outcomes.

What Could Be Done

The report's recommendations are extensive and specific. Investment in primary care and in public health capacity is identified as a foundational priority, with both being widely recognised as high-return investments that improve health outcomes and reduce pressure on specialist services. Workforce strategies — including training, recruitment, retention, well-being, and deployment — are highlighted as critical, with specific attention to the structural conditions that have been driving health workers out of the profession in recent years.

Financing reforms in many systems are identified as necessary, with specific attention to the balance between current spending and capital investment, between different sectors of care, and between short-term response and long-term resilience. The report acknowledges that financing reform is politically difficult in many contexts, but it argues that the costs of under-investment are increasingly visible and significant, and that the political case for sustained health system investment is becoming stronger.

Preparedness for future crises — including pandemics, climate-related health impacts, and the health consequences of conflict and displacement — is identified as a specific priority that cannot be deferred. Specific investments that produce benefits for both ordinary operations and crisis response — including surveillance infrastructure, laboratory capacity, supply chain resilience, and broad-based workforce development — offer particularly high returns.

International cooperation, including on research and development, on health worker mobility, on supply chain resilience, and on specific financing mechanisms, is identified as a necessary complement to national investment. The report calls for specific strengthening of international frameworks and for sustained attention to the global public goods that underpin national health system capacity.

The Political Economy of Health System Reform

The report engages directly with the political economy of health system reform. Health systems are among the largest and most complex undertakings in any country, and their reform involves specific political, institutional, and operational challenges. Public attention to health systems is typically high, but it is often focused on specific issues — waiting times, specific scandals, policy announcements — rather than on the broader structural questions that determine long-term performance.

Electoral cycles, interest-group dynamics, specific bureaucratic structures, and the natural difficulty of making visible improvements in complex systems all contribute to the challenge. The report does not offer simple solutions to these challenges, but it highlights specific features of past successful reforms — including sustained political commitment, broad coalitions of support, attention to implementation as well as policy design, and mechanisms for learning and adjustment — that offer lessons for current efforts.

The report also addresses the specific challenges of reform in contexts of economic constraint. Periods of economic difficulty have often been associated with real reductions in health spending, with consequences that can persist long after economic conditions improve. The report argues for protecting health system investment even in difficult economic circumstances, on the basis of both evidence about the long-term consequences of under-investment and evidence about the economic as well as health benefits of well-functioning health systems.

Voices from the Front Line

Beyond the aggregate statistics, the report includes extensive material drawn from interviews with health workers, managers, patients, and community representatives across multiple countries. These voices give a human texture to the quantitative findings and draw attention to specific experiences that are common across otherwise very different contexts.

Health workers describe exhaustion, a sense that their efforts are being overwhelmed by the scale of demand, and specific concerns about whether they will be able to continue in their roles. Managers describe the difficulty of balancing competing priorities with inadequate resources, and the specific challenge of sustaining staff morale under sustained pressure. Patients describe experiences of delayed care, of disrupted continuity, and of the specific consequences of these delays for their health and lives. Community representatives describe the accumulation of unmet need within their communities and the specific ways in which health system pressures fall unevenly.

These voices are not used in the report for emotional effect but as a source of evidence about specific realities that aggregate data do not capture. They also serve as a reminder that the pressures on health systems are ultimately experienced by specific people whose lives are affected by the choices being made about how those systems are funded, organised, and operated.

Looking Ahead

The report concludes with a measured but urgent call to action. Health systems are facing a convergence of pressures that has no recent parallel, and the response available to national governments, international bodies, and broader societies is well understood in principle but under-implemented in practice. Sustained investment, workforce strengthening, primary care and public health prioritisation, preparedness for future challenges, and specific attention to equity together represent a programme that, if adequately resourced and sustained, could materially improve the situation.

Whether this programme is implemented will depend on political choices, on economic conditions, and on the specific leadership provided by governments, by international bodies, and by institutions within health systems themselves. The report does not minimise the difficulty of the choices involved, but it argues that the cost of continued under-response is high and rising, and that the window for acting before the current strain produces more serious consequences is narrower than many assume.

For health workers, patients, and communities, the immediate experience of health systems struggling under pressure is something they are living with now. Their resilience, and the dedication of the workforces sustaining care under difficult conditions, have been part of what has prevented an already difficult situation from becoming worse. But resilience alone is not a strategy, and the work of strengthening the systems on which so many depend will continue to require sustained attention, sustained investment, and sustained political will.

The report released today is a contribution to that work. Whether its contribution translates into meaningful change will be a test of the broader health and political systems that receive it.