The Alliance for Health Policy and Systems Research convened a three-day expert meeting in Accra, Ghana, to explore how global trends and evolving health sector dynamics are reshaping health systems today and will influence their future trajectories. The meeting is part of Health Systems 2050 (HS2050), the Alliance’s new initiative to understand how economic, technological, environmental and political forces will shape what health systems could – and should – look like in the decades ahead.

The initiative is rooted in the recognition that the world is in the midst of significant and rapid changes coupled with high levels of uncertainty. At the same time, those working on and in health systems are fighting through the day-to-day activities and might not have the time or agency to think about how these bigger changes are shaping the future of health systems.

Setting the stage: what history teaches us about transformation

The meeting opened with a reflections from an exploratory review, which looked at major historical shifts that have reshaped health systems over the past century. The analysis utilized a global systems framework to consider how seven big domains impact on health and health systems.

This historical lens explored how key moments – like the world wars, modern travel and deconolonization and the dissolution of the Union of Soviet Socialist Republics – impacted health systems. Discussions underscored the importance of political choices, societal values and external shocks in driving structural change. They also highlighted how hard it is to reverse path-dependent developments – particularly once market incentives or financing structures become entrenched.

What health systems actors are saying: findings from an online consultation

Ahead of the meeting, the Alliance conducted an online consultation to gather perspectives from health systems actors around the world. This feedback helped frame the discussions in Accra.

Figure 1: Survey respondents felt technological advances will have greatest impact on health systems functioning while transitions in social order and governance most likely to impact health systems equity

Note: Number of votes for each trend. Respondents could select up to two trends for each category. This is not change over time.

Respondents identified technological advances and economic shifts as having the greatest impact on health systems functioning. However, they identified transitions in social order as having a greater potential impact on health systems equity and inclusivity.

Participants discussed this discordance, noting that system functioning is often prioritized over equity – even among those who value equity highly. As Dr Nita Rudra, a Professor at Georgetown University in the United States of America, reflected, “functioning fits neatly within existing political and economic structures – equity does not.”

The consultation also revealed some regional differences: for example, climate change was seen as a central operational threat in some regions, but a more distant or abstract driver in others. These results reinforced the need for HS2050 to explore not only what futures are possible, but whose futures are being imagined, and who is at risk of being left out of these visions.

A moment of profound transformation (and uncertainty)

Across the three days, participants repeatedly emphasized that the next decades will be marked by rapid, non-linear change. Many observed that current disruptions – from the digital revolution to climate change to geopolitical instability – are unfolding faster than health systems can adapt.

As Dr Rubayat Khan, Director of Health Programs at Endless Network in the United States of America emphasized, “We’re still at the beginning of these major changes, and we haven’t seen 80% of what’s coming.”

He continued that, while “prediction is a futile exercise, there are some core principles that we agree on: like equity, how people experience health care, health outcomes. Depending on different contexts we can have that north star, we can course-correct and have our hand on the steering wheel.”

Participants also emphasised that no single future will define all health systems. Dr Jeanette Vega, Vice Chair of the Alliance Board from Chile, observed that “we have health systems operating in different time zones,” highlighting how some countries are preoccupied with ageing populations and noncommunicable diseases, while others are grappling with insecurity, displacement or the rapid advance of new technologies. These different starting points will shape how global trends play out across regions.

The disruptive potential – and limits – of AI

Artificial intelligence emerged as a key theme. Participants explored AI as a general-purpose technology capable of reshaping entire health systems.

Dr Khan argued that clinical intelligence – long considered a scarce and limiting factor – may no longer be the bottleneck, which could have profound impacts on the future of the health workforce.

Discussions explored multiple possible futures for AI, from continuous care companions, to supporting continuously learning systems. But, participants also emphasized caution. Concerns ranged from data misuse and algorithmic bias to dependence on systems requiring enormous electricity and water resources.

The group agreed that the future of AI in health systems hinges on governance decisions made now – including how to protect privacy and ensure that benefits accrue to those most in need.

Climate, conflict and geopolitics: the other megatrends reshaping systems

While AI attracted considerable attention, participants stressed that climate change, insecurity and geopolitical realignments will also be transformative.

Some described climate impacts not as future risks but current lived realities: extreme droughts affecting power grids, environmental degradation reshaping livelihoods and climate shocks driving displacement. Dr Davide Ziveri, Environmental Health Specialist at Humanity & Inclusion in Belgium, argued that the natural and built environment “should be treated as a new building block of the health system.”

Others described a global landscape marked by fragile cooperation, deepening conflict and increased migration. “We’ve never had so many attacks on health facilities since the Second World War,” Dr Joanne Liu, Professor at McGill University in Canada, shared. “We need to rethink how care is delivered in a world where health workers themselves are targets.”

These reflections highlighted the importance of designing resilient, adaptable systems able to function amid overlapping crises.

Whose knowledge counts? People, power and participation

A powerful theme across the meeting was the need to centre people and communities in defining future health systems. Discussions explored intersectionality, exclusion and epistemic justice.

Dr Ramya Kumar, Affiliate Associate Professor at the University of Washington but currently based in Zambia, warned: “There are no voiceless people – only the silenced.” Another challenged the group to rethink conventional hierarchies of knowledge: “Health systems are social systems. Trust and dignity are not optional extras.”

Participants described examples where marginalized communities – from informal workers to displaced populations – have created their own systems of care when formal systems failed them. The group argued that future health systems must move at what they called the speed of trust, building models that reflect the lived realities, aspirations and knowledge of diverse groups.

Country and regional perspectives: diverse pathways, shared concerns

Illustrative country and regional cases highlighted how global trends interact with local political, economic and demographic realities:

• A rapidly ageing middle-income context showed how long-term planning, value-driven reform and technological investment can reshape systems, but also how easily inequalities persist.
• Small island states in the Caribbean illustrated the limits and potential of regional cooperation in the face of economic shocks and climate vulnerability.
• A large federal country demonstrated how decentralization, uneven financing and digital innovation can produce highly divergent subnational futures.

Based on these discussion, participants were clear that path dependence matters, and choices made in the 2030s will shape health systems for decades.

Shaping the road ahead

The Accra meeting concluded with a strong call for imagination, courage and practical action. As Dr Joanne Liu reflected, “Hope is not a strategy – but without imagination, we have no strategy at all.”

The Alliance will now synthesize insights from the meeting to refine the HS2050 framework, shape country-focused work and develop future scenarios. The aim is to continue to consult widely beyond the expert group to ensure diverse voices contribute to this work, as the initiative is an oppotunity to ensure that the futures of health systems are not left to chance, but are shaped deliberately around equity, inclusion and the lived realities of people and communities around the world.

Dr Kumanan Rasanathan, Executive Director of the Alliance, concluded that, “health systems are struggling to adapt to a world changing rapidly along multiple dimensions – but there is no choice. We hope that this work can inform the crucial choices to move health systems towards the futures we want – and away from the dystopian possibilities we fear.”