WHO expert meeting gathers tailored policy advice from past health ministers on large-scale health system reforms


In a pioneering effort to harvest actionable insights and expertise for large-scale health system transformation, WHO/Europe, the Deusto Business School of Spain and the Centre for Public Policy and Health of Durham University jointly gathered over 25 high-level past policy- and decision-makers in health systems in Madrid, Spain on 17–18 December 2015.

Participants included experts from Estonia, Hungary, Italy, Kyrgyzstan, the Netherlands, Poland, Portugal, the Republic of Moldova, Slovenia, Spain, Turkey and the United Kingdom.

The purpose of the meeting was to draw on the experiences of leading change agents to ignite transformation in Europe's health systems. This was done by understanding and capturing how policy-makers have progressed and adopted new policies, models of care and financing schemes.

Discussions centred on learning in a first-hand, frank and friendly environment participants' experiences during their time as health ministers and senior decision-makers. They focused on drivers and enablers, as well as obstacles and barriers that need to be overcome in securing transformative change. The meeting served as a platform to gather policy lessons for the current generations working with similar complex issues and to discuss how WHO/Europe could facilitate an exchange of experience.

Meeting outcomes

The meeting had 3 primary outcomes.

  • Identify lessons learnt in the implementation of health system reforms at macro level, which could serve as an evidence base.
  • Provide advice to health system policy-makers on how to initiate reforms and/or accelerate or improve implementation.
  • Identify steps WHO/Europe could take to develop a health system policy-level implementation agenda and potential mechanisms of collaboration.

Participants agreed that the implementation and sustainment phases of large-scale reform are more difficult than their design and development. There was consensus among the experts that successful transformation requires creating a receptive context for change.

Creating receptive contexts for change

One possibility for creating this context is by tackling environmental pressures for change by engaging the appropriate people with convincing evidence to reinforce political actions, and by emphasizing communications approaches that encourage two-way dialogue.

Ensuring quality and coherence of policy is a key factor in creating receptive contexts for change, and participants suggested several strategies.

  • Look at the system as a whole and avoid partial solutions.
  • Learn from others.
  • Develop specific, measurable, attainable, relevant and timely objectives.
  • Create a plan that engages all stakeholders.

Participants agreed that people are key in leading and sustaining change. Strong distributive leadership and team visions are more important than individual leadership approaches, which may not be sustained when key persons leave their positions.

Participants concurred on the high value of a systems perspective as initiatives often ignore systemic issues. In addition, an engaging, inspiring narrative of change is a key element in large health system transformations. Also, a longer-term vision of the expected change and achievements, and a balanced approach of centralized planning and coordination with local-level autonomy are critical enablers.

Policy-makers welcomed practical advice and guidance on how to move forward based on how others have succeeded, on the lessons learnt and on insights derived from relevant academic research.

Recommendations to WHO included the establishment of a network of past high-level policy-makers able to advise current decision-makers on how to initiate, accelerate, sustain or improve large scale health system reforms.


Many health systems in Europe and beyond are either undergoing or in great need of undertaking extensive macro-level reforms. Most health system reform literature focuses on the contents – what to do – to transform health systems at a larger scale. Less is known about strategies and practical tactics to move them forward – how to prepare, initiate, sustain, accelerate or improve reforms.