Futureproofing Public Health Systems by Teaching Foresight

In the throes of the pandemic, 'unprecedented' became an overused descriptor. But it is a misnomer for COVID-19. Despite its novel nature, the potential for such a health crisis wasn't entirely unforeseen. Foresight studies have contemplated the possibility of a global pandemic, but even a futurethinking veteran like Henk Hilderink admits COVID-19 was a ‘reality check’ for everyone.

It was not so much that a pandemic was unexpected, but more about anticipating its specific features. “Although it was always included in public health forecasts as a red flag, not even the foresight community was really able to conceptualise what a global pandemic would actually look like: face masks, confinement rules, the hesitation of science…”, comments Hilderink.

Witnessing that kind of science fiction plot coming to life, highlights the importance of contemplating also extreme scenarios: “People, including policymakers, have a tendency to think mainstream and dismiss the worst-case outcomes”, notes Hilderink. Black swans (foresight jargon for random, unexpected, but high-impact events) are usually of less interest than the “usual suspects”, such as ageing, technology and economic growth. According to Hilderink, raising awareness about extreme events is one of the duties of the foresight community, along with the assessment of more predictable uncertainties.

COVID-19 caught us unprepared and brought attention to the value of foresight methodologies in developing resilient public health systems for the future. “The momentum to invest in foresight is there and capacitybuilding is key to promote foresight practices across Europe and lead to the institutionalisation of future thinking in public health”, observes Hilderink.

Thirty years in the field make Hilderink one of the most experienced strategic foresight experts in Europe. At Dutch national level, he led the last two editions of the quadrennial public health foresight report published by the National Institute for Public Health and the Environment (RIVM). At European level, Hilderink is involved in several foresight-driven projects and is president of the Foresight Section of EUPHA, European Public Health Association.

A wealth of knowledge Hilderink is eager to disseminate. “At RIVM we are always looking for ways to transfer our foresight experience via capacity building initiatives and structured collaboration with other National Public Health institutes”. RIVM’s specific expertise has brought them to guide foresight activities for the Horizonsponsored PHIRI project, a joint venture of 41 partners across 30 European countries.

Launched in November 2020, in the midst of COVID-19’s second wave, PHIRI (Population Health Information Research Infrastructure) sets out to facilitate cross-border sharing of population health data impacted by the pandemic.

Hilderink explains how “our concern in PHIRI was not only to identify the direct impacts of the pandemic but also the indirect ones”. These include the long-term effects of lower levels of care (reduced access to preventive scanning, follow-ups, and care for chronic conditions), changing lifestyles (less physical activity and increased smoking and alcohol consumption), and mental health issues (fear, stress, and loneliness of social isolation).

PHIRI’s foresight capacity-building course trained about 70 actors from across Europe through a mix of lectures, exercises, and activities. As a practical application of the vision-building training, a dozen EU Countries took part in case studies and were supported in initiating their own national foresight study on a selected public health topic, such as non-communicable diseases, long-term care, mental health and suicide prevention, and digitalisation of healthcare.

Expertise in foresight is quite hard to build and not all member states make place for foresight studies in budget allocations. “In the Netherlands, for example, a legal Act stipulates the production, every 4 years of a report about the future of health”, considers Hilderink.

Behind ‘teaching’ structured and participatory ways of looking at possible futures is the empowering goal to inspire evidence-based policymaking in public health.

“Foresight experts are not policy advisors”, says Hilderink. More like landscape painters, they sketch possible futures: “There is no such thing as risk-free policymaking” – he suggests – “but the foresight community is there to outline those risks and mark uncertainties en route”.

The foresight process should not only anticipate knowledge-driven trends, but also create awareness about harder-to-monitor factors. “We have to consider value-driven aspects as well,” warns Hilderink, “and account for values that influence scenarios which are challenging to investigate but can have huge impacts on society”.

Ultimately, the outcomes of public health will depend on which ‘normative’ aspects will be valued more in societal debate and echoed in policymaking. Will we privilege the economic aspects in healthcare expenditure or concentrate on safeguarding equality in health provision? What impact will value-driven choices have on life expectancy, burden of disease, and social inequalities?

This is an article from the Horizon Future Watch Newsletter (Issue 2, July 2023), presented by Foresight on Demand