Barriers and enablers for health system reform

Introduction Health systems worldwide face escalating pressure from the growing burden of non-communicable diseases and population ageing, as well as chronic workforce shortages, infrastructure limitations, and structural misalignment between care models designed for acute illness and the long-term needs of complex patients. Many countries are pursuing comprehensive transformation efforts including shifting care closer to home, enhancing early disease detection and addressing workforce challenges. This study aims to identify examples of transformation across these domains, including specifically service delivery decentralisation, workforce transformation and enhancement of screening and diagnostic services for early detection and treatment - and determine common barriers and enablers in order to make recommendations for improvement. Methods A mixed-methods approach, combining a scoping literature review and semi-structured one-on-one interviews was utilised. Searches of peer-reviewed literature were performed in EMBASE, Global Health, and Ovid MEDLINE databases. The Rayyan platform was used for systematic management of references, deduplication, and screening. Titles and abstracts were independently reviewed by two members of the research team before full-text review and data extraction. 153 peer-reviewed papers and 35 grey literature reports were analysed, whilst 17 expert stakeholders, including policy experts, academics, health policy experts and clinicians from six countries were interviewed. Results 67 transformation case studies were included. Of these, 36 were focused on service delivery decentralisation, 16 on screening and 12 were related to workforce adaptation. A final set of 34 barriers and 27 enablers was identified and grouped empirically into six areas including: political, governance and policy; funding, incentives & resource allocation; workforce capacity, capability & culture; system integration, structure and care coordination; digital infrastructure, technology and data; communication, engagement, and change management. Discussion Finally, a set of 25 recommendations, across seven groups, are made for policy makers and other relevant stakeholders. These findings provide practical, evidence-based insights to guide policymakers in designing scalable, context-sensitive health system transformation strategies.