The team searched PubMed for studies across two complementary domains: one covering integrated care, digital health transformation, value-based healthcare and system resilience; the other covering health diplomacy and global health governance. From an initial pool of 54 transformation studies and 286 diplomacy studies, multi-stage screening with a structured scoring rubric reduced the final sample to 46 publications—22 on health system transformation and 24 on diplomacy and governance. The corpus consisted mainly of systematic and scoping reviews, policy analyses, and conceptual frameworks. Notably, almost none of the included studies directly examined the relationship between domestic health system reform and public health diplomacy, which is precisely the gap the authors set out to close through thematic and conceptual synthesis.

The conceptual sequence the researchers identified begins with systemic threats. Pandemics, geopolitical instability, and hybrid risks disrupt not only service delivery but infrastructure, emergency response, and public trust, exposing the limits of fragmented, nationally bounded healthcare. Evidence from crisis and conflict settings indicates that resilience depends on the combined capacity of routine healthcare, public health systems, and coordinated governance—often operationalised through integrated models of care. These pressures, the review finds, elevate health from a sectoral policy domain to a strategic component of national and regional security.

In response, health systems worldwide are pursuing reforms aimed at efficiency, sustainability, and crisis preparedness. A central theme is the shift from volume-based care toward value-based healthcare, which prioritises outcomes and coordination over service throughput. Financial incentives are being reconfigured accordingly: fee-for-service models discourage cooperation across providers, so mechanisms such as bundled payments, shared savings, alternative payment models, and pay-for-performance aim to align provider behaviour with integrated, multidisciplinary care. Examples from England, Singapore, the Netherlands, the United States, and Slovenia illustrate this broader reform direction, combining community-based and digitally enabled care with regional population health strategies and value-based financing. Comparative evidence across OECD countries places systems on a continuum between integrated and fragmented provision, with rising chronic disease and multimorbidity accelerating adoption of patient-centred integrated models.

As integration advances, the review highlights a second transformation: the emergence of digital health infostructure. The authors use this term to describe the combined ecosystem of information systems, IT platforms, interoperability standards, data infrastructures, governance rules, and operational processes. Integrated care requires coordination across providers, sectors, and levels of care, and that coordination is increasingly sustained by interoperable data environments. Telehealth, remote monitoring, and electronic health records expanded rapidly during the COVID-19 pandemic, demonstrating how crisis conditions accelerate digital integration. Data thereby becomes a central organising element of the health system, underpinning population health management, resource allocation, and predictive planning.

Here the framework turns geopolitical. Interoperable data environments create interdependence between national health systems through shared data flows, coordinated responses, and global supply chains. Yet governance mechanisms have not kept pace. Evidence from the pandemic reveals persistent gaps in global health governance: weak enforcement, fragmented institutional coordination, and limited accountability. Initiatives such as COVAX were undermined by vaccine nationalism and unequal resource distribution, while the International Health Regulations rely largely on voluntary compliance. Power asymmetries further shape governance outcomes. Emerging efforts like the European Health Data Space aim to harmonise legislation and data structures, but the review concludes that health systems currently operate under conditions of constrained interdependence—collaboration is necessary yet structurally limited.

Under these conditions, cross-border cooperation becomes a functional necessity rather than an institutionalised process. Transnational threats, from pandemics and One Health risks to conflict-related and disinformation-driven hazards, cannot be managed within national boundaries. But cooperation depends on trust, governance compatibility, and aligned incentives, and disparities in digital infrastructure and regulatory frameworks reinforce inequalities and reduce collective effectiveness. This coexistence of shared need and institutional constraint, the authors argue, generates demand for mediating mechanisms—and public health diplomacy emerges as one such mechanism.

The framework distinguishes public health diplomacy from traditional global health diplomacy. Whereas the latter typically involves state-centric multilateral negotiations among ministries, international organisations, and donors, public health diplomacy is positioned as an operational layer of system-level interaction grounded in health system capacities, data infrastructures, and coordination mechanisms. It expands participation to public health professionals, local health agencies, academic institutions, professional networks, and community-oriented stakeholders, emphasising communication, consensus-building, evidence translation, and equity. Digital health diplomacy also features prominently, with data governance, technology access, and interoperability becoming subjects of negotiation in their own right.

The spiral metaphor is deliberate. Each rotation of the cycle—systemic threats prompting integration reforms, reforms producing digital infostructure, infostructure creating interdependence, interdependence colliding with governance constraints, constraints demanding diplomacy—does not simply repeat. It escalates. Public health diplomacy reshapes the understanding of health security to include resilience, data governance, and coordination capacity, building shared norms and institutionalised cooperation. But increased reliance on data infrastructure introduces new vulnerabilities: data dependencies, interoperability constraints, and exposure to hybrid threats. These vulnerabilities redefine systemic threats, and the system re-enters the spiral at a higher level of complexity. The dynamics are iterative and open-ended, not a closed loop.

The authors acknowledge limitations: the search drew on a single database, was restricted to English-language publications from 2015 to 2025, did not use independent dual screening, and the framework itself has not been empirically validated. Its relevance is illustrated rather than tested through examples such as COVAX, the European Health Data Space, and the war in Ukraine’s impact on health systems near NATO’s eastern border. A recent scoping review from Ghana, showing how digital health fragmentation reflected fragmented mandates and weak enforcement, suggests the framework may be especially informative where governance and interoperability constraints are most visible. The authors call for empirical application to specific country contexts and for research into how financing reforms, data governance, and infrastructure interact in practice. For policymakers navigating simultaneous domestic reform and international pressure, the Health Diplomacy Spiral offers a lens for seeing what many already sense: that building a modern health system is, increasingly, an act of foreign policy.

Subject of Research: A conceptual framework linking health system integration, digital transformation, and public health diplomacy

Article Title: The health diplomacy spiral: a conceptual framework linking health system integration and public health diplomacy

Article References: Peckauskas, A., Dulkys, A., Niaksu, O., & Kalediene, R. (2026). The health diplomacy spiral: a conceptual framework linking health system integration and public health diplomacy. Public Health Reviews, 47, Article 1609977. https://doi.org/10.3389/phrs.2026.1609977

Image Credits: AI Generated

DOI: 10.3389/phrs.2026.1609977

Keywords: health diplomacy, health system integration, digital health, global health governance, data governance, public health, interoperability, value-based healthcare, pandemic preparedness, health system resilience, interdependence, health