How health securitisation shapes health system priorities: A realist synthesis.

Health securitisation - i.e., framing health issues as security issues or as threats- is growing in contemporary global health discourse. Given the power disparity between the actors who can frame a health issue or on whose behalf issues are framed and the actors who may experience the consequences of such framing, it is crucial to understand how 'health security' framing impacts health system prioritisation. We conducted a realist synthesis on how ("mechanism") and under what conditions ("context") health securitisation impacts health system priorities ("outcome") at different levels of health governance. To capture contemporary analyses, we searched the SCOPUS, MEDLINE, EMBASE, and Global Health databases for articles published from 2010 to 2023. We included 51 articles in the realist synthesis: empirical studies and conceptual analyses on the effects of health securitisation (and associated security-oriented policies, practices and measures), even if implicitly, on health system priorities. Through the synthesis, we identified five mechanisms by which 'health security' framing is adopted in response to an event - 'uncertainty' (managing the ambiguity of risks), 'self-protection' (safeguarding own group/national interests), 'self-reliance' (projecting own ability to be autonomous), 'self-preservation' (preserving own institutional credibility), and 'norm-setting' (entrenching long-term policy shifts). We also identified contextual factors (e.g., similar past events, inequities between groups/nations, militarisation of governance, donor influence, geopolitical interests) that influence these mechanisms to generate outcomes in the form of priorities (e.g., mobilisation of funds, overemphasis on one disease or approach over others, abuse of power that disproportionately impact marginalised individuals, groups, and nations). Each mechanism is influenced by a set of contextual factors which are peculiar to a place and time. Understanding these links between context, mechanism, and outcome can allow for a closer examination and anticipation of 'health security' framing and its impact on prioritisation in different settings globally.