Human functioning: advancing clinical care, research, and policy

Human functioning is a concept created by the World Health Organization (WHO) to capture what matters to people most about their health – the way they experience it every day. This new way of assessing health integrates people’s physiological and mental state with their ability to perform both basic and complex activities, from walking and eating to working and socializing.

Though the concept was conceived more than 20 years ago together with a framework for assessing functioning, it is still not a standard part of health practice. In their Frontiers in Science lead article, Bickenbach et al. present a strategy for implementing human functioning across health systems and policies that includes establishing a new field called human functioning sciences.

The authors argue this approach will effectively link health and well-being – ultimately enhancing societal welfare. They also explain how recognizing functioning as a major health indicator can advance the United Nations’ (UN) Sustainable Development Agenda. This brief ‘explainer’ outlines their key points.

What is human functioning? 

The World Health Organization’s concept of human functioning represents a paradigm shift in health. It is based on the idea that health is not just the biological state of the body, but also the ability to take part in daily life and achieve personal goals. For instance, different individuals with paraplegia may suffer from the same biological limitations. However, they could have distinct functioning levels depending on their access to assistive technologies and a supportive social context.

Systematically collecting functioning data together with clinical information would allow healthcare providers to develop treatment plans that consider the individual's biological health as well as their goals, preferences, and cultural background. This approach can improve patient satisfaction and increase their engagement in their own health and well-being. If implemented at a large scale – into health practice and policy – functioning could also enhance societal welfare by creating a society made of healthy, thriving individuals.

How is human functioning measured?

The main tool currently used to assess functioning is the Classification of Functioning, Disability, and Health (ICF), originally developed by the WHO. The ICF framework is a comprehensive and person-centered approach that evaluates:

• Biological health: anatomical structures, physiology, and psychological functions

• Lived health: activities and participation, ranging from eating independently and speaking to working and exercising

• Contextual factors: personal and environmental variables affecting people’s biological and lived health, such as accessibility, pollution, and social context.

This framework creates a universal common language that facilitates communication across scientific disciplines and geographical regions.

How can human functioning be integrated into health systems?   

The goals and priorities of health systems are often guided by two major health indicators – morbidity and mortality. These indicators are used to assess the burden of disease within a population and evaluate the success of policies and interventions. While this approach is highly effective for monitoring biological health, it generally doesn’t address people’s lived health experience. Recognizing functioning as the third main health indicator would be the first step toward making lived-health assessment a standardized part of healthcare.  The ‘health systems building blocks’ structure can be instrumental for the practical implementation of human functioning. The WHO established this structure with the aim of strengthening health systems by focusing on the needs of distinct areas while managing the interactions between them:

• Service delivery

• Workforce

• Information systems

• Access to essential medicines

• Financing

• Leadership and governance

Human functioning can be integrated into all six building blocks. For example, it can inform ‘service delivery’ by providing a new perspective on the type of services needed. It’s most relevant, however, to the ‘information systems’ building block. Functioning data (collected through the ICF framework) can complement morbidity and mortality data to create a more complete understanding of population health and well-being.  

Rehabilitation is an example of a discipline where functioning was well-integrated, providing a powerful framework for integrating data, defining new guidelines, and driving technical developments.      

How can functioning help realize the UN 2030 Agenda for Sustainable Development?    

Our health is largely determined by what we do and how we live – our diet and exercise habits, socioeconomic status, and environmental conditions. This means that while traditional healthcare is important for treating health issues, it often doesn’t address what causes them in the first place. Human functioning, on the other hand, provides a framework for both preventing and treating disease.    

This new thinking falls perfectly in line with the 2030 Sustainable Development Agenda, defined by the United Nations in 2015. The agenda specifies 17 Sustainable Development Goals (SDGs) that together serve as a ‘blueprint for peace and prosperity for people and the planet’.     

Among these goals, SDG3 aims ’to ensure healthy lives and promote well-being for all’. Though SDG3 targets both health and well-being, its progress has only been measured by tracking mortality and morbidity. However, well-being is not guaranteed simply by the absence of disease or injury. After all, living a long time is not necessarily the same as living well. Recognizing human functioning as the third major health indicator can help guide policies and health systems toward the picture of health envisaged by SDG3.

What is human functioning sciences? 

Health research has greatly expanded over the last century, with contributions from many disciplines such as engineering, biology, and social sciences. While this led to progress, integrating these diverse fields into effective programs remains a significant challenge. 

Establishing a new scientific field based on human functioning could be the key to solving this problem. ‘Human functioning sciences’ would be a truly integrative discipline, exploring the links between health and well-being and defining strategies for integrating functioning into health and social systems.

What are the major challenges for implementing functioning and how can they be overcome? 

A range of challenges must be overcome for realizing the full potential of human functioning. These include a lack of research and relevant technologies, as well as potential economic and political obstacles. 

One major issue is a simple lack of awareness. Communication must play a major role in promoting functioning among health professionals, policymakers, and the public. While each group needs tailored communication strategies, the overarching goal is to recruit support through an informed appreciation of functioning’s value and its potential for shaping better healthcare and health policies.

Healthcare systems might also need to be redesigned to provide integrated and coordinated care across different settings and providers – for example, updating health information technology, care coordination programs, and team-based care models.

Another issue is the lack of standardized tools and measures for functioning assessment, which makes it difficult to compare and interpret data across different contexts and populations. However, there are continuous efforts to find solutions. For example, the WHO has developed ICF Core Sets for specific health conditions, which provide standardized approaches to measuring functioning in certain populations.

Finally, a new generation of researchers and policy entrepreneurs is needed to form a workforce dedicated to this rethinking of health. This will require academic transformation guided by the development of an innovative curriculum and cross-faculty degree programs, possibly under the umbrella of human functioning sciences.