• health systems
• public health
• COVID-19

Self-care is an approach to advancing health wherein people themselves take health actions towards the better health of themselves, their families or their community.1 These actions include new behaviours and those previously under the control of a healthcare provider that can now be offered or used with greater individual autonomy. Examples of self-care interventions include self-testing for sexually transmitted infections, pregnancy, blood glucose levels; self-management of chronic disease, contraceptive use, HIV prevention tactics; self-awareness of one’s health needs and health status and exercising self-determination to seek healthcare.2

An eminent value of self-care is its potential to improve access to and healthcare coverage while reducing dependency on facility-based services and the overburdened health workforce. Self-care can also elevate and bring greater control to individuals as stakeholders in their own health and well-being.2

Yielding these gains from self-care requires integration as a core component in health systems, not merely an add-on.3 This integration, where systems are reoriented to recognise individuals’ and communities’ role in coproducing health, presents layered obstacles stemming from the need for self-care to be both people-centred and system-centred.3 Among these obstacles is the wide array of ways self-care is understood that leave it open for interpretation between health systems actors and communities.3 4

Amidst this complexity, self-care is having its moment. The recent proliferation of new medical and digital technologies offers numerous configurations for integrating self-led healthcare into health systems. These new configurations, paired with the behavioural and educational theories that support self-management of health,5 elevate self-care from a millennia-old practice into a forward-leaning solution for delivering a broad range of healthcare to a large number of people. And, in the context of the COVID-19 pandemic, solutions that increase access to healthcare and alleviate supply-side bottlenecks are particularly attractive to health systems and consumers alike. As such, Ministries of Health in Uganda, Nigeria and Sierra Leone are in the process of adapting and adopting WHO self-care guidelines.6 7 In Australia, the Minister of Health recently launched a national policy blueprint for advancing self-care for health.8 In the UK, the National Health Service put forth ‘supported self-management’ and patient activation for self-care as key features of their Long Term Plan.9 In the context of the COVID-19 pandemic, WHO has sought to accelerate the adoption of self-care interventions through consultation with member states10 and by including it in the WHO operational guidance for maintaining essential health services.11

The excitement around self-care is also paired with caution. There are valid concerns that self-care can be practised unsafely, give health systems ‘a pass’ on institutional accountability, exacerbate inequity or that self-care practices can shift liability onto self-care users themselves. A series of Good Practice Statements that attempt to mitigate such implementation pitfalls are included within the WHO self-care guidelines.1 But the need to hold space for complexity and nuance in self-care extends beyond what any guideline, interpretation or lens can offer.

Underpinning this deeply human frontier of healthcare are multiple, sometimes contradictory, truths—which often present as a paradox. Consider these seemingly contrary features that can be true simultaneously:

• Of power: self-care can be an act of personal power and control over one’s health and can be undertaken as a last resort by those who have been marginalised, from whom power is withheld.

• Of dependence: self-care can be an autonomous act and can rely on healthcare providers and institutions for facilitation or oversight.

• Of origin: self-care can be natural and innate and manufactured by health systems and industry.

• Of encumbrance: self-care can be liberating and a burden.

• Of accountability: self-care can be a means for individuals to participate productively in health systems and a way for health systems to relinquish responsibility or liability over individuals’ actions.

Each contrasting element seems logical when considered in isolation. However, the multiple elements present a complex picture of paradoxical coexistence in individuals and populations when juxtaposed. For example, the paradox of power might appear when an individual uses an HIV self-test out of necessity and derives power from the act of doing so. The paradox of dependence is present when a person self-injects contraception independently and is bolstered by quality monitoring and oversight mechanisms that uphold her autonomy safely. The paradox of origin manifests when an individual’s self-determination to seek reproductive healthcare is an intimate personal decision and the result of external forces, including commercial influence, that encourage people to partake in or purchase certain healthcare products or services. The paradox of encumbrance may play out when people of marginalised identities find freedom in taking control over aspects of their health that are overlooked by healthcare providers and are concurrently burdened by the prejudice and systemic medical racism that shifts this onus of responsibility to them in the first place.

These paradoxes contribute to the multitude of ways self-care is understood and interpreted, making the integration of self-care into health systems particularly complex and necessarily nuanced in its application. They also demonstrate the danger of positioning self-care as an unequivocal, single-issue solution. As writer, academic and organiser Nakita Valerio put it, ‘shouting ‘self-care’ at people who actually need community care is how we fail people.’12

Management experts have created pathways for navigating this complexity between paradoxical tensions. Rather than choosing between them—an effort that may prove futile by only intensifying a need for the opposite—paradoxical resolution ‘requires continuous efforts to meet multiple, divergent demands.’13

Managing the self-care paradoxical tensions could require accommodating the competing demands or enabling space for paradoxical existence. For example, paradoxical resolution might mean that self-care interventions occurring out of desperation or a lack of alternatives continue to occur but do so alongside efforts to address the imbalance in power that made them so. Or that progress towards making self-care interventions more autonomous is accompanied by innovations in remote support that enhance client safety. Or, that individuals themselves be given the latitude to calibrate, within these polarities, the self-care that suits their needs and goals (and systems shaped to respond to this person-centredness).

Approaching the self-care paradoxes as present and concurrently possible can help integrate a more durable self-care application into health systems. This is because tensions themselves are familiar and even valuable in complex systems—interacting, informing and perpetually defining one another over time.14 In this way, the paradox may sharpen the role of self-care in health systems, shifting self-care from an ‘extracurricular’ part of care to a critically integrated one.

The question for this generation will not be whether to advance self-care, but how to do so in a manner that optimises and delivers on its potential to expand quality health coverage to all. To that end, recognising that self-care will always require careful calibration between opposing forces (ie, paradoxes) can serve as a reminder there will be myriad ways to advance self-care in individuals’ lives and health systems.